Managing Medicare » Part D

PCUG 5.3 Released

jbaker — Mon, 22 Nov 2010 15:30:56 +0000

In case you missed the most recent release of the update to the Plan Communications User Guide 5.3, here is the link. Download and review!

http://www.cms.gov/MAPDHelpDesk/02_Plan_Communications_User_Guide.asp

CMS Reiterates Standards for Selecting a Data Validation Contractor

jbaker — Mon, 15 Nov 2010 16:09:55 +0000

MA, MAPD and PDP plans are required to report measures to CMS for Part C and D benefits. Additionally, plans are required to contract with an outside vendor to review and validate the data that was submitted to CMS. Attached is CMS’s standards that plans should use to select a validation vendor.

Vendor should be independent of the MAO and not involved in the submission process
Vendor should have previous experience in MA reporting requirements and technical specifications
HIPAA compliant
Prior experience in completing project of similar scope and size
Staff must complete CMS web-based CMS Data Validation Training

See the attached document for further details of the standards:

Standards for Selecting a DV Contractor 20101012

CMS Releases Proposed Changes to MA and MAPD Programs for CY 2012

jbaker — Sat, 13 Nov 2010 00:58:37 +0000

CMS on November 10, 2010 release the proposed changes to the MA and MAPD program for CY 2012. The proposed rule changes will is expected to be published in the federal register on November 22, 2010. A headline summary of changes is as follows:

Implementing provisions of the Affordable Care Act;
Clarifying various program participation requirements;
Strengthening beneficiary protections;
Strengthening Medicare’s ability to distinguish stronger health plans for participation in Medicare Parts C and D and to remove consistently poor performers; and
Implementing other clarifications and technical changes.

One of the most notable changes is to the rule governing the 2012 Medicare Advantage Quality Bonus Payment Demonstration program. The current ACA legislation only provides bonus to plans who receive an overall rating score of 4 or 5 stars (The average of the Part C and D scores). Leaving no bonus to plans who score a 1,2, or 3 rating (See chart).

The rule change is intended to test if providing additional bounce opportunities at the 3 and 3.5 star level accelerate the progression of improvement of plans to higher STAR rating levels. The demonstration program will run for 3 years from CY 2012 through 2014.

Based on the 2011 Star ratings, this change in bonus methodology significantly changes the number of plans who qualify for a bonus. Under the original rules only 16 plans would have received a bonus. Under the demo rules an additional 39 plans will receive a bonus totaling 55 plans.

CMS Publishes the 2011 Non-Matched NDC List

jbaker — Mon, 25 Oct 2010 17:15:59 +0000

CMS and the FDA are coordinating with each other to ensure the market is aware of the changes to the regulatory status of marketed prescription drug products. The Non-Matched NDC List represents drug products that have not been properly registered and listed with the FDA. The non-match FDA list is NOT to be used at a point of sale for approval or dis-approval of drug coverage. This list will change during the course of the payment year including retroactive changes to match and non-match status of NDCs.

The impact of a drug on the non mach list will result in a PDE transaction being rejected by CMS. As NDCs are added and removed, previously rejected PDEs may need to be resubmitted for acceptance with CMS.

CMS is recommending that plans monitor the FDA drug registration and listing changes to make correct point of sale coverage decisions and formulary changes during the course of the payment year.

Following is the HPMS CMS memo.

HPMSmemo2011NonMatchedNDCList_102210

CMS Posts New ICD-9 / HCC Crosswalk for 2011

jbaker — Fri, 01 Oct 2010 14:11:06 +0000

CMS has posted an updated Calendar Year 2011 Model Diagnoses crosswalk on the Risk Adjustment webpage. The crosswalk incorporates Fiscal Year 2011 ICD-9 code updates that are effective October 1, 2010.

The crosswalk file link is named “2011 Model Diagnoses” and can be found on the CMS Website here:

http://www.cms.gov/MedicareAdvtgSpecRateStats/06_Risk_adjustment.asp

HEADS UP: CMS To Announce Encounter Submission Meeting in Oct 2010

jbaker — Wed, 15 Sep 2010 16:10:09 +0000

During a breakout session at AHIP on September 13, 2010 CMS announced that there will be an October 2010 meeting where CMS will be reviewing the preliminary files, processes and expectations for MA health plans to transition from submitting RAPS files to ‘full encounter’ data. No details were shared at AHIP, but there is an expected HPMS memo formally announcing this event. The following guidlines were shared

Plans will be allowed to send up to 2 representitives at this event
There is an expected parallel submission period where plans will submit both RAPS and Encounter files. No details on how and what will be monitored
Encounter submissions are expected to start 1/1/2012
Encounter data will replace RAPS data at some point and will be used for risk adjustment factor scores for Part C and D

None of the above is official from CMS but informally shared at AHIP. Watch HPMS for details.

