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2019 Policy Rule Means Host of Changes for Medicare Plans

2019 Policy Rule Means Host Of Changes For Medicare Plans

While plans look predominantly at the annual Call Letter for guidance on policy changes, this year’s Centers for Medicare and Medicaid Services (CMS) policy rule had a host of changes that plans needs to be aware of for 2019. Some major items are noted below.

  • The Final Rule allows plans to use notice of electronic posting for certain bulky documents to Medicare beneficiaries. This was just supplemented in late July with CMS’ announcement of a digital initiative (see our recent blog here). It is also separating the delivery date of the Annual Notice of Change (ANOC) from the Evidence of Coverage (EOC) so Medicare beneficiaries receive the ANOC first as a stand-alone document.
  • CMS codified key aspects of the Part C and D Star Ratings methodology, including its ability to add, update, and remove measures, as well as calculating and weighting measures. CMS is also cracking down on plan consolidation and the benefit plans traditionally received by deeming Star ratings from higher performing plans to lower ones when merged in. It will also add scaled reductions for data issues related to Star measures.
  • CMS is eliminating certain meaningful difference requirements for plan offerings within counties.
  • CMS is reinterpreting uniformity requirements for Part C benefits to allow plans to reduce cost sharing for certain covered benefits, offer specific tailored supplemental benefits, and offer different deductibles for beneficiaries that meet specific medical criteria. As we noted in a recent blog, this variability of benefits provision, as well as the ability to include non-traditional Medicare benefits in the bid, is sea change for the program.
  • CMS will give plans more leeway in what communications need approval.
  • CMS is implementing the CARA Act requirements for a drug management or lock-in program for at-risk drug abusers. See our recent blog on this topic here.
  • CMS is revising the existing policy related to tiering exceptions and will no longer allow plans to exclude a dedicated generic tier from the tiering exceptions process. The lowest applicable cost-share will now apply. This change has already been enforced through a variety of means.
  • Special Enrollment Periods for dual eligible and Low-Income Subsidy (LIS) members will be limited to one change in each calendar quarter in the first nine months of the year. This should reduce the major churn seen by plans in high dual and LIS areas.
  • The transition policy fill amount for those in long term care settings will change from 90 days to a one month’s supply.
  • Plans will be able to immediately substitute generics for brand name drugs on the same or lower cost-sharing tier if they meet certain requirements, which include advising enrollees beforehand that such changes can occur.
  • Application of generic cost-sharing to lower-cost generic biosimilars and similar drugs will occur through all phases of Part D coverage.
  • Delivering on its commitment to push the application of rebates at the point of sale in the Part D program (and thereby giving members immediate savings), CMS is issuing a Request for Information soliciting comments on potential policy approaches to implement the strategy.
  • Due to the 21stCentury Cures Act, CMS is replacing the MA disenrollment period (where members can disenroll from MA plans back to Medicare FFS only) from January 1 to February 14 with a new MA open enrollment period from January 1 to March 31. This will allow members to disenroll from one MA plan and enroll in another or go to Medicare FFS – a boon for MA sales.
  • The turnaround time for decisioning a Part D payment appeal at the plan redetermination and independent review entity (IRE) reconsideration levels will move from seven calendar days to a maximum of 14 calendar days. The plan will still have 30 days to fulfill a favorable reimbursement.
  • CMS is removing the current requirement that MA plans send notice to an appellant when his/her appeal case file is forwarded to Medicare’s Part C IRE. The plan notification is redundant of the IRE notification process.
  • CMS is removing the Quality Improvement Project (QIP) from the Quality Improvement (QI) requirements as it is duplicative of other current requirements.
  • CMS is codifying the existing policy of treating FFS premium adjustments as initial determinations, which gives beneficiaries subject to these adjustments full appeal rights.

Click here to view fact sheet on the Final Rule, and here for the final regulation.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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