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Submission of 2015 Beneficiary-Level Medication Therapy Management Program Data– Dated 01/13/16

Summary: Part D Sponsors with an approved Medication Therapy Management (MTM) program are required to submit beneficiary-level MTM program data for Contract Year 2015 by February 29, 2016. Information on the submission process is provided.

Action: For PACE plans with MTM programs; refer to the memo for complete details. 


Exception Requests and Partial Counties Policy Clarifications– Dated 01/15/16

Summary: CMS released clarification on Medicare Advantage policy regarding requests for exceptions to the Health Services Delivery criteria and requests for approval of partial counties. 

Action: Informational to PACE plans. 


Health Plan Management System Customer Satisfaction Survey for External HPMS Users– Dated 01/11/16

Summary: CMS released the annual HPMS customer satisfaction survey. All HPMS users are invited to participate. Participation is strongly encouraged, as the comments and suggestions will ensure that HPMS improvements align with customer priorities. 

Action: Applicable to PACE plans. Refer to memo for additional information on how to participate.


HEDIS 2016 Patient-Level Data Submission Information– Dated 01/19/16

Summary: Plans that are required to report HEDIS 2016 summary-level data for the 2015 measurement year (MY) must also provide the patient-level data used to calculate the summary-level scores for each contract. Updated CMS documents are available on the CMS website for the creation of the MY 2015 patient level data files. 

Action: Not applicable to PACE plans. For further details on HEDIS please refer to memo. 


CY 2016 Formulary Information– Dated 01/19/16

Summary: CMS released the process for submitting formulary updates for the 2016 contract year. Sponsors are reminded that the earliest effective date to implement approved negative formulary changes is March 1, 2016. Negative formulary change requests were able to be submitted via HPMS NCR beginning December 31, 2015. Only approved negative changes may be implemented. 

Action: Applicable to PACE plans that maintain a formulary. For further information on the formulary update process please refer to the memo. 


Medicare Prescription Drug Benefit Manual- Chapter 6– Dated 01/19/16

Summary: CMS released a revised Chapter 6- Part D Drugs and Formulary Requirements of the Medicare Prescription Drug Benefit Manual. The following sections have significant updates and/or reorganization:

  • Section 30.2.2- Formulary Benefit Management Tools
  • Section 30.4-Transition

Action: Informational to PACE plans. Please review the email for further information on items CMS removed instead of revised.  


Addendum to the 2015/2016 Program Audit Protocols– Dated 01/19/16

Summary: CMS released the 2015/2016 Program Audit Protocols back in October. Since the release of the protocols, many questions have been asked requesting clarification. Based on feedback from the industry, an addendum was created to the protocols offering clarification to the fields that were causing confusion. Please use this addendum in conjunction with CY 2016 audit protocols. 

Action: Informational to PACE plans. Refer to the memo for additional information on the protocols. 


Part D Point of Sale Pilot: Invitation to Attend Conference Call-Reminder and Materials Added– Dated 01/20/16

Summary: CMS held a conference call on Thursday, January 21 from 1:00-2:30pm ET, where organizations that participated in the Point of Sale Pilot could share the information about their experience with Part D plans, PBMs, and other program stakeholders. Presentations included how the outreach process was developed and identified target drugs as well as challenges, successes and lessons learned during the Pilot. 

Action: Informational to PACE plans. Please review the PDF provided in the email for further detail. 


Advance Announcement of the May 2016 Software Release – Dated 01/21/16

Summary: CMS announced a planned release of systems changes scheduled for May 2016 which may require plan action. The change is regarding the Medicare Advantage and Prescription Drug System (MARx) Reset Changes. CMS intends to provide further details on the implementation in February.

Action: Applicable to PACE plan; refer to memo for complete details.


Contract Year 2017 Plan Benefit Package Testing– Dated 01/22/16

Summary: CMS used the comments and feedback from the July 2015 PBP lessons to implement changes to the PBP software for CY 2017. Beta testing is being conducted to ensure all aspects of the CY 2017 PBP software works as designed. A request for assistance in the final testing of the CY 2017 PBP will take place on Monday, January 25, 2016 through Friday, February 5, 2016.      

Action: Applicable to PACE plans. If you are interested in participating in the testing please refer to the memo for directions on items you will need and the testing website. 


Part C Risk Scores Calculated with the Revised CMS-HCC Model –Dated 01/22/16

Summary: CMS received a number of comments and requests to provide additional information for the revised CMS-HCC model. In response to the requests, CMS posted contract-PBP level risk score data in HPMS. In addition, CMS published the relative factors for the revised CMS HCC model on the risk adjustment webpage. 

Action: Informational to PACE. 


Review and Approval of Provider Specific Plans for Contract Year 2017– Dated 01/25/16

Summary: CMS released guidance on the process for evaluating provider specific plans’ networks beginning in contract year (CY) 2017.

Action: Informational to PACE plans. 


Risk Adjustment Processing System (RAPS) Diagnosis Cluster Edit 410 Error Code– Dated 01/27/16

Summary: On January 1, 2016, CMS implemented a change to the diagnosis cluster 410 error code edit in RAPS. This revision prevents plans from submitting diagnoses for beneficiaries who are not members of the plan on the date of service linked to the diagnoses. Previously the 410 error code only prevented plans from submitting diagnoses for beneficiaries who were not members of any plan on the date of service linked to the diagnoses. CMS has analyzed the impact of the revision on plan submission of RAPS clusters for 2014 DOS and has decided to suspend implementation of this change. 

Action: Applicable to PACE plans. CMS will revert back to the previous version of the 410 error code edit on or around February 8, 2016. For further definition and explanation into this please refer to the memo.  


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.