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Learn More About CMS Updates that may impact your PACE Plan.

Contract Year 2019 Monitoring of Marketed Comprehensive Formularies – Dated 11/2/2018

Summary: CMS provided a summary of the results of the CY 2018 monitoring of the posting and accuracy of plan formulary documents and announced that the analysis will be performed again for CY 2019.  

Action: Informational to PACE

Preclusion List Requirements – Dated 11/2/2018

Summary: CMS provided guidance on how plans can implement and comply with the Preclusion List requirements for 2019.  

Action: Applicable to PACE.  Refer to the memo for complete details.  Pharmastar will be working on a process to inform plans when a precluded provider listed is being utilized by the plan to allow the plan sufficient time to notify the participants it impacted and when payment denials and claim rejections will begin for the listed provider.  

Correction to the CTM Plan Download File Record Layout – Dated 11/2/2018

Summary: CMS updated the CTM Plan Download File record layout to restore three fields that were erroneously removed.  

Action: Informational to PACE.

Possible Break in Service for the HPMS Help Desk Phone Number – Dated 11/6/2018

Summary: CMS will be transferring the HPMS Help Desk phone number to a new account.  As a result, there could be a “break in service” for the phone number for up to 24 hours.  CMS will send out alerts when the break in service begins and another when it is fully restored to service.

Action: Informational to PACE.

Correction: Contract Year 2019 Monitoring of Marketed Comprehensive Formularies – Dated 11/6/2018

Summary: CMS corrected the memo titled that was referenced in the previous memo released on November 2, 2018.  

Action: Informational to PACE.

Application of Merit-based Incentive Payment System (MIPS) Payment Adjustment to Medicare Advantage Out-of-Network Payments – File Layout and Additional Guidance – Dated 11/8/2018

Summary: CMS provided the file layout and additional guidance to Medicare Advantage Organizations regarding the application of the MIPS payment adjustment to payments on non-contract MIPS eligible clinicians.

Action: Applicable to PACE depending on the relationship its organization has with its doctors.  Refer to the memo for complete details.

2019 Medicare CAHPS Survey – Dated 11/13/2018

Summary: CMS reminds plans of the 2019 Medicare CAHPS Survey and the procedures for requesting additional sample and rules regarding the number of supplemental items.  In addition, CMS provided information on administering the survey in other languages and timeline and process for receipt of the CMS survey results.

Action: Informational to PACE as PACE is waived of the CAHPS survey requirement.

2020 Quality Bonus Payment Determinations and Administrative Review Process for Quality Bonus Payments and Rebate Retention Allowances – Dated 11/13/2018

Summary: CMS made available to Medicare Advantage (MA) Organizations a process to review payment determinations based on quality bonuses.  MA plans can request an administrative review of their Star Ratings for quality bonus payment determinations and rebate retention allowances by November 29, 2018.

Action: Informational to PACE as PACE does not follow the MAPD marketing guidelines and does not participate in payment adjustments linked to plan Star Ratings.

Model of Care PRA – Dated 11/15/2018

Summary: CMS published a notice for comment on the Models of Care (MOC) and off-cycle submissions of MOC changes.  Comments can be submitted by January 7, 2019.  A link to the notice is provided.

Action: Informational to PACE.

Thanksgiving Holiday

The Pharmastar Administrative Office will be closed on November 22nd in celebration of the Thanksgiving holiday.  As always, the 24/7 Pharmastar help desk will remain open for your needs throughout the coming holiday at 888-298-7770.

Important Date Reminders

Date

      Item

December 14, 2018

Complete and Submit the Annual Full File Replace ATBT and NX Report Distribution Email List for 2016-2019

January 1, 2019

Initial Preclusion List Available

April 1, 2019

Payment Denials and Claims Rejections Begin for the January 1, 2019 Preclusion List

*Subject to change, forthcoming information to be release by CMS.

Please note that this information is provided to you in summary form for general informational purposes only and does not constitute legal or regulatory compliance advice.  It is your responsibility to consult with your Compliance Officer and/or legal counsel to determine applicability of any regulation or standards referenced herein to your organization and/or processes.

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