Medicare Archives • Tier 1 Pharmacy Consulting

CMS Star Ratings Sees Improvements This Year

November 15, 2019November 15, 2019

Last month, the Centers for Medicare and Medicaid Services its released its Star Ratings findings for 2020 with some great news: More plans rated four stars or higher this year compared to the year before.

To get more specific, more than 50 percent of plans rated four and above, up from 45 percent. In addition, the enrollment weighted average increased from 4.06 last year to 4.16 this year. Twenty plans earned five stars, yet another sign of continued improvements.

Why Does it Matter?

Most Medicare Part D and Medicare Advantage plans understand the importance of Star Ratings. The ratings are put out annually by the Centers for Medicare and Medicaid Services to give beneficiaries a look at the quality of the health plan before they sign up. Star Ratings focus on aspects of high-quality care within the control of the plan. They provide a complete, accurate, reliable, and valid picture of a program. Star Ratings also are used for compliance and monitoring, and measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement, and specifications.

Star Ratings are displayed on the Medicare Plan Finder – which recently got a huge facelift – so seniors may consider both quality and cost in their enrollment decisions. In other words, Star Ratings are very important.

Other Key Findings

CMS also found that:

– More than 80 percent of beneficiaries are now enrolled in plans with 4 or more stars, up from 75 percent last year.

– This year, 141 plans earned higher 2020 ratings than they did in 2019.

– Only 57 health plans saw their overall ratings drop year-over-year.

– This year, 56 plans earned a4th star.

– Only 21 plans lost their 4th star this year.

– Approximately 52 percent of contracts for Medicare Advantage plans offering Part D coverage earned 4 stars or higher, compared to about 45% in 2019.

– Of 401 total plans for 2020, 210 are at 4 stars or higher, compared to 172 in 2019 when there were fewer plans – 376 to be exact.

– The comparison between 2020 and 2019 shows 55 contracts rated 3 stars for 2020 as opposed to 66 in 2019.

– The average star rating for a stand-alone prescription drug plan has improved from 3.34 in 2019 to 3.50 in 2020.

– There’s about 1,200 more Medicare Advantage plans operating in 2020 than in 2018, according to the Centers for Medicare and Medicaid Services.

What Can Your Health Plan Do Next Year?

If you didn’t achieve four stars this year, you have time to improve and influence your 2021 ratings with the right strategy, data, and attention to detail. It’s important that you review your current performance figures and use the right resources moving forward.

If you earned four stars this year – congratulations! However, now is not the time to sit back and relax. Star Ratings is a competitive process, and the health plans who get top billing have already started taking steps to ensure the same if not better performance next year.

Get Started

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve your goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be complicated or overwhelming. It’s important that you earn the highest rating possible.

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS Announces 2018 Parts C and D Audit Report

October 2, 2019October 3, 2019

The Centers for Medicare and Medicaid Services (CMS) last month released the agency’s 2018 Medicare Part C and Part D Program Audit Report. Such reports can be challenging to navigate through, but it’s important that health plans understand them in the event they experience an audit.

Background

The Medicare Parts C and D Oversight and Enforcement Group (MOEG), a division of CMS, releases the report every year. It includes data from recent audits. The idea is to explain CMS initiatives and boost transparency of the entire auditing process. Program audits are conducted by MOEG to ensure Medicare Advantage and prescription drug plans are offering the right access to health care services and medications to enrolled seniors.

As CMS writes: “Regular and consistent auditing of these organizations…provides measurable benefits by:

• Ensuring enrollees have adequate access to health care services and medications; • Verifying sponsors’ adherence to selected aspects of their contract with CMS;

• Providing a forum to share audit results and trends; and

• Soliciting feedback from the sponsor community and external stakeholders on potential audit improvements.”

2018 Highlights

Changes to audit processes based on sponsor feedback. Among other things, CMS expanded technological capabilities and reduced the scope of data collection to make submissions more streamlined. It also extended the fieldwork phase from two weeks to three weeks, and made the audit validation and close-out process better.

Audit results. CMS reports lower overall audit scores between last year and the year before, from 1.10 in 2017 to 1.03 in 2018. Scores were lower in Part D Formulary and Benefit Administration (FA) and Part C Organization Determinations, Appeals and Grievances (ODAG). Average FA scores, though, showed improvement with a reduction of 62% in 2018.

Audit Enforcement. CMS imposed $396,736 in 10 CMPs. There were three intermediate sanctions against sponsors for non-compliance, but fewer CMPs imposed for 2018.

To view the full report, go here.

