Weekly CMS Insights: 10/6/14 – 10/10/14

Contract Year 2014 Part D Formulary Administration Analysis

CMS released a memo providing information about an analysis that will evaluate whether Part D sponsors are appropriately adjudicating Medicare Part D drug claims consistent with Part D requirements and sponsors’ CMS-approved benefits. The memo also describes the methodology that will be used by CMS to complete the monitoring process for this program.

Note: CMS initiated the CY2014 analysis due to their concerns with results from the 2013 formulary administration analysis. Unlike 2013 where only select sponsors had to provide claims, for 2014, CMS broadened the scope of eligible plans. Unless your plan is already identified to undergo a program audit in 2014 or if you participated in BOTH a program audit and Formulary and Benefits Administration validation audit in 2013, expect to receive a request.

Recommended Action: Review the attached memo for details. Information regarding the types of rejected claims (i.e. non-formulary, prior authorization, step therapy, and quantity limits) as well as the date ranges based on plan size are included within the methodology section.

CMS expects a 48-hour turnaround time on providing the data, so request the data NOW from your PBM and begin review of the claims to identify any potential issues. June 2014 data will be used.

For questions regarding data extraction, submission, or the secure website, please contact Acumen at FormularyBenefits@AcumenLLC.com. For questions regarding Formulary Administration Analysis, please contact LeAnn Poole at leann.poole@cms.hhs.gov or Réna McClain at rena.mcclain@cms.hhs.gov.

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Contract Year 2014 Chronic Care Improvement Program and Quality Improvement Project – Training Information

CMS released a memo providing Medicare Advantage Organizations with information on upcoming training for the CY 2014 CCIP and QIP Annual Update submissions and “Plan” section submissions (contracts and SNPs that were new in CY 2014).

  • “Plan” sections and Annual Updates will be submitted through the HPMS Plan Reporting Module from November 17 through November 25, 2014
  • Training specific to the “Plan” section will be conducted by CMS on Tuesday, October 21 from 3:30 – 5:00pm ET, followed by training specific to the Annual Updates on Wednesday, October 22 from 1:30 – 3:00pm ET.

Recommended Action: Review the attached memo. Please direct questions to the Medicare Advantage Quality Mailbox at MAQuality@cms.hhs.gov.

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Advance Announcement of the February 2015 Software Release

CMS released a memo providing advanced information regarding the planned release of systems changes scheduled for February 2015. The focus of this release is on improving efficiency of CMS systems and Plan processing. CMS identified changes in four key areas:

  • Limiting the number of MARx User Interface sessions
  • Payment/adjustment data exports from MARx to Microsoft Excel
  • Transaction Reply Code for cumulative number of uncovered month amounts
  • Changes to transaction reply reporting

Recommended Action: Review the attached memo for details regarding the February 2015 release. Plans should contact the MAPD Help Desk at 1-800-927-8069 or mapdhelp@cms.hhs.gov for any issues encountered during the systems update process or if you have questions.

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Draft Medicare-Medicaid Plan (MMP) Marketing Guidance for Michigan Capitated Financial Alignment Demonstration

CMS is soliciting comment on draft marketing guidance for Michigan MMPs. The guidance includes the marketing policy variances for MMPs in Michigan relative to the CY 2015 Medicare Marketing Guidelines.

Recommended Action: Review the attached document. Please complete the comment chart and submit your comments to MMCOcapsmodel@cms.hhs.gov by 5pm on Wednesday, October 14, 2014. Final marketing guidance for Michigan MMPs will be issued later this year.

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Release of CY 2015 Model Materials for Michigan Medicare-Medicaid Plans

CMS has released the following CY model marketing materials for Michigan MMPs:

  • Chapters 1-3, 5-8, and 10-12 of the Member Handbook (Evidence of Coverage)
  • ID Card
  • List of Covered Drugs (formulary)
  • Provider and Pharmacy Directory
  • Summary of Benefits

The model materials will be posted to the Financial Alignment webpage.

Recommended Action: You may access the materials here. Please note that additional materials will be released on a flow basis. You may contact the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov with questions.

Release of Model Participant ID Card for New York Medicare-Medicaid Plans

CMS has released the model Participant ID Card for New York MMPs. The new model will be posted to the Financial Alignment webpage with other New York MMP model materials.

Recommended Action: You may access the model Participant ID Card here. Please contact the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov with questions.

Release of Additional CY 2015 Model Materials for South Carolina Medicare-Medicaid Plans

CMS has released the following CY model marketing materials for South Carolina MMPs:

  • Chapter 12 of the Member Handbook
  • Provider and Pharmacy Directory

The model materials will be posted to the Financial Alignment webpage.

Recommended Action: You may access the materials here. Please note that additional materials will be released on a flow basis. You may contact the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov with questions.

Proposed Prior Authorization Form for Beneficiaries Enrolled in Hospice (Comments due December 2, 2014)

On October 3, 2014, CMS announced an opportunity to comment in CMS-10538 (Prior Authorization Form for Beneficiaries Enrolled in Hospice). Commenters recommended requirement of a standard PA form to facilitate coordination between Part D sponsors, hospices, and prescribers. In response, CMS has developed a standard form in conjunction with the National Council for Prescription Drug Programs that will meet program needs. The updated format is published in accordance with the Paperwork Reduction Act (PRA) requirements.

Recommended Action: You may review the PRA notice and instructions for submitted comments here. The draft form and supporting documents are available here. The comment period ends at midnight on December 2, 2014.

Dates to Remember

  • October 20: Pricing Data Posted on Medicare Plan Finder
  • October 20 – 21: CY 2014 Plan Finder Pricing Data Submission Window
  • October 21: CY 2014 CCIP and QI plan training
  • October 22: CY 2014 CCIP and QI annual update training
  • October 28: Approval Deadline for CY 2014 October Formulary
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