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

 

Additional Guidance and New Model Notice for Favorable Good Cause Determinations for Disenrollment Due to Nonpayment of Plan Premiums –Dated 5/20/2016

Summary: CMS released additional guidance and a new model notice to convey the plan sponsor’s favorable good cause determination when the individual has already paid the amount required for reinstatement.  The new model and revised guidance will also be updated into the MA, PDP, and cost plan enrollment guidance materials at the links provided in the memo.

Action: Applicable to PACE plans.  Refer to the memo for further details.

 

Out-of-Pocket Cost Model (OOPC) for CY 2017 Bid Submissions –Dated 5/20/2016

Summary: CMS is releasing an updated version of the CY 2017 OOPC model as a number of generic drug products were absent from the drug list file.  Plan sponsors must utilize the CY 2017 OOPC Plan model Version 2 to calculate OOPC values for each plan prior to bid submission.

Action: Informational to PACE as PACE plans are waived of the out-of-pocket provisions.

 

Corrected Total Beneficiary Cost (TBC) Data for CY 2017 Bid Preparation –Dated 5/23/2016

Summary: CMS advise Medicare Advantage Organizations that offer Medicare Advantage-Only plans or plans that do not include a Part D benefit, that there have been corrections to the “technical adjustment for the impact of changes in the OOPC model between CY 2016 and CY 2017”.  

Action: Informational to PACE as PACE plans are waived of the out-of-pocket provisions.

 

Draft 2017 Part C and Part D Reporting Requirements 60-day Comment Period –Dated 5/23/2016

Summary: CMS announced an opportunity for plans and other stakeholders to comment on the proposed 2017 Medicare Part C and Part D Reporting Requirements.  Comments on the Medicare Part C Reporting Requirements must be received by July 11, 2016.  Comments on the Medicare Part D Reporting Requirements must be received by July 5, 2016.

Action: Informational to PACE plans as PACE is waived of the Part C and Part D reporting requirements.

 

Reminder of CY 2017 Plan Benefit Package and Additional Demonstration Drug (ADD) File Submission Deadlines for Medicare-Medicaid Plans (MMPs) –Dated 5/23/2016

Summary: CMS announced that all plan benefit package (PBP) submissions for CY 2017 are due no later than June 6, 2016 at 11:59 p.m. PT.  In addition, any organization not submitting a PBP by the required deadline will be non-renewed for CY 2017 absent documented technical issues with submission.

Action: Informational to PACE plans.

 

June 2016 Medicare Parts C & D Fraud, Waste and Abuse Training Webinar –Dated 5/23/2016

Summary: Registration is now open for the June 2016 Medicare Parts C & D Fraud, Waste and Abuse Training webinar.  It will be held on June 29, 2016 from 12:30 p.m. to 4:00 p.m. ET.  The following topics will be addressed:

  • CMS policy and initiatives
  • FWA trends and successes
  • Resources for fighting Medicare Advantage and Prescription Drug fraud

All plans are encouraged to take advantage of this training opportunity.

Action: Informational to PACE plans.  For individuals who would like to participate, refer to the memo on how to register.

 

REMINDER: Payment Year 2015 Risk Adjustment Attestation –Dated 5/23/2016

Summary: CMS released a reminder to all plans that the deadline for submitting the required risk adjustment attestations for payment year 2015 is June 10, 2016 by 11:59 p.m. ET.  All plans are required to submit an “Attestation of Risk Adjustment Data” to certify that information provided for the purposes of risk adjustment are accurate, complete, and truthful, and acknowledge that the information will be used for the purposes of obtaining federal reimbursement. 

Action: Applicable to PACE plans.  Refer to the memo for further details.

 

Continued Monitoring of Medicare-Medicaid Plan Provider and Pharmacy Directories Auto forwarded by a Rule- Dated 5/26/2016

Summary: CMS provided a letter to every currently operational MMP in early May 2016. Each letter summarized MMP-specific results of the review of CY 2016 Provider and Pharmacy Directories and indicated an MMP meeting less than 100% of the requirements might be reassessed starting 60 days from the date of the letter.  

Action: Informational to PACE plans.  Refer to the memo for further details.

 

Closing the Drug Data Processing System (“DDPS”) for benefit year 2009 –Dated 5/26/2016

Summary: CMS will close the DDPS for PDE data with dates of service for benefit year 2009.  This will take effect on July 1, 2016.  Submitted PDE data with dates of services prior to January 1, 2010 will receive reject edit code 788 “DDPS no longer accepts PDEs with dates of service before 1/1/2010”.  

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

 

Bid Pricing Tool (BPT) for Contract Year (CY) 2017 Update –Dated 5/27/2016

Summary: A new version of the BPT add-in file has been released to correct an error that may occur in the bid upload/BUNT process.  The new add-in file will not change any values in your finalized BPTs and is only correcting an error in the bid upload/BUNT process.

Action: Informational to PACE plans.  Refer to email for further details.

 

Nondiscrimination Health Programs and Activities –Dated 5/27/2016

Summary: The Department of Health and Human Services issued a Final Rule, Nondiscrimination in Health Programs and Activities to implement the prohibition of discrimination under Section 1557 of the Affordable Care Act of 2010.  CMS released this notice to make organizations aware of the rule which is effective on July 18, 2016.  

Action: Informational to PACE plans.  Refer to email for further details.