Medicare plans and pharmacy teams are increasingly subject to closer CMS monitoring and review, so an audit is more likely now than ever before. Typically, CMS audits plans once per audit cycle, which runs between three to five years. It’s important to be ready for an audit – especially if your health plan has performance issues. Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to ensure compliance and get you through the process.

Get Started

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be scary. It’s necessary to get you the best rating possible. We will make sure your vendors are on board, too, supporting your efforts and all of the needs of the Star Ratings plan.

A four or five star rating is within your reach for 2020. We can help you get there.

About Tier 1

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected

OIG: CMS Should Do More to Reduce Medicare Fraud

August 20, 2019

The U.S. Department of Health and Human Services’ Office of Inspector General has called on the Centers for Medicare and Medicaid Services to take steps that officials believe would reduce fraud among Medicare Advantage and Medicare Part D plans.

In its 2019 report, “Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: Top Unimplemented Recommendations” the OIG outlined its top recommendations to reduce fraud, abuse, and waste amount HHS programs, including Medicare.

This blog focuses on the recommendations for Part D and Advantage (also known as Part C) for this year.

OIG Unimplemented Recommendations

– CMS should tighten its oversight for Part D payments for compounded topical drugs, which are often at risk for fraud, waste and abuse. The OIG report found that spending on compounded drugs increased by nearly 180% between 2010 and 2016. For its part, CMS has released a reminder memo of its policies for compounded topical drugs, but OIG officials believe more steps should be taken.

– CMS should gather stronger, more consistent data from plan sponsors that includes information on the potential for fraud and abuse. By doing so, CMS oversight will improve to better detect and prevent fraud and other problems, the OIG says. Plans are not required to report potential fraud by pharmacies and providers to CMS – but they can by their own admission. Not as many do as the OIG would like, so it wants CMS to do a better job at data collecting. For its part, CMS has said it will start requiring plan sponsors to report their own data as well.

– Medicare Advantage plans should be required by CMS to include ordering and referring provider identifiers in their encounter data. Encounter data is information submitted by health care providers, such as doctors and hospitals that documents both the clinical conditions they diagnose as well as the services and items delivered to beneficiaries to treat these conditions. Ordering and referring provider identifiers is not always required in encounter data and was often overlooked, the OIG says. Officials wants CMS to require Medicare Advantage plans to include ordering and referring provider identifiers from here on out.

Summary

With these recommendations, health plans should anticipate stricter regulations and guidance requiring reporting of potential fraud by network providers and updates to encounter reporting requirements.

We Can Help

Tier 1 Pharmacy Consultants helps health plans navigate the often murky and confusing waters of CMS changes, regulations, and oversight. The rules change often, and it’s difficult for health plans to keep up, much less stay compliant. Our team can help.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

Drug manufacturer rebate audit: Are you owed money?

July 21, 2019July 29, 2019

There is one kind of audit a health plan actually wants: A drug manufacturer rebate audit.

What is a drug manufacturer rebate audit?

A drug manufacturer rebate audit is an in-depth look at a health plan’s rebate agreement previously put in place by drug manufacturers and a pharmacy benefit manager. The idea behind a rebate audit is to ensure that a health plan is recouping the most money possible through its drug benefit.

Why should health plans seek rebates from drug companies?

Brand-name prescription drugs are expensive, especially for medications that treat many serious, yet common medical conditions. Rebates are often the deciding factor when a health plan chooses to cover a drug and how much of the cost should be covered by a patient.

Medicare Part D members, for example, are likely to pay anywhere between $12.40 and $77.40 and higher for prescription drug coverage, according to Medicare.gov, and that doesn’t include the required copay when you get to the pharmacy counter, which runs anywhere from $5 for generic drugs and $25 to $40 for name brand prescription medications. There are many reasons a health insurer may choose to cover or not cover a name brand prescription drug, but manufacturer rebates are a big one.

How does a drug manufacturer rebate audit work?

A drug manufacturer rebate audit analyzes the rebate agreements that exist between a health plan and drug manufacturers – typically the top five to ten manufacturers that contract with the PBM. The top is selected based on dollar value of the rebates on the drugs, often the top 50% to 75% of all rebates invoiced.

Very few health plans conduct drug rebate audits. But as the possibility of more money to recoup grows, audits are likely to increase as well. Plans often are not receiving the level of rebates they are entitled to due to formulary exclusivity provisions in the contract. Or, competitor drugs on the formulary have limited PBM rebates. At the same time, incorrect goals and invoicing can result in wrong or limited rebate payments to the health plan.

