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MedHOK Compliance Insights Newsletter: October 2015

IMPORTANT REMINDERS

October 15, 2015
2016 Annual Election Period Begins

Early November, 2015
First display of Plan Finder data in HPMS for sponsors/MA organizations that submitted a plan correction request after bid approval

December 1, 2015
Enrollees in Medicare cost-based plans not offering Part D must receive the combined ANOC/EOC

December 1, 2015
Cost-based plans must publish notice of non-renewal

December 7, 2015
End of the Annual Election Period

COMPLIANCE NEWS

2015/2016 Program Audit Protocols and Process Updates

On October 20, 2015, CMS released a memo regarding its updating and republishing the 2015 audit protocols. The revised versions will be posted to their Program Audits website. CMS will be not be making changes to the protocols for 2016. The revised protocols will function as the 2015 and 2016 MA and Part D program audit protocols.

The following audit process documents and protocols are being re-posted:

  • Part D Formulary and Benefit Administration
  • Part D Coverage Determinations, Appeals, and Grievances
  • Part C Organization Determinations, Appeals, and Grievances
  • Special Needs Plans– Model of Care (SNP-MOC)
  • Part C and Part D Compliance Program Effectiveness
  • Program Areas/Elements Modified for 2015/2016
    • Compliance Program Effectiveness – (UPDATE)
      • Starting in 2016, the CPE universe request will include additional documentation that will provide CMS with a general overview of the sponsor’s Medicare compliance program structure and operations.
      • The compliance interviews have been modified to eliminate the employee interviews (with some limited exceptions) and adds one interview with the individual(s) involved with managing the sponsor’s accountability for and oversight of its first-tier, downstream and related entities (FDRs).
      • The number of tracer samples used to test the seven elements of an effective compliance program has increased from five to six.
      • Sponsors are required to provide PowerPoint presentations that document the full story of compliance tracers. CMS will conduct all tracers in week two, to ensure that compliance personnel are able to attend as many webinars as possible in week one.
    • Record Layouts (Appendix A) – (UPDATE)
      • CMS added instructions to clarify the types of cases that should be included and/or excluded for individual record layouts.
      • The format of the record layouts remains the same except for the addition of a “Column ID” field.
      • CMS added changes to streamline and clarify the content, including: rearranging variables, adding or renaming variables, removing superfluous fields and revising field descriptions to include more detail, examples of what was being requested and/or additional entry options (e.g., N/A).
      • Sponsors can submit record layouts as text (.txt) or Excel (.xlsx) files.
  • New Program Areas/Elements Added for 2016
    • Medication Therapy Management – (PILOT)
      • All Medicare Part D sponsors are required to have an established Medication Therapy Management program in place to ensure optimum therapeutic outcomes for targeted beneficiaries through improved medication use. The objectives of this program audit area will be to
      • Assess a Medicare Part D sponsor’s performance with their CMS-approved MTM Program in accordance with 42 CFR § 423.153(d) and other related CMS guidance;
      • Educate sponsors and correct area(s) of deficiency; and,
      • Initiate enforcement actions and/or identify possible performance measures for sponsors to implement.
    • Provider Network Adequacy – (PILOT)
      • Sponsors are required to maintain an adequate provider network and ensure access to specialty and sub-specialties providers. The objectives of this program audit area will be to
      • Examine the adequacy of a sponsor’s provider network,
      • Examine the standards for accessibility and ensure that the providers in networks are open to treat enrollees.
  • Modifications to the program audit process
    • Universe Submission Accuracy – (UPDATE)
      • Sponsors will have a maximum of three attempts to provide each universe requested, whether these attempts all occur prior to the entrance conference or both before and during the audit.
      • If the sponsor fails to provide accurate and timely universe submissions twice, CMS will document this as an observation in the sponsor’s program audit report.
      • After the third failed attempt the sponsor will be cited an Invalid Data Submission (IDS) condition relative to each element that cannot be tested grouped by the type of case.
      • If a universe is completely unusable for purposes of evaluating an element, the sponsor will be cited every applicable condition for the affected element that cannot be tested and the sponsor may be referred for possible enforcement action.
    • Previously Disclosed versus Self-Identified Issues – (UPDATE)
      • Disclosed issues are those reported to CMS prior to the date of the audit start notice.
      • A self-identified issue is one that has been discovered by the sponsor for which no prior notification has been provided to CMS.
      • Issues discovered by CMS throughout the year during the course of routine monitoring and reported to the sponsor will be treated as self-identified.
      • For 2016, sponsors will be asked to provide a list of all previously disclosed and self-identified issues of non-compliance, from January 1, 2016 through the date of the audit start notice.
      • Within 5 business days after receipt of the audit start notice, sponsors must provide a description of each issue as well as the remediation status using the PreAudit Issue Summary template.
    • Impact Analysis (IA) Templates (UPDATE)
      • The name of the templates has been changed from “Beneficiary Impact Analysis” to “Impact Analysis”
    • Calculation of Score (UPDATE)
      • Starting in 2016, CMS will cite a new type of condition, called Invalid Data Submission (IDS).
      • IDS conditions will be cited when a sponsor is not able to produce an accurate universe within a maximum of 3 attempts.
      • IDS conditions will be worth one (1) point.

