skip to Main Content

November 2018 Compliance Insights

Important Reminders

Industry Collaboration Effort (ICE) Conference December 3 & 4, 2018 –  The annual ICE conference will again be held at the Hyatt Regency Embarcadero in San Francisco. The conference focuses on health care industry developments and operational improvements. Click here to learn more and register to attend.

Model of Care changes – comments due January 7, 2019 – On November 8, 2018, CMS published notice for comment on collection of Models of Care (MOCs) and off-cycle submissions of MOC Changes as required by the Paperwork Reduction Act of 1995 (PRA). The notice can be found in the Federal Register.

Plan Preview of 2019 Display Measures in HPMS November 20 through December 6, 2018 – CMS issued an HPMS memo on November 19, 2018, regarding Plan Preview of 2019 Display Measures in HPMS. CMS publishes display measures each year, which include measures that have been transitioned from the Star Ratings, new measures that are tested before inclusion into the Star Ratings, or measures displayed for informational purposes only. These are separate and distinct from CMS’ Part C & D Star Ratings. Part C & D sponsors can preview their display measure data in HPMS prior to posting on the CMS website. CMS has also included a separate data page that contains the HEDIS 2018 data submitted by contracts that had less than 500 enrolled in July 2017. There is a separate Technical Notes document to cover these additional data. In December, the 2019 display measures will be posted to the CMS.gov website on this page: http://go.cms.gov/partcanddstarratings.

Comment period for NCQA Health Plan Accreditation updates open through December 17, 2018 –  NCQA has opened their comment period regarding the proposed updates to Health Plan Accreditation. In addition to the standards updates, NCQA is also seeking feedback on proposed changes to scoring, changes to HEDIS®/CAHPS® measures and changes to process. NCQA reviews all comments and presents results to its advisory groups for deliberation and approval. Comments may be submitted via NCQA’s public comment website. The proposed changes below may be modified or eliminated based on public comment and other feedback. NCQA focused improvements on the following areas:

  • Earning Accreditation
  • Accreditation Status and Health Plan Star Ratings
  • Retired requirements
  • Renewal
  • HEDIS/CAHPS Measures for 2020
  • Utilization Management
  • Long-Term Services & Supports

 

Compliance News

Part D Drug Program Policy Guidance

An HPMS memo issued on November 20, 2018, provided implementation guidance regarding Medicare Part D drug management programs. Section 704 of the Comprehensive Addiction and Recovery Act (CARA) of 2016 included provisions permitting Part D sponsors to establish drug management programs (DMPs) for beneficiaries at-risk for misuse or abuse of frequently abused drugs (FADs). In a final rule (CMS-4182-F) published in the Federal Register on April 16, 2018 (“final rule”), CMS established the framework under which Part D sponsors may implement a DMP. Highlights from the memo are below:

  • Under DMPs, Part D sponsors are required to communicate in writing with beneficiaries for whom they intend to limit access to FADs. CMS has developed and beneficiary-tested standardized notices for this purpose. Currently, these notices are pending approval at the Office of Management and Budget (OMB). Part D sponsors will be required to use these notices for their DMPs and may not develop their own.
  • In the meantime, sponsors with DMPs in 2019 must implement their programs beginning January 1 and move forward with those aspects of the programs that can be completed without the notices.
  • Once available, sponsors may issue notices and implement coverage limitations. Because CMS understands it may take some time for sponsors to update their systems with the approved notice language, sponsors will have up to 90 days following the release of the standardized notices to fully implement aspects of their programs requiring the notices.
  • In addition to the final rule, implementation guidance and the 2019 OMS technical guidance for DMPs is available on the CMS Part D Overutilization website here.
  • The updated MAPD Plan Communications User Guide (PCUG), including technical guidance for submitting DMP information to the MARx system, will be released on or about November 30, 2018. Please reference the MAPD Plan Communications User Guide (PCUG) page for the updated Guide here.
  • Enrollment guidance, including information on the special enrollment period (SEP) limitation, can be found in the Medicare Managed Care Manual and Medicare Prescription Drug Benefit Manual
  • Guidance concerning appeals of at-risk determinations will be provided in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance. We appreciate the diligent efforts of Part D sponsors to implement drug management programs in 2019.

See the memo for additional information and details.

 

CMS Medicare Preclusion List Requirements Go into Effect in 2019

In April of this year, the Centers for Medicare and Medicaid Services (CMS) rescinded the requirement that providers serving Medicare Advantage (MA) and Part D (PDP) plans be enrolled in the Medicare program. Instead, CMS is dictating that these plans ensure that any provider in MA and PDP plans must not be on a Preclusion List that will be maintained and updated by CMS.

