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December 2015 Release Pharmacy Risk Assessment – Feedback Requested – Dated 12/17/15

Summary: The Risk Assessment for December 2015 has been completed by CMS in collaboration with National Benefit Integrity Medicare Drug Integrity Contactor. CMS provided a list of retail pharmacies categorized with a high risk assessment and expects plans to use the information provided to make further determinations about potential fraud, waste and abuse to the pharmacies that have been identified for your plan. CMS expects plans to take the actions mentioned in the memo. Any feedback on action taken on pharmacies in your network even if they are not included in the attached list can be sent to CMS within 30 days of receipt of this memo. 

Action: Applicable to PACE plans. Refer to memo for further information. Pharmastar will review the list of pharmacies and reach out to plans if a pharmacy they utilize for their participants has been identified as high risk assessment.


Medicare Plan Finder Plan Version of Out-of-Pocket Cost Model for CY 2016 and Updated Total Beneficiary Costs Data Released on HPMS – Dated 12/18/15

Summary: An updated version of the 2016 Out-of-Pocket Cost model is now available to use in calculating CY 2016 OOPC values, which are reflected in the Medicare Plan Finder. The new version will assist in preparing for CY 2016 bid submissions.  The OOPC values displayed in the new version released are based on CY 2016 approved bids and may be used in forecasting CY 2017 bids. 

Action: Informational to PACE plans. The CY 2017 OOPC model will be released in April 2016. 


VBID-Additional Guidance and Application Deadlines Extended– Dated 12/21/15

Summary: Medicare Advantage Value-Based Insurance Design model is updated and available for download on the model’s webpage. CMS is offering the option of an extension of time to submit an application to the MA-VBID model test. Applicants are to submit an application by the original deadline of January 8, 2016. Otherwise, CMS will accept applications until 8PM EST on January 22, 2016

Action: Informational to PACE plans. 


Reporting of Emergency Part C & D Issues for January 1, 2016 through January 4, 2016– Dated 12/21/15

Summary: CMS is establishing a Part C & D operations monitoring program for non-technical significant emergency issues for January 1- January 4, 2016. Plan sponsors are to report the issues to both drugbenefitimpl@cms.hhs/gov and CMS Account Manager.

Action: Informational to PACE plans. 


Final Encounter Data Diagnosis Filtering Logic – Dated 12/22/15

Summary: CMS finalize the EDS filtering logic that will be used for PY2015 to identify risk adjustment eligible diagnoses submitted on encounter data records. 

Action: Applicable to PACE plans. Please refer to memo for additional details on the EDS filtering logic.


Minimum Essential Coverage Reporting for Medicare Beneficiaries– Dated 12/22/15

Summary: CMS will be reporting to IRS all beneficiaries who have Medicare Part A as required by the Individual Shared Responsibility provision under the Affordable Care Act. In addition, CMS will be mailing a cover note from CMS and IRS Form 1095-B for tax year 2015 to the list of beneficiary populations. 

Action: Informational to PACE plans. 


Medicare Advantage/Prescription Drug System (MARx) January 2016 Payment-Information– Dated 12/22/15

Summary: The memo provides information related to the January payment:

  • 2016 User Fees
  • 2010 Part D Reopening

End Stage Renal Disease (ESRD) Post Graft Calculation Cleanup – Phase 2

Action: Applicable to PACE plans. For further information on payment related items that may require plan action please review the memo. For any questions or concerns please email the MAPD Help Desk. 


Medicare-Medicaid Plan Advisory Committee Stipends and Non-Monetary Incentives – Dated 12/23/15

Summary: CMS released additional clarification to Medicare-Medicaid Plans regarding stipends and non-monetary incentives for enrollees who are members of MMP advisory committees.

Action: Informational to PACE plans. 


2016 Part C and Part D Call Center Monitoring and Guidance for Timeliness and Accuracy and Accessibility Studies– Dated 12/23/15

Summary: CMS will continue to monitor Part C and Part D call centers in 2016 in order to ensure compliance with CMS call center standards. If any of the phone numbers change during the year, Plans must update their phone numbers in HPMS. CMS conducted two studies on call center quality and performance issues and the detailed results are provided. Additionally, a webinar will be held on January 26, 2016 from 2pm to 3:30pm EST about the 2016 Timeliness, Accuracy and Accessibility Study. 

Action: Pharmastar has reviewed our call center standards against the study results and we are in compliance. Further, if plans have not verified their call center information as explained in the memo, you should do so as soon as possible. See memo for additional details including how to register for the webinar.


Distribution of the MAO-004 Reports–Dated 12/23/15

Summary: Those using the MAO-004 report will be informed by CMS which diagnoses have been submitted on the encounter data and which ones are eligible for risk adjustment. Distribution of the MAO-004 reports will start on or after December 23, 2015 and contain data for January 2014, then another report containing February 2014 will be sent and so on. CMS will send these monthly reports as often as twice a day, until we they have provided all reports for 2014 and 2015 submission months. Going forward reports will be sent monthly on or around the 22nd of the month.   

Action: Applicable to PACE plans.  


Release of Network Management Module in the Health Plan Management System (HPMS)– Dated 12/23/15

Summary: CMS has implemented a new Network Management Module (NMM) into HPMS. The functionality of this new module is to allow both CMS and organizations to evaluate the health service delivery provider and facility networks separately from the annual application process. 

