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Retail Pharmacy Network Access and Preferred Cost-Sharing Pharmacy Network Access Analysis Results– Dated 11/19/15

Summary: Part D sponsors can now access the data from CMS’s Spring 2015 retail pharmacy access analysis in HPMS. CMS used Medicare Plan Finder data submitted April 27-28, 2015 and analyzed plans’ entire networks and preferred cost sharing pharmacy networks. Please review the results from your plan to familiarize yourself with the report layout, data fields and your plans’ results. 

Action: Informational to PACE plans. PACE programs are not required to submit the data necessary for this analysis.

 

2016 Risk Score Reruns For Purposes of Payment Recovery– Dated 11/19/15

Summary: CMS intends to rerun risk scores for payment years and dates of service listed in this memo. This is in regards to the overpayment regulations that MA Organizations are required to report and return per the Affordable Care Act. MA Organizations will be notified at least 30 days in advance of the deadline for submitting deletes for each data run. Organizations should also look to the monthly payment letters to determine when adjustments will be applied to payments.

Action: Applicable to PACE plans. For questions relating to the Risk Score Reruns please email riskadjustment@cms.hhs.gov and specify “HPMS memo-2016 Risk Score Reruns For Purpose of Payment Recovery” in the subject line. 

 

Agent/Broker Compensation– Dated 11/20/15

Summary: This memo is to clarify guidance that was sent out to Medicare Advantage Organizations, 1876 Cost Plans, and Prescription Drug Plan Sponsors on October 30, 2015, titled Agent/Broker Compensation. Organizations are expected to correct their compensation processes to conform to guidance as soon as possible and by January 1, 2016. 

Action: Informational to PACE programs as PACE is not authorized to utilize agents and/or brokers for enrollment purposes. 

 

Retail Pharmacy Network Access and Preferred Cost-Sharing Pharmacy Network Access Analysis Results–Duplicate Memo-Dated 11/20/15

Summary: Part D sponsors can now access the data from CMS’s Spring 2015 retail pharmacy access analysis in HPMS. CMS used Medicare Plan Finder data submitted April 27-28, 2015 and analyzed plans’ entire networks and preferred cost sharing pharmacy networks. Please review the results from your plan to familiarize yourself with the report layout, data fields and your plans’ results.   

Action: Informational to PACE plans. PACE programs are not required to submit the data necessary for this analysis.  

 

Revised 2016 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, and Cost Plans – Dated 11/20/15

Summary: CMS is reminding organizations of critical Medicare Part C and D requirements for the AEP and Coverage beginning January 1, 2016. The CY 2016 Readiness Checklist summarizes key operational requirements as established in statutes, regulations, manual chapters, Health Plan Management System memos, applications, and other advisory materials. Your organization should review this checklist carefully and take the necessary measures to fulfill these key requirements for CY 2016.

Action: Informational to PACE plans. The Readiness Checklist is broad in relation to PACE. NPA recommends PACE plans utilize the Part D provider application. Pharmastar will review the readiness checklist and Part D provider application to send the plans a list of the sections we will take responsibility for. If you have any questions, please contact your Client Support Specialist.

 

Coverage Gap Discount Program: December Participating Labeler Code Update– Dated 11/24/15

Summary: CMS will update the list of participating manufacturer labeler codes for the Coverage Gap Discount Program by December 1, 2015. The update includes the following changes:

  • 42702 Paragon BioTeck, Inc.
  • 49808 Metacon Labs
  • 58604 Sprout Pharmaceuticals, Inc.

Updates will be posted to the CMS website in Bold Red. 

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.

 

2016 Resource and Cost-Sharing Limits for Low-Income Subsidy – Dated 11/24/15

Summary: CMS is releasing guidance on the updated resource limits for individuals who apply and qualify for the LIS and announcing the maximum co-payments that LIS eligible beneficiaries, including full-benefit dual eligible and partial dual eligible individuals, will pay as enrollees of Medicare prescription drug plans in 2016. CMS is required to update the Part D resource limits, income standards, and cost-sharing amounts for the low-income subsidies each year. 

Action: Informational to PACE plans. CMS will release the 2016 income standards for the low-income subsidies in early 2016 after the 2016 Federal poverty lines are released. 

 

Medicare Advantage/Prescription Drug System December 2015 Payment-INFORMATION– Dated 11/24/15

Summary: December 1, 2015 is the scheduled receipt for December payment for Risk Adjustment Overpayment Re-Runs for 2009 through 2014. The FY 2016 user fee collections resume in the January-September 2016 payments. The MARx Operating Calendar for 2016 has been completed and is attached to the memo; please note that some of the “Plan Data Due” dates occur early in the month. 

Action: Applicable to PACE plans. For further information on payment related items that may require plan action please review the memo.

 

Informational Call on the Potential Options for addressing the Impact of Socio-economic and Disability Status on Star Ratings–Dated 11/25/15

Summary: CMS will hold a call on Thursday December 3, 2015 from 2:30to 3:30 ET with the industry to review examples of the two potential options proposed to address the impact of socio-economic a disability status on Star Ratings. Slides will be available on CMS website on the afternoon of December 2, 2015. 