CMS Announces STAR Rating Preview and Comment Period

jbaker — Sat, 11 Sep 2010 13:49:31 +0000

CMS has released a HPMS memo letting MA and MAPD plans know they will be provided a preview period of the STAR Rating that will be published on the Medicare Plan Finder (MPF)for the 2011 open enrollment period.

In August 2010 plans were provided a preliminary preview and now the final results are in. Make sure your plan review the scores and calculation methodology and make sure your scores are accurate.

Here is how your plan can access your documentation in HPMS:

“ To access the Plan Ratings Preview in HPMS, from the left navigation bar select: “Quality and Performance”, then “Part D Performance Metrics and Reports” and then “Part D Report Card Master Table”. Technical notes are available via the “Technical Notes” link found on the “Summary” tab of the Master Table.”

Here is the memo: Memo_PlanRatingsPreview_09.10.10

Additional Changes to 2011 ANOC/EOC

jbaker — Tue, 07 Sep 2010 15:03:45 +0000

From CMS via HPMS on Sept 3, 2010:

“On August 11, 2010, we issued a memo describing corrections to the 2011 Annual Notice of Change/Evidence of Coverage. We have the following additional corrections.

1 – Under the bullet, EOC Chapter 4, section 2.1, Your medical benefits and costs as a member of our plan, the standardized language should read, “Your provider will bill Original Medicare while your hospice election is in force.”

2 – Additionally, the current language in EOC Chapter 4, Kidney Disease Education Services, should read as follows:

“Education to teach kidney care and help members make informed decisions about their care. For people with stage IV chronic kidney disease ,when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime.”

Please make the appropriate changes to your plan’s EOC, as applicable. Plans that have already submitted their EOC must resubmit the document with the revised language. Please contact your Regional Office marketing reviewer if you have additional questions.”

CMS Distributes CY 2011 Readiness Checklist

jbaker — Tue, 07 Sep 2010 15:00:47 +0000

That time of year again! CMS has distributed via HPMS the 2011 MA and PDP Readiness memo. Make sure you incorporate in your plan a review of the checklist and implement any corrective action to ensure your plan is in compliance. CMS has been increasing their review of plans and this checklist is your compliance insurance.

CY2011_Readiness_Checklist_090310

Be Prepared for Spring 2011 MARx System Upgrades! Will You Be Ready?

jbaker — Tue, 29 Jun 2010 14:33:28 +0000

CMS has planned a major overhaul of their MARx system impacting enrollment file layouts and changes to TRR processing in April 2011. Here is a run down of the changes:

IMPACTED SYSTEM / INTERFACE	DESCRIPTION	FROM	TO
Enroll Disenroll File	Combining transaction codes 60, 61, 62 and 71 in to a single transaction code 61. The file layout will be changed and processing logic will be updated – MAJOR IMPACT	PLAN	MARx
Enroll Disenroll File	Submission Cut-Off Dates are aligning to calendar months, allowing for clear transaction submission based on CMS policy and compliance. – MAJOR IMPACT	PLAN	MARx
Enroll Disenroll File	CMS is creating a new process for canceling enroll and disenroll transactions that have already been submitted to CMS. There will be new transaction types (TC 80- enroll cancel and 81 – disenroll cancel) that will cancel the transaction. CMS will no longer allow for ‘opposite’ transactions to cancel transactions. – MAJOR IMPACT	PLAN	MARx
TRR	New TRCs from CMS will notify the Plan when retro changes to a member’s NUNCMO and LEP have taken place to a member. All plans will receive this information regardles of enrollment dates and withholding status. – MINOR IMPACT	MARx	PLAN
Enroll Disenroll File	CMS will automatically reset a member’s NUNCMO to zero when they turn 65 and enter another IEP for Part D – MINOR IMPACT	MARx	PLAN
TRR	Gone are TRC 165 errors! The processing of enrollment and payment are separated with this CMS upgrade and errors in payment processing will NOT block enrollment processing anymore – no more TRC 165! – MINOR IMPACT	MARx	PLAN
TRR	Daily TRR Files!This is great news. BCSS files will go the way of the dinosaurs and the TRR will be the daily batch response to plan submissions.In addition to faster response the layout will change to include all of the data that was submitted, confirming the values of the submission transaction– MAJOR IMPACT	MARx	PLAN
Enroll Disenroll File	Submit member address changes to CMS using a new transaction code, 76 rather than sending SCC changes to the retroactive processing contractor. – MAJOR IMPACT	PLAN	MARx

All of this and more will dramatically change the way plans report and exchange data with CMS and MARx. These changes are GREAT NEWS for plans that are prepared to move with CMS. The proposed changes will greatly simplify processing rules and improve traceability with data exchanges with CMS. However for those that do not have a plan and resources to execute will be at a great deal of risk.

Will you be ready to meet the new system and compliance requirements by April 2011?

DOWNLOAD THE CMS MEMO HERE.