The memo, protocols and other associated audit documents are located in the Downloads section of the CMS Program Audit website, located at: https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-andPart-D-Compliance-and-Audits/ProgramAudits.html

Update to the Part D Reporting Requirements Technical Specifications for Contract Year (CY) 2015

The Centers for Medicare and Medicaid Services (CMS) has released an updated version of the CY2015 Part D Reporting Requirements Technical Specifications. This update is necessary to correct errors in the start and end positions in the Medication Therapy Management (MTM) Record Layout, and also to further clarify information in the Enrollment/Disenrollment and Retail, Home Infusion, and Long Term Care Pharmacy Access reporting sections. Note – CMS does not expect plans to resubmit their 2015 pharmacy access data; these clarifications are intended to help improve plans’ processes for reporting in future years.

Changes since August 2015 version:

* Disenrollment: Added clarifying language under the “NOTES” section for Elements B, C and D.

* Retail, Home Infusion and Long Term Care Pharmacy Access: Specified plan reporting requirements and added a “NOTE” regarding 2015 pharmacy access data resubmission.

* MTM Record Layout:
– Changed end position for Element U
– Changed start and end positions for Element V
– Changed start and end positions for Element W
– Changed start and end positions for Element X

This document is posted on the HPMS Plan Reporting site and on the external CMS website at the following link: http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/RxContracting_ReportingOversight.html.

Contract Year 2016 Translated Materials Requirements and Methodology

As a reminder, Medicare Advantage Organizations (MAOs) and Part D sponsors (sponsors) must translate certain materials as indicated at http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/InformationandGuidanceforPlans.html into any non-English language that is the primary language of at least 5% of the individuals in a plan benefit packages (PBP) service area.

Marketing Guidelines (MMG), MAOs and sponsors that have service areas that meet the 5% threshold must provide specific translated materials on their websites and in hard-copy upon beneficiary request.

INFORMATION SECURITY

Password Hacking

Developing a strong password and keeping it safe should be at the top of everyone’s list for best practices whether at work or at home. Although many of you might think “hackers” use advanced technical skills to tunnel their way into companies, you might be surprised if you knew that they take a least aggressive approach by guessing passwords.

The majority of security breaches that occur are in the form of password hacking. Having an easily guessable password or using the same password for multiple applications creates a huge void in security for your company and yourself and gives opportunity’s to those who want to do harm.

  • Understand what a weak password is
    • Some passwords are vulnerable such as, P@s$W0rd and QwErT5$3@1 because they commonly used.
    • Other things to avoid include using Names, Addresses and any word found in a dictionary.
    • Having a password that contains any of these can be easily found with crawling through a victim’s social media profile and with the use a password cracker.
  • Creating a strong password
    • When creating a strong password, it should also be something that you can remember without having to write it down.
    • If you decide to build a password that is consisted of a phrase ensure that you replace some letters within the phrase to include a number or special characteristic such as T8g0d!t$FriD@y

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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