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October 2015

October 2015

IMPORTANT REMINDERS

Medicare Parts C & D Fraud, Waste and Abuse (FWA) Training hosted by CMS Center for Program Integrity (CPI) will be held as a virtual training as two webinars scheduled for September 13 and 14, 2016, from 12:30-4:30 pm ET each day. All Medicare Advantage (Part C) organizations and Part D plan sponsors are encouraged to take advantage of this training opportunity. Please log in to the CMS O&E MEDIC website to register for the two-day virtual training.

Since June 2016 CMS has been releasing CY 2017 Model MMP member materials for states, and on September 2, 2016, the Medicare-Medicaid Coordination Office (MMCO) completed and released finalized updates to the Medicare-Medicaid Plan (MMP) National Enrollment Guidance & Exhibits, effective January 1, 2017.

On June 29, 2016, CMS announced the availability of the updated Chapter 14 “Contract Determinations and Appeals” of the Medicare Managed Care Manual. Chapter 14 has been updated and reorganized for clarification and incorporates guidance that has been released since the last update to this chapter on September 2, 2005, and is available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c14.pdf

On September 6, 2016, CMS announced the release of the 2015 Part C and Part D Program Audit and Enforcement Annual Report. This report provides information on the program audit process, a current snapshot of the program audit landscape, and a summary of the 2015 program audits, as well as CMS’ enforcement actions. The 2015 Part C and Part D Program Audit and Enforcement Annual Report is attached to the notice and will also be made available on the Part C and Part D Compliance and Audits website located at: https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits.html

The September 7, 2016, MMP Provider and Pharmacy Directory Technical Assistance Webinar presentation has been posted to the “Information and Guidance for Plans” webpage under the “General Marketing Guidance” heading halfway down the page. Please contact the Medicare-Medicaid Coordination Office at mmcocapsmodel@cms.hhs.gov with any questions or with topics for additional technical assistance opportunities.

COMPLIANCE NEWS

Update on Chapter 6 Revisions—Transition Requirements and Expiring Formulary Exceptions

On January 19, 2016, the Centers for Medicare & Medicaid Services released the latest revision of Chapter 6 of the Medicare Prescription Drug Benefit Manual. After the release, CMS received many questions, which were triggered by some of the revised language, on whether transition requirements apply to expiring formulary exceptions. While CMS addressed these questions at the 2016 Medicare Advantage and Prescription Drug Program Spring Conference and Webinar on May 6, 2016, it understands that Part D sponsors generally had not interpreted the guidance on transition to apply to expiring formulary exceptions and will need to make significant system changes to implement this policy, particularly with respect to exceptions expiring mid-year.

After reviewing the revised Chapter 6, CMS is persuaded that the guidance is not sufficiently clear with respect to the transition policy and its application to expiring formulary exceptions. Moreover, they continue to receive additional questions with respect to implementation details. Therefore, on August 16, 2016, CMS clarified that they do not expect Part D sponsors to include expiring formulary exceptions in their transition policies. CMS notes, however, that the language in the CY 2017 model transition letter to be issued shortly will be sufficiently flexible for use by sponsors that already apply transition rules to expiring formulary exceptions and will continue to do so. Questions concerning this update may be directed to PartDPolicy@cms.hhs.gov.

Update to CY 2016 Core Reporting Requirements for Medicare-Medicaid Plans

On August 10, 2016, the Core Reporting Requirements for Medicare-Medicaid Plans were updated. A summary of the changes are as follows:

Part C and Part D sections were revised to reflect recent updates to the corresponding reporting requirements, including:

  • Revisions to the Part C Organization Determinations and Reconsiderations reporting section to clarify withdrawals, dismissals, and denials
  • Revision to the Part D MTM section to reflect an update to the reporting deadline

MMP-specific Reporting Section:

  • CMS has decided to temporarily suspend the collection of Core Measure 3.1, which evaluates the percentage of members discharged from an inpatient facility for whom a transition record was transmitted within 24 hours of discharge to the provider designated for follow-up care. This measure has presented significant data collection challenges in its application at the payer level.
    • Since CMS expects to reinstate the measure at a later date, they strongly encourage MMPs to work with their provider network to develop infrastructure that would facilitate greater communication in the discharge process between the inpatient facility, MMP, and follow-up provider.

Update to Chapter 16b of the Medicare Managed Care Manual

On August 30, 2016, CMS announced the updated version of chapter 16b of the Medicare Managed Care Manual, titled “Special Needs Plans.” The guidance is currently available here.

This update includes guidance that has been released since the last update to chapter 16b, including relevant guidance from the Health Plan Management System (HPMS) memo “Discontinuation of Dual Eligible Special Needs Plans Sub-type Categories” released on December 7, 2015, the HPMS memo “Clarification of Benefit Flexibility and Coverage Guidance for Dual Eligible Special Need Plans and Process to Request to Offer Flexible Supplemental Benefits in Contract Year 2017” released on January 8, 2016, and the HPMS memo “Changes to Special Needs Plan and Medicare-Medicaid Plan Model of Care Submissions and Updates in the Health Plan Management System” released on January 14, 2016. Chapter 16b has been structurally reorganized to provide greater clarity and revised to incorporate policy changes affecting special needs plans (SNPs). Below is a summary of the major changes reflected in the updated version of chapter 16b:

  • Dual Eligible SNPs – General (section 20.2.1): Revised to clarify that CMS no longer categorizes D-SNPs by CMS-designated subtypes.
  • Benefit Flexibility for Certain D-SNPs (section 20.2.6): Streamlines guidance related to benefit flexibility eligibility requirements and clarifies the characteristics and categories of benefits. Guidance describing the benefit flexibility approval process has also been incorporated.
  • Existing SNP Model of Care Re-Approval and Application Submissions (section30.3): Clarifies and provides examples of when a Medicare Advantage organization (MAO) must submit a Model of Care (MOC) for a SNP.
  • Service Area Expansion (section 30.4): Incorporates the policy that MAOs are not required to submit a new MOC when requesting a service area expansion for a SNP.
  • Enrollment Requirements (section 40): Duplicative enrollment guidance removed, which can be found in the Medicare Advantage Enrollment and Disenrollment Guidance (chapter 2).
  • Continued Eligibility When an Enrollee Loses Special Needs Status (section 40.4): Clarifies the benefits and cost sharing requirements for D-SNPs during the period of deemed continued eligibility.
  • SNP Crosswalks (section 50.3): Table 6 updated to include the crosswalk scenarios for all SNPs, not just D-SNPs.

For any questions about the policies articulated in this updated chapter 16b, please contact your Regional Office Account Manager or submit an inquiry to the Medicare Part C Policy Mailbox, located at: https://dpap.lmi.org.

2017 Draft Program Audit Protocols

On Thursday, June 16, 2016, The Medicare Parts C and D Oversight and Enforcement Group (MOEG) sent an email announcing the release of the 2017 draft Program Audit Protocols for public comment in the Federal Register, as part of the Paperwork Reduction Act approval process. The 2017 draft protocols can be accessed using this link.

The draft protocols include revisions to the Part C Organization Determinations, Appeals, and Grievances (ODAG) and Part D Coverage Determination, Appeals and Grievances (CDAG) Universe record layouts. In anticipation of CMS finalizing these revisions, MedHOK is in the process of updating the record layouts. The updated layouts and reports will be provided to our clients once the finalized requirements are issued.

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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