Weekly CMS Insights: 9/29/14 – 10/3/14

2013 Final Part D Payment Reconciliation

CMS released a memo informing sponsors that calculations for the 2013 Final Part D Payment Reconciliation have been completed and reflect PDE records submitted through June 30, 2014.  The reports were made available in reconciliation mailboxes at the CSSC on Tuesday, September 30, 2014.  Please contact CSSC at 877-534-2772 if you are unable to access the reports.  In addition, sponsors will receive the Part D Exclusion from Reconciliation Report, which will identify PDEs that were excluded from the 2013 Part D payment reconciliation.

Recommended Action: Review the attached memo for details.  Please note that if filing for an appeal, you must do so by October 15, 2014.  Requests for appeal should be directed to Cheri Rice, and sent to the Reconciliation Support Contractor, Acumen LLC.  You may also file an electronic appeal by submitting the appeal to Acumen at PartDPaymentSupport@acumenllc.com.  Please direct questions regarding this memo to Acumen.

View Attachment

Direct and Indirect Remuneration (DIR) and Pharmacy Price Concessions

CMS released a memo providing draft guidance for Part D sponsors on reporting DIR data for pharmacy price concessions for CY 2016 and beyond.  CMS will accept comments on the draft guidance through October 17, 2014.

Recommended Action: Review the attached memo for instructions for submitting comments.  CMS will accept comments on the proposed guidance until October 17, 2014.  Comments may be submitted to DIR_Reporting_Reqts@cms.hhs.gov or mailed to:

Amanda Johnson
Director, Division of Payment Reconciliation
Centers for Medicare & Medicaid Services
7500 Security Boulevard C1-13-07
Baltimore, Maryland 21244

Excelsior Solutions expects PBMs to submit comments as the proposed guidance reflects changes to the definition of negotiated price and other key changes that can impact DIR.  Request copies of the comments from your PBM.

Please submit questions regarding this guidance to DIR_Reporting_Reqts@cms.hhs.gov.

View Attachment

Updates to the Prescription Drug Event (PDE) layout – Adjustment Reason Code and Adjustment Reason Code Qualifier

CMS  is providing sponsors additional time to implement the new PDE layout, outlined in the September 4, 2014 HPMS memo titled, “Updates to the PDE layout and the CGDP Reconciliation Reports”.

Sponsors may submit the updated file layout beginning November 9th or continue using the old file layout until April 1, 2015 (leaving the new fields blank).

In addition, the memo addresses questions regarding the use of the Adjustment Reason Code and Adjustment Reason Code Qualifier are addressed.

Recommended Action: Review the attached memo for details.  Find out from your PBM (if delegating PDE submission), if they will be ready with the new file layout by November 9th or are planning to extend the time using the old layout.  You may also need to make system updates if loading PDEs elsewhere to accommodate.  Please direct questions regarding this memo to pdejan2011@cms.hhs.gov.

View Attachment

Updated Quality Assurance Checks for 2015 Data Submitted for Posting on the Medicare Plan Finder Tool

CMS released a memo providing updates to the quality assurance checks for 2015 data submitted for posting on the Medicare Plan Finder Tool.  Please note that Part D sponsors are expected to perform their own QA checks to ensure the files are complete and accurate.

In addition, all known exceptions that have been granted from the 2014 pricing and pharmacy data will be removed for the 2015 QA analyses.  Therefore, plans seeking an exception will need to do so again for 2015 data. CMS will also continue to require Part D Sponsors to submit plan finder files during each regular submission window.

Recommended Action: Review the attached memo for details, including information regarding data checks which will be incorporated in the MPF.  These data checks will be used to identify potential inaccuracies within the submissions prior to display on the MPF.  Please direct questions regarding this memo to PlanFinderQA@cms.hhs.gov.

Excelsior Solutions recommends that you review this information with your PBM and verify what checks they perform on the data prior to submitting to CMS.  Items to consider:  What type of reports and validation can or are they providing to demonstrate these QA checks?  Is that sufficient to meet CMS intent?

View Attachment

Closing the Drug Data Processing System (DDPS) for benefit years 2007 and 2008

CMS has announced the closure of DDPS for PDE records for benefit years 2007 and 2008 effective January 1, 2015.  This change will affect all Part D sponsors, with the exception of the Limited Income Newly Eligible Transition (LI NET) plans.  Please note that PDEs submitted after January 1, 2015 will receive reject edit code 788 (DDPS no longer accepts PDEs with dates of service before 1/1/2009).

