Further References:

Kaiser Health News

Stockton (Calif.) Record: “These sanctions will remain in effect until each of the three plans demonstrates to CMS that it has corrected the related deficiencies and that those deficiencies are not likely to recur. The actions will not impact the 1 million Medicare beneficiaries enrolled in these health and drug plans” (11/23).

The Associated Press/Bloomberg Businessweek: “Health insurer Universal American Corp. said Monday federal regulators will suspend the company from enrolling new members in its Medicare Advantage plans as an open-enrollment period for the government-subsidized health coverage gets under way. The Rye Brook, N.Y., company said the suspension by the Centers for Medicare and Medicaid Services starts Dec. 5 and is tied mainly [to] agent oversight and market conduct issues. It said it was ‘working diligently’ to resolve the issues as soon as possible” (11/22).

• 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

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

Summary of Changes:

1. PLAN BID TABLE – New table that contains abbreviated plan bid information including the plan’s ICL, and application for supplemental benefit coverage
2. MANUFACTURER AGREEMENT TABLE  - This will be the same information that CMS will publish that lists labeler codes for manufacturers that signed the Medicare Coverage Gap Discount Program Agreement.
3. FDA BRAND / GENERIC TABLE – document New Drug Application (NDA) and Biologic License Application (BLA) marketing status as reported by the FDA

In addition to the new DDPS tables there are significant changes to the edit codes that CMS will be providing in the PDE Reply files.  I suggest your review these changes with your PBM and internal monitoring departments to ensure accurate reporting and monitoring of PDE data to CMS.

CMS’ focus to monitor all data submitted will include a focus on accurate and timely PDE reporting.

See the memo here: Prescription Drug Event (PDE) Edit Guidance Effective 1.1.2011 9.24

—————————-MEMO START——————————

Date: September 21, 2010

To: Part C and D Compliance Officers

From: Cynthia G. Tudor, Ph.D., Director, Medicare Drug Benefit and C & D Data Group

The data included as part of the Plan Ratings preview which began on September 15th are considered by CMS to be draft data. While we expect that the data that are posted in the preview will become final, there is the possibility that an error in a calculation could be found at some point during the preview period, either by a health or drug plan or by CMS. If that were to occur, then the possibility exists that your summary or overall rating would change as a result. Because these data are draft, CMS suggests that plans not incorporate these ratings into their marketing materials until such time as they are final.

Plan sponsors must provide the plan ratings template (which is generated from HPMS), and include it in their enrollment kits, using the prior year’s template information until such time as the template for the following contract year is made available. Once the current year’s plan performance rating template is available and final, plan sponsors may update the enrollment kit to ensure the most up-to-date plan performance ratings are provided to current and prospective enrollees. Plan rating information may not be altered relative to information on www.medicare.gov. Use of these data for marketing purposes must adhere to CMS marketing guidelines.

——————————END MEMO—————————–

I encourage you to attend this webinar and understand ECRS, COB and MSP better!

Here is the memo.

Read the complete AIS article here:  http://www.aishealth.com/Bnow/hbd090710.html

“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.”

CY2011_Readiness_Checklist_090310

http://optimalsolutionsgroup.com/CMS/index.html

Questions can be answered by the CMS contractor:

EMAIL:  maqro@optimalsolutionsgroup.com
PHONE: 866-962-6826

 CMS has extended the data submission deadline to Aug 27, 2010.  This is a compliance requirement so make sure your plan has a program to collect and report this information to CMS.