Action: Informational to PACE plans. For further information please read through the memo. 

 

Quality Assurance Checks for 2016 Data Submitted for Posting on the Medicare Plan Finder Tool-Updates– Dated 11/25/15

Summary: CMS released a memo to Part D sponsors on May 27, 2015, that provided the CY 2016 guidance and schedule for the submission of pricing and pharmacy data for posting on the Medicare Plan Finder. Part D Sponsors are expected to perform their own QA checks before submitting the files to CMS to ensure that these files are complete and accurate. An updated CMS memo went out on June 19, 2015 on quality Assurance Checks for 2016.

Action: Informational to PACE plans. For information on the three new targeted QA Checks for CY 2016 please refer to the memo. 

 

Close-Out Letter for Organizations and Sponsors that are Non-Renewing a Contract Effective– Dated 11/30/15

Summary: Information has been supplied in this memo for post-contract non-renewal requirements for all organizations and sponsors with MA, MA-PD, PDP, Employer/Union-Only Group Waiver Plans and Section 1876 and 1833 Cost-Based Plan contracts that are non-renewing effective January 1, 2016. The close out letter provided in the memo is broken into two subject areas: 1) Payment and 2) Additional Part C and D requirements. Please follow instructions for you organization type. 

Action: Informational to PACE plans. A separate memo will be issued containing close-out instructions for non-renewing Medicare Medicaid Plans. 

 

Classification of Audit Conditions: ICARs, CARs and Observations– Dated 11/30/15

Summary: In May of 2013, CMS released a memo detailing final audit scoring methodology for audits. Audit condition is classified in one of three ways:

  1. Immediate Corrective Action Required (ICAR)
  2. Corrective Action Required (CAR); or
  3. Observation

Also provided were descriptions of what constituted each of these   classifications. Per feedback from audited sponsors and their concern indicating the difficulty in not being able to predict how audit conditions will ultimately be classified has triggered CMS to further clarify their definition of the three categories. In addition, a new category has been added called Invalid Data Submission (IDS) and is explained in detail in the memo. 

Action: Informational to PACE plans. Please refer to memo for an up to date explanation on each category. 

 

Early Preview-CY 2017 Medicare Advantage Rate book Growth Rates– Dated 12/01/15

Summary: On November 16, 2015, CMS published in the Federal Register the CY 2016 Part A and Part B premiums. Supporting the premium determinations are the underlying estimates of the Unites States Per Capita Cost (USPCC) for beneficiaries entitled to Part A and/or enrolled in Part B. Estimates for CY 2017 rate book growth rates for non-ESRD is projected to be 2.56 percent for total USPCC and 3.10 percent for fee-for-service USPCC. 

Action: Not applicable to PACE plans. All estimates are preliminary and could change. Please review the memo for more in depth information and charts. 

 

Announcement of the February 2016 Software Release– Dated 12/01/15

Summary: CMS continues to implement software improvements to the enrollment and payment systems that support MA and MAPD programs. The information provided in this memo details the system changes scheduled for February 2016 and focuses on the efficiency of CMS systems as well as plan processing.  

Action: Applicable to PACE plans. Please review the list of changes to different systems in this memo as some of them may require action from your Plan. 

 

**********Memo Alert**********

Updates regarding Automated TrOOP Balance Transfer and Plan-to-Plan Reconciliation– Dated 11/25/15-Applicable to PACE plans and should be reviewed to determine if your plan needs to take action.

CMS released updates on the automated TrOOP balance transfer and Plan to Plan reconciliation.  

The update to the automated TrOOP balance transfer request plans to reach out to the Part D facilitator (Relay Health) to create a proxy enrollment when there is a beneficiary who your plan thought was enrolled in your plan but was actually disenrolled before the end of a coverage year.  The Part D facilitator will then include the new plan as a “non-plan of record” as CMS does not show the beneficiary’s enrollment in that plan for the months your plan paid Part D claims for the beneficiary.  By creating a proxy enrollment, the Part D facilitator will include the non-plan of record in the FIR transaction for the month(s) your plan paid Part D claims.  This will allow the new plan to have the correct TrOOP data to position the beneficiary in their TrOOP benefit phase. The responsibility for making the creation of proxy enrollment request will be with the prior plan.   

The update to the Plan to Plan Reconciliation allows your plan to confirm that an enrolled beneficiary had a previous Part D plan that paid claims for the beneficiary when they were later retroactively terminated or cancelled by CMS due to a retro enrollment into the your plan for that time the paid claims occurred.  The Part D plan may seek recoupment for payments on the paid claims for when the beneficiary retro enrolled into your plan.  Plans can confirm an enrollment existed with the Part D plan for the beneficiary that was later retroactively terminated or cancelled by CMS by contacting MAPD Help Desk to prevent any delays in payment reconciliation.

 
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.