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Appropriate Access and Use of the Part D Eligibility Query – Dated 12/03/15 

Summary: CMS released information on the appropriateness in accessing and using the Medicare Part D Eligibility transaction (E1) by a pharmacy provider.  E1 transactions are used to help a pharmacy provider determine which plan to bill and to support the coordination of benefits when a beneficiary is at the pharmacy and does not have their Medicare Part D ID card, and also to verify a beneficiary’s eligibility for Part D coverage.  E1 transactions cannot be used for the purpose of ruling out Medicare coverage in order to use pharmaceutical manufacturer co-pay assistance coupon programs.   

Action: Informational to PACE plans.  

 

Health Plan Innovation Part D Enhanced Medication Therapy Management Model Webinar– Dated 12/03/15

Summary: The third Health Plan Innovation Part D Enhanced Medication Therapy Management Model learning event is being held on Tuesday, December 15, 2015 at 3:00-4:30 pm EST. The webinar will focus on HIT-Enabled MTM-Related Team Based Care Coordination and is open to all Part D sponsors and other interested Stakeholders.  

Action: Informational to PACE plans. If you are interested in further information in regards to the MTM model test, or are looking to submit a request for application to take part in this testing please refer to the memo for detailed information.

 

Reopening of the 2010 Final Part D Payment Reconciliation– Dated 12/04/15

Summary: CMS completed calculations for the reopening of the 2010 Final Part D Payment Reconciliation. The calculations were in accordance with the associated regulations and guidance within the Social Security Act. The reconciliation calculations utilize all PDE data found on the PDFS response report, on or before 09/30/2015 Cycle 3; all payments made for Part D net of all adjustments processed through December 15 payment; and DIR information received in the HPMS by August 28, 2015.  

Action: Informational to PACE plans. Reconciliation reports for reopening will be available in your reconciliation mailboxes at the CSSC on Monday, December 7, 2015. If the attestation has not been received, the payment adjustment will not occur in January 2016 payment. The payment adjustment will occur after the attestation is received. 

 

Discontinuation of Dual Eligible Special Needs Plans Sub-type Categories-Dated 12/07/15

Summary: As of CY 2017 effective contracts for Medicare Advantage Organizations (MAOs) and Dual Eligible Special Needs Plans (D-SNPs) will no longer be categorized by enrollment eligibility sub-types in the HPMS system. MAO’s offering a D-SNP must document the categories of eligibility for dual eligible beneficiaries to be enrolled under the SNP in their State Medicaid Agency Contract. Information is captured in the SMAC, thus CMS can determine the D-SNP’s categories independent of any MAO action.     

Action: Informational to PACE plans. Information regarding the CY 2017 application and any operational changes that MAO’s should take can be referenced in the HPMS memo. 

 

Implementation of the Cost Contract Plan Transition Requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)– Dated 12/07/15

Summary: CMS released guidance on how a Medicare Advantage plan can meet the minimum enrollment thresholds for the cost plan competition requirements. 

Action: Informational to PACE plans. 

 

Discontinuation of Dual Eligible Special Needs Plans Sub-type Categories– Dated 12/07/15

Summary: Effective CY 2017, Dual Eligible Special Needs Plans will no longer be categorized by enrollment eligibility sub-types in the Health Plan Management System. Therefore, MAO’s offering a D-SNP must document “the categories of eligibility for dual eligible beneficiaries to be enrolled under the SNP” in their State Medicaid Agency Contract. Information is already captured in SMAC hence CMS can determine the D-SNP’s enrollment categories independent of any MAO action. 

Action: Informational to PACE plans. MAO’s should take note of the following operational changes listed in this HPMS memo. Correction was made to this memo in December 9th HPMS memo regarding the correct mailbox URL. 

 

Due Dates for 2015 Part C Reporting Requirements Data– Dated 12/10/15

Summary: Corrections have been made to a recent version of the 2015 Part C Reporting Requirements Technical Specifications posted at Medicare Health Plans Reporting Requirements link. The data due dates were incorrectly listed as February 1, 2016 for three reporting sections- Part C Grievances, Employer Group Sponsors, and Plan Oversight of Agents. The data due dates should be February 29/2016.

Action: Informational to PACE plans. All end-of-year reporting due dates should be February 29, 2016 for 2015 measurement year reporting. This differs from previous years as February 28, 2016 falls on a Sunday and is a leap year. 

 

Long-Term Institutionalized Resident Report– Dated 12/11/15

Summary: On December 11, 2015, the fourth 2015 LTI Resident Report was distributed. Organizations will only receive a LTI report if they have LTI enrollees. The layout of the profile is provided in this memo.  

