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Learn more about CMS Updates that may impact your PACE plan.

Updates to Payment Year (PY) 2019 Model Output Report (MOR) – Dated 11/30/2018

Summary: CMS released the Model Output Report (MOR) to plans to identify the Hierarchical Condition Codes (HCCs) used to calculate risk scores for each beneficiary.  For PY 2019, risk scores for PACE plans continue to be calculated based on diagnoses from RAPS, encounter data and FFS in equal measure and will have specific MOR record types to report HCCs from any of these three sources.

Action: Informational to PACE. Refer to the memo for complete details.

Medicare Advantage/Prescription Drug System (MARx) December 2018 Payment – INFORMATION – Dated 11/30/2018

Summary: CMS provided information about the December payment which is scheduled for December 1, 2018 and may require plan action:

  • Third 2016 Final Risk Adjustment Reconciliation
  • Coverage Gap Discount Invoice Offsets
  • MARx Operating Calendar for 2019
  • 2019 Use Fees

Action: Informational to PACE.  Refer to the memo for complete details and items that may be applicable to your plan.

Advance Announcement of the February 2019 Software Release – Dated 11/30/2018

SummaryCMS continues to implement software improvements to the enrollment and payment systems that support Medicare Advantage and Prescription Drug programs (MAPD).  The plan released of systems changes schedule for February 2019 include the following and may require plan action.

  • Changes to the Medicare Part C Advantage Medicaid Status Data File 

Action: Informational to PACE plans.  Refer to the memo for complete details on the release system changes.

Coverage Gap Discount Program: December Participating Labeler Code – Dated 11/30/2018

Summary: CMS will update the following participating manufacturer labeler code for the Coverage Gap Discount Program by December 1, 2018 to include 72626 Asegua Therapeutics LLC.

Action: Although the Coverage Gap Discount Program does not apply to PACE, the participating labeler codes are applicable because only brand name prescriptions with NDCs from these codes are accepted for Part D payment. Pharmastar will make the necessary software adjustments to accommodate for the change.

Third round of CMS’s review of Medicare Advantage plans’ outline provider directories – Dated 11/30/2018

Summary: CMS released a report from the agency’s most recent review of the Medicare Advantage plans’ online provider directory.  The report and supporting data can be found on the link provided.

Action: Informational to PACE.

Part D Drug Management Program – Standardized Beneficiary Notices and Instructions – Dated 12/4/2018

Summary: CMS announced the availability of standardized beneficiary notices and instructions for plans to use for their Part D Drug Management Programs.  As plans are required to communicate in writing with beneficiaries for whom they intent to limit access to frequently abused drugs, plans are required to use the notices provided and may not develop their own.

Action: Applicable to PACE plans who selected to implement a Drug Management Program in 2019.  Refer to the memo for complete details and a link to the notices and instructions.

2019 Program Audits – Dated 12/4/2018

Summary: CMS released the Program Audit Process Overview document to provide the industry with information about the changes and updates to program audits in 2019.  The 2019 version is available on the program audit website.

Action: Informational to PACE as PACE has a separate audit guide and process protocol.  

Plan Call on Recently Released Notices of Proposed Rulemaking – Dated 12/4/2018

Summary: CMS hosted a plan call on December 7th to provide an overview of two recently released Part C and D proposed rules: CMS-4185-P and CMS-4180-P.  Both documents are available via the links provided. 

Action: Informational to PACE.  For those interested in reviewing the documents and providing feedback/comments, refer to the email for complete details.

Long-Term Institutionalized Resident Report – Dated 12/4/2018

Summary: The fourth 2018 Long-Term Institutionalized Resident Report will be distributed on December 4, 2018.  Plans will only receive an LTI Resident Report if they have LTI enrollees.  The layout of the report is provided.

Action: Informational to PACE.  For PACE plans with LTI enrollees, refer to the memo for details on how to retrieve the report and other general report details.

Reporting of Emergency Part C & D Issues for January 1 through January 4, 2019 – Dated 12/7/2018

Summary: CMS established a Part C & D operations monitoring program for non-technical significant emergency issues for January 1 through January 4, 2019.  Plan sponsors are to report the issues that arise to both CMS and the plan’s CMS Account Manager.  CMS expects plans to monitor and track opioid-related access issues and inbound appeals and grievances as they may be related to the implementation of the new opioid policies.  CMS also request plans to update their CEO and Emergency Contact Information in HPMS by December 27, 2018.  

Action: Applicable to PACE.  Refer to the memo for complete details on when a plan should report issues to CMS and their CMS Account Manager.

Updates to the Risk Adjustment Suite of Systems (RASS) for Delete Transactions using a Beneficiary Identifier – Dated 12/10/2018

Summary: CMS provided information on an enhancement to the RAPS processes for deleting transactions with the MBI.  Starting January 8, 2019, RAPS will accept either the MBI, HICN, or RRB where applicable on delete transactions regardless of which beneficiary identifier was originally submitted.  

Action: Informational to PACE.  Refer to the memo for complete details on the update to the RAPS process.

Part D Opioid Policies – Release of CMS Training Materials – Dated 12/11/2018

Summary: CMS provided training materials to assist plans in their efforts to provide outreach and training for the new 2019 opioid safety edits at the point of sale to its prescribers, pharmacists and beneficiaries.  

Action: Applicable to PACE.  Refer to the email for complete details and links to where the training materials are posted.

December 2018 Encounter Data Software Release – Dated 12/13/2018

Summary: CMS continues to implement software improvements on accepting and processing encounter data to support Medicare Advantage program.  The memo provides detailed information regarding the release of system changes implemented on December 21, 2018 as well as submission and policy guidance related to the changes, if applicable.  The Encounter Data Processing System changes are listed and may require plan action.

Action: Applicable to PACE.  Refer to the memo for items that may be applicable to your plan.

Christmas Holiday

The Pharmastar Administrative Office will be closed early on December 24th at 12PM CT and on December 25th in celebration of the Christmas 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



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.

A real person always answers the phone at Pharmastar.
Sometimes the most important questions happen after normal business office hours. That’s why you can always talk to one of our pharmacy technicians 24/7/365 simply by calling us at (888) 298-7770.