 

2016 Part D Reporting Requirements and Technical Specifications –Dated 5/27/2016

Summary: CMS released the CY 2016 Part D Reporting Requirements and Technical Specifications.  Effective May 2016, CMS extended the reporting due date from the 1st Monday of February to the last Monday in February 2017.  The documents are available and posted on the HPMS website.  The link is provided in the memo.

Action: Not applicable to PACE as PACE is waived of the Part D requirements.

 

Contract Year 2017 Agent and Broker Compensation Rate Adjustments, Submissions, and Agent and Broker Training and Testing Requirements –Dated 5/27/2016

Summary: CMS released updated agent and broker compensation limits for Contract Year 2017 and information regarding submitting compensation amounts to CMS through HPMS.  

Action: Informational to PACE as PACE plans are not authorized to utilized Agents and Brokers.

 

CY2017 Initial Actuarial Certification Deadline –Dated 5/31/2016

Summary: As part of the CY 2017 bid submission requirements, an actuarial certification must be submitted via the HPMS actuarial certification module for every Bid Pricing Tool uploaded to HPMS.  The module is now available and all initial certifications are to be completed by June 10, 2016.  If a certification is not submitted via HPMS, the bid(s) will not be considered for CMS review or approval.

Action: Informational to PACE as this is not applicable to PACE plans.

 

Release of Medical Loss Ratio (MLR) Reporting Tool for Contract Year 2015 –Dated 5/31/2016

Summary: CMS reminds plans of the requirement to submit an MLR report to CMS for each contract year pursuant to the regulations noted in the memo.  The memo announces the release of the MLR reporting tool and instructions for Contract Year 2015.

Action: Informational to PACE as this is not applicable to PACE plans.

 

Final 2015 DIR Reporting Requirements for 2015 –Dated 5/31/2016

Summary: On April 27, 2016, CMS released draft guidance regarding Medicare Part D direct and indirect remuneration (DIR) reporting requirements for Summary and Detailed DIR Reports for Contract Year 2015.  Comments on the draft guidance were accepted until May 16, 2016.  This memo provides an overview of the comments and responses as well as the Final Medicare Part D DIR Reporting Requirements for 2015.  The deadline for submissions is 11:59 PM PT on June 30, 2016.  Resubmissions for summary DIR reports for prior years eligible for resubmission will begin on July 1, 2016 and end at 11:59 PM PT on July 31. 2016.

Action: Applicable to PACE plans.  Refer to the memo for complete details on the DIR requirements.  Pharmastar will receive the initial DIR reporting in the coming weeks and will format per CMS requirements before sending them on to the plan sponsors.  Your Client Support Specialist (CSS) will communicate with previous years’ DIR contact(s) when the reports are available.  Please notify your CSS of any applicable changes. 

 

Incorrect Plan Benefit Package (PBP) Prescription Drug Validation –Dated 5/31/2016

Summary: CMS reports that a validation within the Contract Year 2017 PBP software is incorrectly validating against the CY 2016 Initial Coverage Limit (ICL) amount.  Plans should disregard the warning message and continue with the validation process and uploading of the bid with the ICL amount of $3,700.  

Action: Informational to PACE plans.

 

Important Bid Submission Reminders –Dated 6/1/2016

Summary: CMS released information to make organizations aware of the most recent information on bid submission as CMS received several questions about it. 

Action: Informational to PACE plans. Refer to email for items applicable to your plan.

 

Agent/Broker Compensation Submission –Dated 6/1/2016

Summary: CMS is notifying organizations that the agent/broker compensation submission/attestation module in HPMS is displaying an error message when organizations try to enter the specific amounts noted.  CMS is currently working to correct the error and if organizations submit other amounts, the error message will not display and should be able to submit and attest accordingly.

Action: Informational to PACE as PACE plans are not authorized to utilized Agents and Brokers.

 

Medicare Advantage/Prescription Drug System (MARx) June 2016 Payment –INFORMATION –Dated 6/1/2016

Summary: CMS released information about the June payment and other payment related items that may require plan action:

  • Coverage Gap Discount (CGD) Reconciliation Reopening for 2014
  • CGD Invoice Offsets for 2015 and 2016
  • Premium Withhold Cleanup

Contacts for Payment and Premium Issues

Action: Informational to PACE plans. Refer to memo for items applicable to your plan.

 

Advance Announcement of the August 2016 Software Release –Dated 6/1/2016

Summary: The following areas of the enrollment and payment systems support Part D programs are scheduled for system changes in August 2016:

  • Report Changes- Plan Payment and Monthly Membership Summary Reports
  • Center for Medicare and Medicaid Innovation Division of Health Plan Innovation Models
  • New Enrollment Source Code for Rollover

Elimination of Overpayment Edits

Action: Informational to PACE plans.  Refer to memo for items applicable to your plan.

 

Long-Term Institutionalized Resident Report –Dated 6/1/2016

Summary: The memo announced the distribution of the second 2016 Long-Term Institutionalized (LTI) Resident Report to plans who have LTI enrollees.

Action: Informational to PACE plans with LTI enrollees.  Refer to the memo for details on how to retrieve the report and other general report details.

 

In-person Registration Closing for CMS’ 2016 Medicare Advantage and Prescription Drug Plan Audit & Enforcement Conference & Webcast (June 16, 2016) –Dated 6/2/2016

Summary: CMS is reminding individuals who are interested in joining the conference in-person to register by 6pm EDT on June 3rd.  

Action: Informational to PACE plans.  For individuals who would like to participate, refer to the memo on how to register.

 

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.