The Centers for Medicare and Medicaid Services (CMS) recently announced that it is seeking comment on merging Chapters 13 (Part C ODAG) and 18 (Part D CDAG) of the Medicare Advantage Manuals. As those familiar with Medicare regulation, compliance, and audits know, these manuals are the most referenced by compliance and operations teams as they cover all things prior authorizations, appeals, and grievances.
While some may object to reading about medical authorizations when they cover Part D and vice versa, the combination of the chapters is clearly a good idea:
- In general, the chapters are hard to maintain, and updating often lags interim announcements by CMS via HPMS memos.
- Because of the above, sometimes a divergence between Part C and Part D rules emerges. It seems to us that while timeframes for decisioning may differ, most other rules should be consistent.
In addition to the combination of the manuals, CMS is making some changes to the two chapters in the text itself. The announcement and draft chapter can be found at the end of this blog. Comments need to be in to CMS by October 22, 2018 and sent to Part_C_Appeals@cms.hhs.gov.
CMS also announced changes to Chapter 13 (Part D Premium and Cost-Sharing Subsidies for Low-Income Individuals) and Chapter 14 (Part D Coordination of Benefits (COB)). These proposed changes can be found here. Comments can be sent to PartD_COB@cms.hhs.gov.
The major ODAG and CDAG revisions include the following:
*Note that plan policies and procedures do not need to be amended until the new manual is deemed final by CMS
- Removed or condensed duplicative language. The combined manual is 100 pages, compared with over 211 in the former ones.
- Used simple, universal terminology where guidance is applicable to both Part C & Part D.
- Guidance applicable to only Part C or Part D is clearly separated and easily identifiable.
- Sections were reorganized to align with timing of requests to plans.
- Timeframes and notification requirements are more clearly spelled out with charts and tables.
- The new Part D Tiering Exceptions policy is included. See this at 40.5.1 and 40.5.6 of the new chapter. The language is consistent with recent policy clarifications in this area.
- Part D payment timeframes are lengthened to provide plans and IREs additional time to issue appeal decisions. Plans have 14 days to decide and 30 days to pay.
- Part C plans do not have to notify enrollees if their case is forwarded to the IRE.
- Guidance related to implementation of the CARA Act as it relates to at-risk determinations for drug management programs. In these cases, members can go right to a redetermination.
- Clarity regarding the fact that cases should not be auto-forwarded to the IRE if plans approve, effectuate and notify the member within 24 hours of the due date.
- Clarity around satisfying verbal notification requirements by making and documenting good faith attempts and following up with written notice. See 10.4.2 of the new chapter.
- Defining outreach requirements if additional information is needed for either medical or drug requests. This can be found at 10.4.5 of the new chapter.
- Clarification on Appointment of Representatives – this is a huge change that will save plans a lot of administrative effort and mean better member satisfaction. Some plans practiced this without clear guidance while others were afraid to go this route. The new chapter notes at 20.2 that: “If the representative form is maintained and accessible by the plan, a photocopy of the signed representative form is not required to be filed with future grievances, coverage requests, or appeals made on behalf of the enrollee in order to continue representation. If the plan uses a representative form that is on file for requests, it must include a copy when sending a case file to higher level adjudicators, if applicable.” The filed AOR would be good for one year.
- Other clarifications, include:
- Treatment of verbal requests, withdrawals and dismissals.
- When a request is considered received and when timeframes begin (see this at 10.4.1 of the new chapter)
- Notifying enrollees of favorable determinations.
- When to use the reopening process. This begins at 80 in the new chapter. To us, the section still feels a bit ambiguous and clunky. We would love for CMS to deep dive here and explain in simple language the dos and don’ts of reopens.
- When to issue an Integrated Denial Notice (for members with Medicare and Medicaid). Plans must still refer to the instructions of the IDN to understand population of the ID, however.
- Tolling for exceptions requests in Part D. CMS is indicating that the tolling period generally should not exceed 14 days.
MedHOK will be submitting comments in a few areas including:
- The new chapter’s outreach requirements speak to at least one outreach attempt to obtain missing information. Much of the information in this section, however, conflicts with the October 2016 and February 2017 enhanced outreach memos issued via HPMS. We are asking CMS if it is backing away from the more rigorous approach, which included a minimum of three outreach attempts (multi-modal in some cases), with an initial outreach within certain prescribed timeframes.
- We will be asking CMS on how receive dates of AORs should be populated if plans use AORs on file as noted above.
- We will be asking for some clarification related to dismissing grievances and coverage requests.
- Recent audits have indicated that CMS is changing its views on how requests that don’t require authorizations should be treated. Historically, on audit CMS has said these should be treated as CD or OD approvals. On some audits this year, CMS auditors have said that these should now be treated as inquiries. The new chapter does not specify this although MedHOK has received confirmation from CMS.
- Last, we don’t believe CMS is tackling a big issue out there at the plan level – whether a plan should be able to process a request as a prior authorization within the appeal window (usually thought of as 60 days in both Parts C and D). Plans have traditionally had to deem these subsequent requests as appeals. In some cases, this clearly is appropriate. But in others we wonder if that should be the case. Clinical circumstances can change and perhaps plans should have the ability to create new authorizations if clinicals do change. This could be fore previous denials because of deterioration of health or because certain denied units (e.g., home health visits) are now justified. While we believe in the rigor CMS is attempting to put around timeliness and escalation of requests to ensure consistency in the program, allowing new authorizations would be in the best interest of the member in these situations as authorization timeframes are much swifter and the appeals process is cloaked in complexity and little utilized by members. We think CMS could build compliance checks around this as they do in other areas.
See supporting appendices: