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Compliance Insights: November 2015

IMPORTANT REMINDERS

Mid December 2015
Display measures data on cms.gov updated

January 1, 2016
Plan Benefit Period Begins

COMPLIANCE NEWS

Revised 2016 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, and Cost Plans

CMS issued a revised 2016 Readiness Checklist on November 20, 2015. The revised checklist addresses a new section A. X. which addresses risk adjustment data submissions on page 6, and clarifies the section on reinstatement for good cause for Part D-Income Related Monthly Adjustment Amount on page 14. The 2016 Readiness Checklist can be found here.

Part D Sponsors – Quality Assurance Checks for 2016 Data Submitted for Posting on the Medicare Plan Finder Tool – Updates

On November 25, 2015, CMS released an update to its May 27, 2015, and June 19, 2015, memos. The memos highlight key information for plan sponsors regarding the Quality Assurance (QA) analysis process and provided an updated listing of the three (3) new targeted QA checks for CY2016.

The targeted QA checks are:

  1. CMS will check the bi-weekly submitted pricing files against the organizations approved Plan Benefit Package (PBP). If CMS finds that the PBP offers a particular benefit that is not reflected in the pricing files, the data will be marked as outliers, and an e-mail will be generated. At this time, this error will not be suppressible, but may lead to compliance action(s).
  2. CMS will set low and high thresholds for the proportion of preferred pharmacies submitted in the bi-weekly pricing and pharmacy files. This will only apply to organizations whose uploaded PBP indicates that preferred cost sharing pharmacies are available to beneficiaries. All other preferred pharmacy checks will continue to be performed. If the proportion of preferred cost sharing pharmacies in the submitted data is below the low threshold or exceeds the high threshold, the data will be marked as outliers, and an e-mail will be generated. Sponsors will have a chance to confirm the data are correct or submit corrected data. If the data cannot be verified, this will lead to suppression.
  3. CMS will check the bi-weekly submitted pharmacy cost files for discrepancies between the pharmacy type and the pharmacy preferred status fields. If a pharmacy is submitted as mail order only but also has a retail preferred status, or vice versa, the data will be marked as outliers, and an e-mail will be generated. Sponsors will have a chance to submit corrected data. If the data cannot be corrected, this will lead to suppression.

As stated in the June 19, 2015, memo, CMS provided further updates for the QA analysis process for CY2016.

These updates included:

  • All known exceptions that have been granted for the 2015 pricing and pharmacy data will be removed for the 2016 QA analyses. If a Part D sponsor receives an outlier notification for their 2016 pricing and pharmacy data which was previously a known exception in 2015, that sponsor must re-confirm that the data continue to be accurate. Part D sponsors who do not confirm these data may have their pricing data suppressed on the MPF.
  • CMS will continue to require Part D Sponsors to submit MPF files during each regular submission window. Sponsors will not be able to auto-certify the pharmacy cost file (PC), pricing file (PF), or ceiling price file (CP) for the CY2016 MPF.
  • Starting CY 2016, for MPF display, plan sponsors are required to only submit data for pharmacies that are contracted as network retail or network mail order pharmacies. Sponsors are also required to submit data for pharmacies contracted as both network retail or network mail order pharmacies and contracted as network long-term care (LTC), home infusion (HI), or other non-retail or non-mail order type pharmacies. Sponsors must not submit data for MPF for non-retail and non-mail order pharmacies (such as LTC only or HI only pharmacies). If plan sponsors submit data for pharmacies that are not contracted retail or mail order network pharmacies, their pricing data will be suppressed on the MPF, until corrected data can be displayed.
  • Also for CY 2016, CMS will check to ensure that only Formulary Reference File (FRF) NDCs are submitted in the pricing submissions, as specified in the MPF guidance. At this time, submission of non-FRF NDCs will not result in suppression, but sustained noncompliance to CMS guidance may lead to compliance actions. A QA check will be added in CY 2016 and notifications will be sent.

INFORMATION SECURITY

As the holidays are upon us and Christmas fast approaching, scammers are in full swing turning some individual’s times into a saga of “The Grinch Who Stole Christmas”. This past week, US-CERT sent a reminder to all consumers to be on the lookout for phishing scams. US-CERT stated that many scams this year will come in the form of fake shipping notifications of delivery and tainted ecards. In order to remain cheerful during this time and out of reach of the scammers, please remember the basics of online safety. Here are some helpful tips:

  • Do not open any attachments or emails from unsolicited sources.
  • If an email looks fishy, go directly to the sender’s website and do not click on any links.
  • If you believe you are a victim of a scam report the attack to the police and file a report with the Federal Trade Commission and contact your financial institution.

Please stay safe this holiday season online and don’t get phished.

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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