A drug manufacturer rebate audit can identify all of those problems and more. Many audits are conducted annually; sooner if there have been recent changes to PBM payments or the plan. Most Medicare Advantage plans report directly and indirectly to the Centers for Medicare and Medicaid Services (CMS). CMS expects rebate oversight if it conducts its own audit.

How do health insurers choose an drug manufacturer rebate auditor?

An independent auditor must have lengthy experience in drug manufacturer rebate audits. The process is complicated at best. It’s also wise to have a consultant there to guide you through the process, which can take months. A team of experts assisting can help ensure you get the rebates the health plan is entitled to receive.

Tier 1 Pharmacy Consulting can help

The team at Tier 1 Pharmacy Consulting works closely with health plans on every single aspect of their prescription drug benefits. Health plans are always looking to do more — but sometimes the resources just are not there. Let Tier 1 assist you with opportunities that might be limited by time and resources – including the chance of recouping drug manufacturer rebates.

We want the same thing as our clients and their members: high quality prescription drug options at the lowest possible cost. We are sensitive to the need for lower prescription drug costs. At the same time, we believe it’s important to increase the value that the plan provides, and look for savings and rebates whenever possible.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

CMS to audit Medicare Advantage plans in response to overbilling

July 20, 2019July 20, 2019

The Centers for Medicare and Medicaid Services (CMS) is at the center of a controversy that could affect health plans across the country.

Last week, national news outlets – including National Public Radio – reported that CMS is proposing a series of new audits designed to take back $1 billion of the $30 billion the government says health insurers have overcharged Medicare in the last three years. CMS’ goal is to recoup some of that money by 2020. With the new year just five months away, the government could move full steam ahead with its plan – and health plans should be prepared.

Some background, as noted in the NPR story and others:

Some Medicare Advantage plans, the government says, have tried to boost their revenues by billing Medicare more than necessary. These plans have done so by stretching the truth on how much medical care their elderly patients need. Or, plans have charged Medicare for treating illnesses and conditions they can’t prove their members have truly been diagnosed with.

With 22 million seniors – that’s one in three men and women over the age of 65 – on Medicare, the problem is nothing new. In fact, CMS has known about inflated billing practices for several years; the agency has long considered auditing plans before to address billing dishonesty and mistakes but before had always backed off.

Meanwhile, the U.S. Department of Health and Human Services Inspector General’s Office has kicked off its own round of nationwide Medicare Advantage audits of health plans billing practices.

The scrutiny is growing.

The insurance industry, for its part, is highly critical, arguing CMS audits are unfair and have the potential to negatively impact seniors’ medical care.

“If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care,” Insurer Cigna Corp. wrote in a May financial filing.

If CMS proceeds with the audits, the penalties are unclear for health plans who are accused of overbilling Medicare.

It’s important to be ready at all times for an audit – especially if your health plan has faced CMS oversight in the past. Being prepared will help plans identify and respond to potential gaps and address them as quickly as possible. The normal audit process is extensive, so one can imagine this latest round of audits will be in-depth at best. Plans are going to need help – and that’s where Tier 1 Pharmacy Consulting can help.

We provide support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. Even for the kind of audits that are forthcoming.

With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to get you through the process and avoid fines if at all possible.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

New CMS Rules to Increase Transparency and Lower Drug Costs

June 29, 2019June 30, 2019

The Centers for Medicare and Medicaid Services (CMS) recently published a final rule intended to increase transparency and lower drug prices. This announcement has been in the works since CMS first posted their proposal in November 2018. Now that the final ruling has arrived, it’s important for health plans to understand what’s changed and how the rule may affect their business. Tier 1 is available to consult with health plans about these important updates. In the meantime, here’s a brief look at what this final rule means for health plans and the health care industry more generally.

What Does the Final Rule Mean for Your Health Plan?

If you’ve been following along with this blog, this topic will already be familiar to you—we’ve been keeping you posted about its various updates since the proposal was first announced. Published on May 23, the CMS’s final rule is formally entitled, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” As the title suggests, the amendments within the final rule pertain to both Part C (Medicare Advantage program) and Part D (Prescription Drug Benefit program) regulations. The amendments aim to help health plans negotiate for lower drug prices and reduce out-of-pocket costs for enrollees of Part C and Part D programs. The CMS ruling achieves this aim by improving regulatory frameworks and facilitating the development of products that meet patient needs while also reducing their fees. Health plans only want the best for their members—and reducing patients’ out of pocket costs help minimize the expenditures of Part C and Part D programs.

What Does the Final Rule Say that Your Health Plan Needs to Know?