Action: Informational to PACE plans who receives the LTI Resident Reports 

 

2016 PACE Application Guidance–Dated 12/11/15

Summary: CMS has announced the release of the electronic PACE application for all new organizations under the PACE program. Beginning in 2016, the initial PACE application will be web-based in the HPMS. 

Action: Applicable to PACE plans. A copy of the 2016 initial PACE application is posted on the CMS web page. Please refer to the memo for a direct link. 

 

PACE Level 1 Quality Reporting Module-2016 Module Update– Dated 12/11/15

Summary: CMS is announcing the upcoming February 1, 2016 release of the updated HPMS PACE Quality Reporting Module for the reporting of Level 1 PACE data. The module has had numerous enhancements in data entry, layout, navigation, reminder notification and updated requirements.  

Action: Applicable to PACE plans. Please refer to memo for further information on the enhancements. 

 

Medicare-Medicaid Plan (MMP) Advisory Committee Stipends and Non-Monetary Incentives– Dated 12/14/15

Summary: Supplied in this memo guidance for MMPs regarding the provision of stipends or non-monetary incentives to enrollees serving on MMP Advisory Committees. This will be posted to the “Information and Guidance for Plans” webpage under General Plan Guidance. 

Action: Informational to PACE plans. Please refer to email for direct link to the Information and Guidance for Plans.  

 

Revised CY 2015 Core Reporting Requirements for Medicare-Medicaid Plans– Dated 12/14/15

Summary: Medicare-Medicaid Plans should follow the new release of the revised Calendar Year 2015 Capitated Financial Alignment Model Reporting Requirements for future submissions of 2015 measure data. Summary of the Substantive Changes included Introduction, Part C and D Reporting Sections, as well as MMP-Specific Reporting Section. 

Action: Informational to PACE plans. Please review the changes listed in this memo for further explanation of each item.

 

Good Cause Triage Flow Process and Frequently Asked Questions– Dated 12/16/15

Summary: CMS’ Medicare Enrollment & Appeals Group has posted a Frequently Asked Questions document and a triage process flowchart for good cause requests as a result of recently hosting the November 18th Plan User Call. They have developed these documents for plan use and assistance in implementing the good cause process. 

Action: Informational to PACE plans. Please review the email for direct links to the Good Cause Triage Flow Process and Frequently Asked Questions.

 

Request for Comments Regarding Plan Reimbursement Column on BPT– Dated 12/16/15

Summary: CMS is considering making one of two changes in regards to plans with a high percentage of DE# members and Rebate Allocation under the current MA BPT guidance. It seems these plans have an unintended advantage as in they are able to change cost sharing amounts with no affect on the DE# members since these members do not pay cost share. Please review both proposals in the memo and supply your feedback to CMS. 

Action: Informational to PACE plans.

 

Release of Annual Reports and Public Use File of 2013 Part C and D Plan-Reported Data– Dated 12/17/15

Summary: CMS has posted a Public User File (PUF) and PUF Technical Specifications of 2013 Part C and D Plan-Reported Data on the CMS.gov Part C and Part D Data Validation page. Data reported by MA Prescription Drug Plans and Prescription Drug Plans relate to various matters including the cost of operations, patterns of service utilization, availability and accessibility of services. The annual reports analyze the data submitted by sponsors in accordance with Part C and D Reporting Requirements for CY 2013. 

Action: Informational to PACE plans. Please refer to memo for direct links to the annual reports.

 

Payment Year 2013 Overpayment Recovery– Dated 12/17/15

Summary: The deadline to submit all PY 2013 (2012 dates of service) deletions to the Risk Adjustment Processing System is Friday, January 8, 2016. The sweep will occur as of January 8, and all deletions received by the deadline will be included in the risk score rerun and subsequent overpayment recovery. MAO’s are required to report and return overpayments. MAO’s should obtain an overpayment remedy ticket number by calling the MAPD Help Desk at 1-800-927-8069 or email mapdhelp@cms.hhs.gov at least 24 hours prior to the submission deadline. 

Action: Informational to PACE plans. Please refer to the HPMS memo released on February 18, 2015, “Guidance for Reporting and Returning Medicare Advantage   Organization and Sponsor Identified Overpayments to CMS”, for further information.

 

As a reminder we will be closed on Christmas Day and New Year’s Day, but the Help Desk will be available as usual at 888-298-7770 to assist you.
 
Happy Holidays and be safe in your travels!

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.