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

Contract Year (CY) 2017 Plan Benefit Package (PBP) Software Patch – Dated 4/22/2016

Summary: The CY 2017 Plan Benefit Package (PBP) software has been updated to reflect the recent changes to the bid submission process requirements for Medicare Advantage (MA) Employer/Union-Only Group Waiver Plans (EGWPs). The download and installation of the PBP software is mandatory for all MA organizations that offer one or more EGWPs.

Action: Informational to PACE plans as the memo applies to EGWP.


Release of the 2017 Service Area Verification Functionality –Dated 4/22/2016

Summary: The HPMS CY 2017 Service Area Verification functionality is now available in the Bid Submission module for all organizations to begin reviewing their entire contract service area and applicable attributes for accuracy and completeness.  Organizations must concur or non-concur with their contract service area by June 6, 2016 bid submission deadline. Bid submissions will not be sent forward to the desk review process until an organization completes this upload requirement.

Action: Applicable to PACE plans.  Refer to memo for additional details.


Medicare Advantage/Prescription Drug System (MARx) May 2016 Payment – INFORMATION –Dated 4/26/2016

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

  • Beneficiaries Enrolled but not Entitled
  • Late Enrollment Penalty (LEP) Cleanup
  • Enrollment Certification Dates on the Marx Operating Calendar

Action: Informational to PACE.


Correction: Deadline for Submitting Risk Adjustment Data for Use in Risk Score Calculation Runs for Payment Years 2016, 2017, and 2018 –Dated 4/27/2016

Summary: CMS updated the schedule of payment years for risk adjustment data runs.

Action: Informational to PACE. Refer to the memo for the updated schedule.


Proposed Medicare Part D DIR Reporting Requirements for 2015 –Dated 4/27/2016

Summary: CMS is seeking feedback on the proposed changes to the reporting of DIR data for CY 2015.  All feedback and comments will be accepted until May 16, 2016.  The final CY 2015 DIR reporting requirements will be posted prior to June 1, 2016.

Action: Applicable to PACE.  Refer to the memo for additional information.  


Information related to Contract Year 2017 Applicants and the Data Sources that CMS uses for Supply Mapping –Dated 4/28/2016

Summary: CMS is providing all Medicare Advantage Organizations the public data sources that CMS uses in the review of HSD Exception Requests.  The public data sources listed are attached.

Action: Informational to PACE as PACE plans are not required to comply with the CMS network adequacy standards. 


PFFS Plan Network Area Locations for 2018 –Dated 4/28/2016

Summary: CMS has updated the Private Fee-for-Service (PFFS) plan network areas for CY 2018.  For a list of the 2018 network areas, refer to the link provided.

Action: Informational to PACE.


CMS Clarification Regarding Options for Medicare Advantage Organizations Related to Network Deficiencies for the CY 2017 Part C Application –Dated 4/28/2016

Summary: CMS will not approve initial or service area expansion applications if network deficiencies are found in any counties, including counties in which the applicant is currently operational.  Applicants who had application deficiencies were notified in the notice of intent to deny sent on April 18, 2016.  

Action: Informational to PACE.


Update to Chapter 4 of the Medicare Managed Care Manual –Dated 4/28/2016

Summary: CMS released an updated version of Chapter 4 of the Medicare Managed Care Manual. A summary of the major changes is listed in the memo and the Chapter 4 manual is attached to the memo.

Action: Informational to PACE. 


Final Medicare-Medicaid Capitated Financial Alignment Model Quality Withhold Technical Notes for Demonstration Years 2 and 3 –Dated 4/29/2016

Summary: CMS released the final Medicare-Medicaid Capitated Financial Alignment Model Quality Withhold Technical Notes for Demonstration Years 2 and 3.  

Action: Informational to PACE as the memo does not apply to PACE plans.


Preparation for 2017 Star Ratings Quality Assurance Reviews on Part D Coverage Determinations and Redeterminations –Dated 4/29/2016

Summary: CMS released an overview of the responsibilities of Part D sponsors that are selected for the 2017 star ratings quality assurance review and the new process for submitting the required documentation.

Action: Informational to PACE as PACE plans are excluded from the memo.


Part D Formulary Frequently Asked Questions –Dated 4/29/2016

Summary: CMS released frequently asked questions on the Part D formulary requirements to provide clarity and transparency to the Part D formulary processes raised by plan sponsors and other stakeholders.  

Action: Informational to PACE plans who utilizes a formulary.  


Coverage Gap Discount Program Benefit Year Closeout Invoice Reports –Dated 5/2/2016

Summary: CMS announce the upcoming release of a set of new reports, the Benefit Year Closeout Invoice Reports for manufacturers and Part D sponsors on July 15, 2016.  The reports will be released annually though the Third Party Administrator approximately fifteen months after benefit year’s Quarter 17 invoice receipts date.  The reports will communicate the status of all upheld disputes for the close benefit year as to whether or not the disputed PDE record has been resolved and if it resulted in financial or non-financial change to the invoice data.  

Action: Informational to PACE as the Coverage Gap Discount Program does not apply to PACE plans.


MMP Coverage Options for 2018 –Dated 5/3/2016

Summary: CMS is issuing guidance for states and plans participating in the capitated financial alignment model demonstrations to establish parameters for two scenarios that may arise beginning with the 2018 contract year.  Detailed for both scenarios are provided in the memo.

Action: Informational to PACE.  


Registration Update for CMS’ 2016 Medicare Advantage & Prescription Drug Plan Spring Conference & Webcast (May 5, 2016) –Dated 5/3/2016

Summary: CMS announced that registration will remain open for participants interested in participating virtually.  CMS encourage individuals interested to register early as virtual seating is limited. 

Action: Informational to PACE.  Refer to memo for instructions on how to register and for complete details on the conference.


Coverage Gap Discount Program: May Participating Labeler Code Update –Dated 5/3/2016

Summary: CMS will update the manufacturer labeler codes for the Coverage Gap Discount Program May 1, 2016.  The updates include:


  • 24510 Collegium Pharmaceuticals
  • 69516 Intercept Pharmaceuticals, Inc.
  • 69918 Amring Pharmaceuticals Inc.
  • 70165 Neos Therapeutics, LP

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.


Release of Encounter Data Report Cards – INFORMATION –Dated 5/5/2016

Summary: CMS announced the availability of contract-specific Encounter Data report cards.  Each report card will represent information on the encounter data submitted by your organization for selected services that was provided to your enrollees in calendar years 2013 to 2015.  The report cards are to be informative summaries that will assist your organization in evaluating your encounter data submissions.

Action: Applicable to PACE.  Refer to memo for further details and how to access the report cards.


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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.