Action: Informational for PACE plans. Please refer to memo on how to access the new NMM network. 


Final 2017 Application Cycle Past Performance Review Methodology– Dated 12/24/15

Summary: CMS conducts a yearly comprehensive review of the past performance of MAO, PDP Sponsors and Cost Plans. The methodology is what CMS uses to evaluate the performance of all Medicare Contractors; these evaluations also identify organizations with performance so impaired that CMS would prohibit the organization from expanding its Medicare operations. 

Action: Informational to PACE plans.  


Posting of Historical Plan Benefit Data on – Dated 12/24/15

Summary: CMS announced the release of the historical Plan Benefit Package data on the CMS public website. This posting includes approved PBP data from CY 2001 through 2013.  

Action: Informational to PACE plans. The files are available for downloading at the URL listed in the memo. 


Classification of Audit Conditions: ICARS, CARS and Observations Additional Guidance-Compliance Program Training Requirements and Audit Process Update – Dated 12/28/15

Summary: CMS suspended the requirement for plans on adopting the CMS’ compliance training module into their organization’s compliance training program.  In addition, CMS released guidance on the flexibility in implementing this new requirement. 

Action: Applicable to PACE.  Refer to the memo for additional information on how to meet the compliance program training requirements. 


Revised Reopening Request Process and Notification of Overpayment Related to PDE and DIR – Dated 12/29/15

Summary: CMS revised the processes for reporting and returning overpayments involving PDE data and DIR data.  Starting January 1, 2016, Part D sponsors will no longer report sponsor-identified overpayments to the MAPD Helpdesk and should be reported through the reopening request process as described.   

Action: Applicable to PACE.  Refer to memo for additional information on reporting PDE/DIR overpayments and reopening requests.


Extension of Special Needs Plans through December 31, 2018– Dated 12/29/15

Summary: In accordance with section 206 of title II of the Medicare Access and CHIP Reauthorization Act, effective April 1, 2015, the legislative authority to offer all specialized Medicare Advantage plans for special needs individuals, or special needs plans, will be extended through December 31, 2018

Action: Informational to PACE plans. 


Coverage Gap Discount Program: January Participating Labeler Code Update – Dated 12/29/15

Summary: CMS will update the manufacturer labeler codes for the Coverage Gap Discount Program by January 1, 2015. The updates include:


  • 17350 Sucampo Pharma Americas, Inc
  • 65197 WellSpring Pharmaceutical Corp


  • 00642 Exeltis USA, Inc.
  • 24492 PARI Respiratory Equipment
  • 28640 GREER
  • 42543 Vensun Pharmaceuticals, Inc.
  • 58487 New Haven Pharmaceuticals, Inc.
  • 59467 Hikma Americas, Inc.
  • 59617 Stallergenes
  • 61364 BioCryst Pharmaceuticals, Inc.
  • 63090 Acadia Pharmaceuticals Inc.
  • 65293 The Medicines Company
  • 68974 Retrophin, Inc.
  • 68992 Veloxis Pharmaceuticals, Inc.
  • 69616 Catalyst Pharmaceutical Partners, Inc.
  • 69916 Tribute Pharmaceuticals US, Inc.
  • 69973 Halton Laboratories

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 has made the necessary software adjustments to accommodate for the updated codes.


Technical Guidance on Implementation of the Part D Prescriber Enrollment Requirement– Dated 12/29/15

Summary: CMS is providing technical guidance to Part D sponsors and their PBMs to apply once the Part D Prescriber Enrollment Requirement is enforced beginning June 1, 2016. The guidance CMS has provided acknowledges the preamble to the IFC as well as comments received directing further guidance needed in the technical areas. CMS intends to publish a final rule that addresses the comments received on the May 6, 2015 IFC.    

Action: Applicable to PACE plans. Please refer to the memo to read through the two applicable rules listed in this memo. 


Good Cause Policy Clarifications for Contract Year 2016– Dated 12/30/15

Summary: CMS hosted a Plan User Call on November 18, 2015 in which they discussed and clarified the previously released good cause policy and related operational changes. As of January 1, 2016 responsibility falls to the plans for intake and processing of good cause reinstatements requests for individuals disenrolled effective January 1, 2016, and later, due to nonpayment of plan premiums. CMS will continue to process good cause reinstatement requests from individuals disenrolled by CMS for failure to pay Part D-IRMAA. 

Action: Informational to PACE plans.   


Part D Transition Monitoring Program– Dated 12/30/15

Summary: CMS is providing Part D Sponsors with an overview of the CY 2015 Transition Monitoring Program Analysis (TMPA) results. CMS will be repeating the TMPA for CY 2016 as there were concerns that some Part D sponsors are not fully complying with the transition requirements. PACE organizations are excluded from the CY 2016 Analysis. 

Action: Informational to PACE plans. 


Complaints Tracking Module (CTM) Enhancements, Casework Reminders, Updated Standard Operating Procedures (SOP), and Other Helpful Information– Dated 12/30/15

Summary: CMS released updates to the Standard Operating Procedures (SOP) for the handling of Complaints Tracking Module (CTM) Complaints and reminds all plans that the proper use of the CTM is critical to ensure the accuracy of complaint information. Plans are encouraged to work with CMS to resolve individual complaints and examine root causes that drive compliant volumes in a timely manner. 

Action: Applicable to PACE. PACE organizations are expected to monitor CTM and adhere to the procedures outlined. 


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.