Complaints Tracking Module Updates – On November 2, 2018, CMS will provide an update to the CTM that affects all plan users. There will be a new field on the resolution screen called “Resolution Notification?” that will be a required field upon resolving a complaint, and changes have been made to Plan Casework Upload File Record Layout and the Plan Download File Record Layout to reflect the Resolution Notification field (see Attachment A and Attachment B) on the October 9, 2018 memo.
Health Plan Management System (HPMS) will be unavailable after close of business (8:00 p.m. ET) on Friday, November 16, 2018 through Sunday, November 18, 2018 for migrating the HPMS from its current web hosting facility to the cloud-based Amazon Web Services (AWS). The transition to AWS should be seamless for all end users that are currently accessing HPMS over the Internet. Please note that the website URL will remain the same: https://hpms.cms.gov.
Combining Medicare Advantage Chapters 13 and 18
On October 1, 2018 CMS announced that it is seeking comment on merging Chapters 13 (Part C ODAG) and 18 (Part D CDAG) of the Medicare Advantage Manuals into one comprehensive guidance document. The memo gives an overview of the structural changes, regulatory updates and policy changes.
Some general and structural changes include:
- Removed or condensed duplicative language, resulting in a significant reduction in the volume of the guidance (Chapter 13 & 18 was a total of 211 pages. Merged guidance is 100 pages).
- Simple, universal terminology is used 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 the order of the appeals process, as well as make it easier to reference important guidance, such as timeframes or notification requirements.
Updates to reflect recent regulatory changes include the following:
- Tiering Exceptions policy (Part D).
- Part D payment timeframes will provide plans and IREs additional time to issue
- Appeal Decisions.
- Part C plans do not have to notify enrollees if their case is forwarded to the IRE.
- Guidance related to at-risk determinations made under a plan sponsor’s drug management program (Part D).
Changes to align Part C and Part D policies were also noted.
Comments were due by October 22. 2018. We look forward to the final version.
CMS Removes Compliance Training Requirements for Downstream Providers Under Medicare Advantage and Part D
As we look towards 2019 and annual compliance trainings, we wanted to reiterate what the Centers for Medicare & Medicaid Services (“CMS”) enacted in the Final Rule. CMS removed certain compliance training requirements previously applicable to first tier, downstream and related entities (“FDRs”) of Medicare Advantage and Part D Plan Sponsors (“Plan Sponsors”). Beginning January 1, 2019, health care providers that participate in Medicare Advantage and Part D are no longer required by CMS to complete CMS-issued general compliance and fraud, waste and abuse training. However, Plan Sponsors will still have discretion to include compliance training requirements in their provider contracts.
CMS wants to reduce administrative burden and allow Plan Sponsors more flexibility to oversee their FDR counterparts as it sees fit. CMS expects Plan Sponsors to continue monitoring, auditing and oversight of their FDRs; however, CMS will consider that to be a private contractual matter between the Plan Sponsors and the FDR. The previously required trainings on the CMS website are being removed.
Given that Plan Sponsors are responsible for their FDRs’ compliance with applicable federal laws and regulations, it is likely that Plan Sponsors will continue to require FDRs to annually attest to compliance with other Medicare requirements such as performing exclusion list screenings; maintaining a code of conduct; establishing reporting mechanisms; and complying with offshoring restrictions. FDRs should closely monitor communications from Plan Sponsors to ensure they remain in compliance with each Plan Sponsor’s contractual requirements.
Appeal of At-Risk Determinations (CARA)
As discussed in the CARA/Opioids presentation at the CMS Spring conference, enrollees in a Drug Management Program have the right to appeal the lock-in.
- Once an enrollee is identified as at-risk, the enrollee will receive a second written notice that explains the limitations and appeal rights
- At-risk determinations are subject to the existing Part D benefit appeals process
- If an enrollee disagrees with an at-risk determination made under a plan’s drug management program, the enrollee has the right to request a redetermination
- The enrollee has 60 days from the date of the second notice to request an appeal, unless there is good cause for late filing In addition to the right to appeal an at-risk determination, an enrollee always has the right to request a coverage determination, including an exception, for a drug he or she believes may be covered.
New request reason fields are being added to the MedHOK Pharmacy Appeals solution that will accommodate this requirement and allow the user to identify the type of CARA request being appealed.
Special Needs Plans (SNP) changes coming in 2021
Bipartisan Budget Act of 2018 created major changes for Medicare Advantage Special Needs Plans including:
- Permanently reauthorizing SNPs
- Requiring D-SNPs to meet specific integration requirements with states by 2021
- Uniform grievances and appeals procedures by 2020
Beginning in 2021, D-SNPs must do at least one of the following with their Medicaid regulators:
- Become a Fully Integrated Dual Eligible SNP
- Provide LTSS or behavioral health services under a capitated arrangement with the state
- If the MA plan’s parent offers a Medicaid plan for LTSS or behavioral health in the state, the MA plan will need to assume all clinical and financial responsibility for Medicare and Medicaid benefits
- Coordinate LTSS and/or behavioral health based on requirements to be set by CMS’ dual coordination office
CMS has also added additional Model of Care requirements for members with severe or disabling chronic conditions to include:
- Minimum benchmarks for each MoC element
- Stronger review of plan MoC goal outcomes
- Ensuring HRA is addressed in individualized care plan
- Stricter ICT participant requirements
- Face to face member visits
Cal MediConnect LTSS Best Practices Issued
A key focus of Cal MediConnect (CMC) – as well as the broader Coordinated Care Initiative (CCI) – is to better integrate long-term services and supports (LTSS) for Medicare and Medi-Cal beneficiaries. Several years into the program, evaluation findings indicate that, while CMC provides a valuable new pathway for serving dual eligibles, more work can be done to:
- Connect members to LTSS services; and
- Better integrate and coordinate those services with the more traditional medical benefits that health plans offer.
As one of several initiatives to address this ongoing challenge, during the spring of 2018, the CMC plans participated in a best practices process to examine their own internal operations and share learnings with each other. A summary of the best practices meetings was published in September 2018 and key findings from the best practices process include:
- Identifying LTSS Needs
- Connecting Members to Services
- Care Coordination Infrastructure
- Training and Education
- Working with LTSS Partners
Click here to download the full summary of the Cal MediConnect Best Practices Meeting.
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