Recommended Action: Please direct questions regarding this announcement to PDEJan2011@cms.hhs.gov.

View Attachment

Participation in 2015 HOS for MA Organizations Planning to Sponsor FIDE SNPs in 2016 – Response needed by Friday, October 31, 2014

Per the Affordable Care Act (ACA), CMS is allowed to pay a frailty adjustment to a Dual Eligible SNP, and is in the process of calculating a frailty score for each FIDE SNP.  MA organizations that may be sponsoring a FIDE SNP in 2016, and wish to be considered for a frailty payment, must participate in the 2015 HOS or HOS-M to allow for CMS to calculate the frailty score.

Recommended Action: If any MA organization intends to sponsor a FIDE SNP in 2016 and would like to participate, they should email RiskAdjustment@cms.hhs.gov no later than Friday, October 31, 2014, with “2015 HOS – H####” in the subject line.  Please review the attached memo, as it contains the information you will need to provide.

View Attachment

Health Plan Innovation Request for Information Announcement

CMS released a memo informing plans that the Innovation Center seeks to solicit stakeholder perspectives through a formal RFI on health plan innovation opportunities related to plan design, care deliver, beneficiary and provider incentives, and/or network design.

Recommended Action: The RFI will be available here and available for comment until 11:59pm on November 3, 2014.

Commenters are required to submit responses to HealthPlanInnovationRFI@cms.hhs.gov, using the form available on the website listed above.  Please direct questions to this email as well.

View Attachment

View Attachment

Release of Final Contract Year 2015 Marketing Guidance and Marketing Material Codes for Medicare-Medicaid Plans in South Carolina

CMS announced the release of the final CY 2015 marketing guidance and marketing material codes in the HPMS specifically for South Carolina MMPs.

Recommended Action: Review the final guidance here.  Additional marketing materials will be released on a flow basis as they are finalized.

Please contact the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov with questions.

Release of Additional CY 2015 Model Materials for New York Medicare-Medicaid Plans

CMS released the following model marketing materials for New York MMPs:

  • Chapters 3, 4, and 9 of the Member Handbook
  • Part D Model Transition Letter

The information will be posted to the Financial Alignment webpage with other New York MMP model materials.  Additional model materials will be released on a flow basis as they are completed.

Recommended Action: You may contact the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov with questions.

Coverage Gap Discount Program:  October Participating Labeler Code Update

CMS has added the following to the list of participating manufacturer labeler codes for the CGDP:

  • 16781 Onset Dermatologics LLX
  • 60846 Gemini Laboratories, LLC

Please note that additions will be identified in bold red.

Recommended Action: You may access the updated information here.

2015 PDE Submission Timetable

CSSC Operations released a PDE submission timetable schedule on their website.

Recommended Action: Visit here. Use this to create the master submission calendar for your organization.

Should you need the PDE certification package, it may be found here.

Revisions to the Medicare Part D Medication Therapy Management Program Standardized Format

CMS has posted additional documents in relation to OMB-approved revisions to the Part D MTM Program Standardized Format, in the Downloads section of the CMS MTM webpage.  These materials can be accessed at here by opening the file named “MTM Program Standardized Format Revisions (v07.15.14) [ZIP, 2MB].”

Recommended Action:  Please note that all written summaries provided to beneficiaries must comply with the revised Standardized Format, Form CMS-10396 no later than January 1, 2015.  Questions may be directed via email to PARTD_MTM@cms.hhs.gov.

Dates to Remember

  • October 6 – 7: CY2015 Plan Finder file submission
  • October 10: Star Ratings go live on medicare.gov
  • October 15: Annual Election Period begins; sponsors must post PA and ST criteria on the website for 2015 contract year
  • October 15: Last day to file appeal for CY2013 payment reconciliation
  • October 30: Last day to submit comments on proposed DIR and pharmacy price concessions proposed guidance
  • October 31: Notify CMS if seeking frailty adjustment for FIDE SNP plan
  • October 31: EDI agreement and submitter application deadline for PDEs
  • November 3: Responses due to Health Plan Innovation RFI
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