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MedHOK Compliance Insights: September 2015

Important Reminders

Early September 2015
CMS begins accepting plan correction requests upon contract approval.

September 8-11, 2015
Second CY 2016 Medicare Plan Finder (MPF) Preview and Out-of-Pocket Cost (OOPC) Preview.

September 16-30, 2015
CMS mails the 2016 Medicare & You Handbook to Medicare beneficiaries.

Late September 2015
D-SNPs that requested review for FIDE SNP determination notified as to whether they meet required qualifications.

September 23, 2015
Deadline for Part D sponsors, cost-based, MA, and MA-PD organizations to request
a plan correction to the plan benefit package (PBP) via HPMS.

Deadline for Part D Sponsors, cost-based, MA, and MA-PD organization to request
any SB hard copy change.

September 30, 2015
The following documents are due to current enrollees by September 30, 2015:

  • Standardized Annual Notice of Change/Evidence of Coverage (ANOC/EOC) for all MA,
    MA-PD, PDP, and cost-based plans offering Part D.
  • Standardized ANOC with the Summary of Benefits for D-SNPs and MMPs that choose
    to separate the ANOC from the EOC.
  • Abridged or comprehensive formularies LIS rider.
  • Pharmacy/Provider directories.

The multi-language insert should be sent with the ANOC/EOC and the SB.
The documents identified above are the only documents permitted to be sent prior to October 1, 2015.

October 1, 2015
Organizations may begin marketing their CY 2016 plan benefits.
Note: Once an organization begins marketing CY 2016 plans, the organization must
cease marketing CY 2015 plans through mass media or direct mail marketing (except
for age-in mailing). Organizations may still provide CY 2015 materials upon request,
conduct one-on-one sales appointments, and process enrollment applications.

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2015 CMS Medicare Advantage Prescription Drug Plan Fall Conference

The Centers for Medicare & Medicaid Services (CMS) held its annual Medicare Advantage
and Prescription Drug Plan Fall Conference and Webcast on September, 10, 2015. The
agenda included an array of topics, including 2016 Program Audits.

As this is always a hot topic for CMS and those highly impacted by an audit, CMS
has received a great deal of feedback from the industry and auditors. An overall
consensus thought that errors with appeals and grievances audit protocols were a
result of CMS’ large record layout. Acting on this feedback, CMS announced that
it has updated many of the record layouts and protocols, as well as some additional
changes:

  • Extraneous fields included in record layouts in error have been deleted.
  • Headers on each of the record layouts have been added, as well as direction on what data should be included or excluded.
  • Data dictionaries have been updated to explain what each field means and what is being requested. Also clarification was provided on how certain data should be reported, such as by request received date, issued date, etc.
  • In Organization Determinations, Appeals and Grievances (ODAG) and Coverage Determinations, Appeals and Grievances (CDAG), grievances will be based on the date of resolution of the grievance and not based on the receipt of the request.

On the updated audit layout, CMS is still finalizing the update to the layout and once completed, they will be sending out an HPMS memo and posting on CMS website.

Another topic discussed surrounds a plan self-disclosing or self-identifying known or potential issues. A self-disclosed issue is one your organization identifies and discloses to your account manager prior to the receipt of an audit start notice. A self-identified issue is an issue you may or may not have been aware of before you received your audit start notice but you have not previously disclosed to CMS.

In 2016, CMS will no longer request a Beneficiary Impact Analysis (BIA) on self-identified and self-disclosed issues prior to the start of or during the audit. CMS found that attempting to confirm correction was a difficult process to operationalize. They will no longer be asking for the BIA; however, they still expect organizations to self-identify and self-disclose.

Furthermore, for organizations that were unable to provide CMS with a valid and accurate universe within three submissions, CMS is no longer offering a “grace period”. For 2016, CMS has created a new condition type called Invalid Data Submission (IDS). When an organization submits an inaccurate universe three times, there will be a certain set of IDS conditions around any element CMS cannot test. For example, if CMS cannot run a universe timeliness test around CDAG for dates and times for 1, 2, or 3 universes, the organization will get an IDS condition relative to CMS’ inability to test decision making notification.

CMS sent its final audit notices on Monday, September 14, 2015. If an organization did not receive an audit notice after this mailing, it will not be audited in 2015.

Since CMS has made a lot of updates to the 2015 audit protocols and are going to repost them (hopefully in September), those updates will be effective as the 2016 protocols. CMS is not making any additional changes. CMS wants to keep things steady for a couple of years to let the industry catch up.

An HPMS memo will be distributed once the protocols have been reposted.

All event materials and slides from the CMS Medicare Advantage & Prescription Drug Plan Fall Conference and Webcast can be found on the CMS website.

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Malware – 800,000 Each Day

As many of you know, cyber-attacks have increased sub­stantially over the past months. In early 2015 we learned about the Anthem breach which impacted over 80 million individuals. This breach was one of the largest of its kind and has incurred expenses to Anthem in excess of over $100 million.

This is only one of many breaches that has occurred this year. Recently, the Office of Personal Man­agement (OPM) was breached leaking data of many if not all U.S Government employees and potential employ­ees’ personal data which was submitted for background checks.

In both cases, Anthem and OPM have identified that both breaches were infiltrated by the same form of malware. It is not definite on the origins of the malware or where it came from, but it has been concluded that the malware was likely first sent via malicious links in phishing emails or spam.

Many people place all of their trust in the company they work for and the departments which help keep them safe. But as hard as these departments try in keeping them safe many threats can still make their way through.

In the last year, over 317 million new pieces of malware and other malicious files were created. That is over 865,000 new forms of malicious programs being created every day. Security companies are being stressed with detecting and preventing these threats from infecting company networks and personal computers. Many forms of malware slip through the cracks and are difficult to detect.

In order to combat against these threats, companies can­ not place all of their trust in antivirus software and tech­nical controls. Instead, they should train and inform the users on how to prevent these attacks from occurring in the first place.

  • Stay clear from unknown/unauthorized websites.
  • If you browse to a site, you can still become infected with malware without even
    clicking on links or attachments. This attack is called a Drive-by-Download Attack.
  • Do not open or reply to suspicious email.
  • The most common way for malware to be installed is in the form of a phishing attack. Clicking on any link is not recommended unless you are certain of the sender.
  • Do not download or attempt to download software.

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Additional Research on Potential Effects of Socioeconomic Factors of Star Ratings
(HPMS Memo dated September 8, 2015)

As discussed in CMS’ 2016 Part C and Part D Star Ratings User Call in August, CMS has posted a slide deck to their website summarizing their additional research on the potential effects of socioeconomic factors on Star Ratings. The results were presented during the CMS 2015 Medicare Advantage & Prescription Drug Plan Fall Conference and Webinar on September 10th.

Some of the policy goals include:

  • Recognizing the challenges of serving vulnerable populations and providing incentives
  • for a continued focus for improving health care for these important groups;
  • Proposing adjustments that reflect the actual magnitude of the differences observed
    in the data;
  • Providing valid quality ratings to facilitate consumer choice;
  • Providing incentives for MA and Part D quality improvement; and
  • Recognizing the need for options that are both transparent and feasible for the
    plans and CMS to implement.

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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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