In general, the Preclusion List includes individuals that have committed or are suspected of committing waste, fraud and abuse (FWA) or have run afoul of other Medicare requirements. CMS will assemble these suspect providers from various lists within CMS. Providers will be notified of their potential inclusion on the list and their appeal rights. CMS will add the provider only after an appeal is denied. CMS will make the initial Preclusion List available beginning January 1, 2019, with updates monthly.

What must plans do? See MedHOK’s November 13, 2018, blog to read the full article.

 

Clarifications from CMS Regarding the Integrated Denial Notice (IDN)

As MedHOK is beginning to see more and more plans with Integrated Dual Special Need Plans, we reached out to CMS to clarify a few questions.

  • Let’s say there is a drug available at a pharmacy that is not a Part D drug but covered under Medicaid. It is being denied under Part D and a plan would use the standard Part D denial notice. Would the IDN be used if denying under Medicaid because there is no breakout of medical and pharmacy in Medicaid? If an approval is being made on this drug, we assume a straight Medicaid approval letter would be issued.

CMS RESPONSE: No, the IDN is not for used for Part D, therefore, plans should contact their state Medicaid agency to ensure they issue the correct state specific Medicaid denial notices.

  • If a service or benefit is only Medicaid, do you issue an IDN? Would you only issue a Medicaid approval or denial notice?

 CMS RESPONSE: If the request is classified as a request for only Medicaid payment or coverage, issue the notice required by Medicaid.

  • If a service is denied under Medicare and is denied under Medicaid as well, you issue the IDN. You include Medicaid appeal rights? Would you also send a Medicaid denial notice and appeals rights? If a state says you must send such, should you include Medicaid appeal rights in the IDN?

CMS RESPONSE: Yes, Medicaid appeal rights must be included. The point of the IDN is to allow a plan to use a single notice to convey both Medicare and Medicare appeal rights, as applicable. Plans should contact their State Medicaid Agency to assure that all state-specific requirements for notices are met.

  • If the service is denied under Medicare but approved under Medicaid, my understanding is you issue an IDN but indicate it is covered under Medicaid. IS it fair to say that some states will have you send a Medicaid approval as well?

CMS RESPONSE: An IDN would be issued if a service is denied under Medicare, but approved under Medicaid, and language would be added in free-text fields indicating Medicaid would cover the service. For any additional Medicaid notifications please contact the State Medicaid Agency to assure that all state-specific requirements for notices are met.

  • How do the rules work for various categories of dual eligible?
  • FBDE, QMB Plus, and SLMB Plus – always gets full Medicaid so answers above apply
  • QMB – since they get full cost-sharing under Medicaid for Medicare services, do you issue Medicaid appeals and FH rights under 3 above?
  • SLMB, QI, others – do you issue any sort of Medicaid appeals or FH for these categories because they are only receiving full or partial premium subsidies

CMS RESPONSE: An IDN is issued in any instance where there is a denial and there may be beneficiary liability or services are denied under Medicare but fully covered under Medicaid and the IDN explains the service will be covered under Medicaid.

 

C-SNP Updates for 2020

The Bipartisan Budget Act of 2018 put into effect several changes for Severe or Disabling Chronic Condition SNP’s (C-SNP plans) beginning in year 2020. Below are a few high-level updates, however the full version can be found here.

  • The interdisciplinary team includes a team of providers with demonstrated expertise, including training in an applicable specialty, in treating individuals like the targeted population of the plan.
  • Provide face-to-face encounters with individuals enrolled in the plan not less frequently than on an annual basis.
  • The results of the initial assessment and annual reassessment of everyone enrolled in the plan are addressed in the individual’s individualized care plan.
  • As part of the annual evaluation and approval of such model of care, the Secretary shall consider whether the plan fulfilled the previous year’s goals (as required under the model of care).
  • The Secretary shall establish a minimum benchmark for each element of the model of care of a plan. The Secretary shall only approve a plan’s model of care under this paragraph if each element of the model of care meets the minimum benchmark applicable under the preceding sentence.

There are also some revisions to the definition of a severe or disabling chronic conditions specialized needs individual:

  • On or after January 1, 2022, have one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits overall health or function, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination
  • Not later than December 31, 2020, and every 5 years thereafter, the Secretary shall convene a panel of clinical advisers to establish and update a list of conditions that meet each of the following criteria:
    • Conditions that meet the definition of a severe or disabling chronic condition
    • Conditions that require prescription drugs, providers, and models of care that are unique to the specific population of enrollees in a specialized MA plan for special needs individuals
    • Inclusion of certain conditions–The conditions shall include HIV/AIDS, end stage renal disease, and chronic and disabling mental illness.