On the same day they published their final rule, CMS posted a helpful fact-sheet outlining significant changes that your health plan needs to consider moving forward. Key takeaways include:

Part D policy relating to six classes of drugs has now been codified.
Part D plans are now required to adopt one or more electronic Real Time Benefit Tools that have the capability to inform prescribers when lower-cost therapies are available under their drug benefit.
Policy is now being finalized that would allow Medicare Advantage plans to implement step therapy for Part B drugs as a recognized utilization management tool.
CMS will now require Part D plans to inform members of drug price increases and lower-cost therapeutic alternatives in their Explanation of Benefits.
A new prohibition against gag clauses in pharmacy contracts now restricts Part D sponsors from prohibiting or penalizing a pharmacy from disclosing a lower cash price to an enrollee.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

Should my health plan outsource or handle CMS compliance in-house?

May 26, 2019May 27, 2019

Why You Should Outsource Your Health Plan Headaches

Benjamin Franklin once said nothing in this world is certain except death and taxes. In twenty-first century America, this quote could be updated with a refrain: Nothing is certain except death, taxes, and the labyrinthine nature of our healthcare system.

Right now, the United States is in a state of flux when it comes to health care compliance. As lawmakers move towards different ends of the spectrum when it comes to how health care should be managed in this country, and by whom, health plans are often left to muddle through endlessly complex and quickly-changing rules and regulations. Changes occur so quickly in the health care space that it can seem like the Centers for Medicare and Medicaid Services are throwing out new regulations by the day. How can health plans keep up with the pace while also focusing on their clients’ needs and meeting their bottom line?

The answer is simple: by partnering with Tier 1 Pharmacy Consulting, health plans free up hours in their workday and save their employees time and countless headaches. CMS audits, guidelines, regulations, and changes to all of the above can be confusing. Outsource the work to us and your health plans will never have to worry about important business decisions falling through the cracks – possibly costing thousands of dollars and years of scrutiny.

Pharmacy Benefits Don’t Have To Be Complicated

At Tier 1, our goal is simple: Offer our health plan customers strategic, cost-saving solutions that boost the plan’s overall value and help its members by proving high-quality care. The way we go above and beyond that goal is just as simple: We offer a full suite of services designed specifically to save health plans both time and money.

Is your health plan well-versed on CMS’s 2019 update to the agency’s audit program? Every year, the CMS conducts thousands of audits, from BID audits to Formulary Administration audits, Transition Monitoring Program analysis, Data Validation audits and more. For some health plans, it would take a year just to work through the 2019 update, let alone take measures to prepare for the audits that may come along at any time. Tier 1 helps hundreds of plans a year by taking the grunt-work out of audit preparation: by outsourcing audit woes to Tier 1, health plans not only save time and money, but also greatly reduce their chances of paying fines due to accidental oversight.

Audits are just one example of what Tier 1 can offer health plans to make their schedules lighter and more able to innovate in other ways. We also help health plans to get answers to compliance questions more efficiently by acting as a liaison between them and pharmacy benefit managers. If your health plan has ever had questions about something as deceptively simple as website management or as straightforwardly complex as finding a new pharmacy benefit manager altogether, let Tier 1 help: we have the expertise and the insight needed to help health plans and PBMs get on the same page fast.

Reach Out Now and See What’s Possible

What would your health plan do if they didn’t have to worry about the endless complexities of CMS rules and PBM issues? It’s time to start thinking big. Hire Tier 1 Pharmacy Consulting today and start to see what’s possible for the future of your health plan.

Get in touch.

About Tier 1

CMS proposals to Medicare Part D address skyrocketing prescription drug costs

January 31, 2019

Prescription drug costs are a huge concern for Americans of all ages, especially those age 50 and older. A 2016 AARP survey of nearly 2,000 people found that 81 percent of older patients believe drug prices are too high. Nine out of 10 want the government to address the problem.

At the same time, a Bloomberg survey of 3,000 brand name prescription drugs determined that prices had doubled in some cases – and even and quadrupled in others – since December 2014.

The Centers for Medicare and Medicaid Services has released proposals to help contain prices in the Part D prescription drug benefit (and Medicare Advantage plans, but we only will cover Part D in this article). The hope is that the recommendations will offer health plans and pharmacies some flexibility as they try to help patients who often need expensive drugs to survive.

The complete CMS document is 185 pages long. Here are a few highlights that impact Part D plans.

– Part D policy requires plan sponsors to include on their formularies all drugs in six “protected” therapeutic classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals and antineoplastics. The proposal would create three exceptions that would allow Part D sponsors to impose formulary actions on drugs in protected classes: prior authorization and step therapy; a protected class single source drug or biological if its WAC has increased; and a new formulation of a single source protected class drug or biological that has the same active ingredient as the original.