 

CMS Clarification Regarding AOR Requests

In 20.2 of the proposed consolidated chapter, CMS states “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 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.” It goes on to state that the form is valid for the life of a grievance, coverage request, or appeal if the grievance, coverage request, or appeal was received within one year of the date a representative form is signed by both the enrollee and appointee.

So, the guidance is now clear:  if the CMS AOR form or an equivalent document is submitted, if the plan maintains the signed AOR and it is available for review when future requests come in, this is enough to satisfy requirements.

In comments to CMS on the proposed consolidation, we are seeking to clarify for current universes whether a plan should use the original AOR receipt date for the AOR receipt date element?  We are asking as the draft 2019 ODAG protocols (deferred until 2020) eliminate the AOR receipt date element and ask plans to report the AOR receipt date as the receipt date of the case. Regardless of the answer, plans will need to ensure that their systems calculate a correct due date for the case, which in this case would be from the receipt date of the case.

 

Medicaid Mega Rule Tweaks Proposed

Earlier this month the Centers for Medicare and Medicaid Services (CMS) proposed some small changes to the 2016 regulation.

  • Changes to the strict network adequacy standards in the rule. In the proposed amendment, states can set more flexible quantitative access standards. Examples include:
    • Minimum provider-to-member ratios
    • Maximum travel time or distance to providers
    • Minimum percentage of providers accepting new patients
    • Maximum wait times for an appointment
    • Allowing tele-health services to contribute toward adequacy
    • Allowing states to define various specialties
    • As managed care programs are phased in to replace FFS, states would be allowed to require plans to make pass-through payments to providers (such as graduate medical education, federally qualified health center, and certain hospital reimbursement).
    • Plans will be able to use some electronic communication with members, including not having to re-print provider directories monthly.
    • A few revisions are made to the quality bonus program requirement, but the Star-like mandate remains substantially in place.
    • The new case turnaround times remain in force. One change on this front: oral appeals from members do not require a follow-up written signed appeal. Another small change: the timeframe to request a State Fair Hearing was changed to no less than 90 days (from 120 days). This makes it consistent with the FFS program.
    • A series of changes to the State Children’s Health Insurance Program (SCHIP) were proposed as part of the rule as well.

To read MedHOK’s full write up on these changes to the Medicaid Mega Rule, please click here.

 

Digital Communication

CMS has reiterated new guidance that allows plans to use digital means to fulfill most communications.

As we outlined in our recent blog post, there are huge long-term cost-savings, but at the same time cost, compliance, and HIPAA implications in the shorter term.

To refresh on the topic, the MCMG (Medicare Communications and Marketing Guidelines) announcement outlined the following, with some clarifications below from the Fall Conference:

  • CMS is requiring that individuals opt into the digital provision of communications and that plans must have a mechanism for individuals to opt out and receive hard copies of materials on request. As CMS noted at the conference, email is no longer considered an unsolicited contact.
  • Two obvious means of providing communications digitally include secure email of the actual communication as well as member portal postings (with an email to the member notifying that the communication is on the portal that directs the member to the posting area).
  • CMS noted at the conference that text messages or other means of direct messaging are not allowed to fulfill communications.
  • CMS also noted that the email must provide an opt out function, and should contain language directing them on how to obtain a hard copy of the communication
  • The following information was also communicated:
    • Members should be able to call the plan and opt in to electronic communications.
    • If a member opts in to electronic fulfillment and then requests a hard copy, a member can be asked if this is a one-time request or are they opting out of digital permanently.
    • Delivery Date is defined as when an email is sent. CMS clarified it is not when the member opens the email.
    • A hard copy must be fulfilled on bounced emails.
    • If a plan encounters an invalid email, the delivery date is when the email was sent, not when the hard copy is sent/received.
    • If both email and hard copy are sent, the delivery date is the email sent date.

 

Security News

During the Holiday season, employees may be visiting non-work-related websites in higher volumes due to visiting social media sites with friends and family and doing some online shopping. This is also a time when hackers are gearing up to take advantage of the spike in online transactions. Now is a good time to review some of your controls. Remind employees about your policies regarding acceptable use and ensure workstations are up to date with all security patches. Review anti-virus, anti-malware and behavior monitoring software settings and ensure workstations are up to date with the latest signatures.

Back To Top