– The CMS proposal would allow plan sponsors to remove a Protected Class drug from their formulary if the drug price is too high. The idea is to give plans an opportunity to receive bigger rebates on those drugs, which until now have seen lower rebates than non-PC drugs. That would boost price competition and help keep costs low.

– CMS also is proposing changing the definition of negotiated price so that it reflects the minimum price available. That way, a pharmacy could be reimbursed for any drug. Before, pharmacies could receive additional reimbursements to lower drug costs based on performance. The reimbursements are determined at the end of the end of a coverage year. The problem is, the majority of pharmacies don’t quality for the reimbursements.

– Under the proposals, plan sponsors and pharmacy benefit managers could use pricing tables based on the lowest possible reimbursement in their claims processing systems that interface with contracted pharmacies. That way, pharmacies could create stronger, more accurate budgets based on projected revenues.

The new CMS proposals are beneficial for pharmacies, plans and patients. But they can be difficult and time-consuming for busy health plans to wade through and implement. Tier 1 Pharmacy Consulting can handle it all for you.

How? Our experience is rooted in clinical practice and evidence-based medicine. We can help your plan develop effective, proactive initiatives – including complicated CMS changes to prescription drugs and everything else – that lead to quality health outcomes for your members.

Working with Tier 1 also will improve your plan’s performance and ensure compliance to prevent a CMS audit (although we provide extensive audit guidance and support as well).

We also can help monitor and assess the initiatives delegated to your PBM to ensure you are receiving the right type of ROI.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

Opioid epidemic a CMS priority in 2019

January 29, 2019

At least 130 people a day die of an opioid overdose in the U.S., according to the Centers for Disease Control and Prevention.

In 2017, fatal opioid overdoses were six times higher than they were in 1999. More than 191 million opioid prescriptions – including Oxycodone, Hydrocodone and Methadone – were dispensed to patients across the country that same year, the CDC reports.

“To reverse this epidemic, we need to improve the way we treat pain,” the agency’s website says. “We must prevent abuse, addiction and overdose before they start.”

Older Americans are not immune to the dangers of opioid misuse. Millions of men and women over the age of 65 are filling prescriptions for many different opioid medications at the same time, the Agency for Healthcare Research and Quality has found. Many of them are hospitalized to treat opioid-related complications.

The statistics are startling. It comes as no surprise, then, that the Centers for Medicare and Medicaid Services announced that it has issued major changes to its 2019 Medicare Part D Opioid Prescribing Policies. The changes target Medicare patients of all kinds who have been given opioids – first-timers, chronic users, users with the potential to mix medications and high-risk users who are prone to addiction.

As these new opioid safety alerts are implemented, ongoing communication between pharmacists, Part D plans and prescribers is crucial. Health plans with pharmacy benefits should take note of the following changes.

Seven-day Supply Limit for New Patients

Medicare Part D patients prescribed opioids for the first time will now be limited to a seven-day supply or less. If more is needed, the provider must request a coverage determination on behalf of the member. This new rule does not apply to patients already taking prescription opioids.

Opioid Care Coordination Alert

Whenever a Medicare patient whose cumulative morphine milligram equivalent is 90 or above gives a pharmacist a prescription for opioids, an alert will go out to the prescriber. The pharmacist may consult with the doctor about the patient’s need for a high MME. The idea is to address the potential for danger yet keep the doctor-patient relationship positively intact.

Drug Management

Under the new guidelines, part D plans will be required to contact doctors treating Medicare patients identified as high-risk for abuse to evaluate whether the medication is safe, medically necessary, and if the risk for misuse is there. The plan representative also will ask the provider if a Part D drug management tool is appropriate, such as a POS claim edit, pharmacy lock-in or prescriber limitation.

The Bottom Line

Health plans should be ready to implement the changes and contact providers as needed. We must work together to address to stop the opioid epidemic, and that includes properly caring for our Medicare recipients. Tier 1 Pharmacy Consulting can help you navigate it all.

Visit the Centers for Medicare and Medicaid Services for more information on its new opioid safety guidelines.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.

Is Your Website up to CMS Standards? If Not, We Can Help

January 29, 2019January 11, 2019

The ongoing requirements and regulations imposed by the Centers for Medicare and Medicaid Services can create an administrative headache for health plans who already have a laundry list of things to accomplish every day.

All marketing materials – including a health plan’s website – must comply with CMS guidelines that are often confusing, extensive and time-consuming.

Here is an overview and reminder of the general website requirements CMS has issued for Plan/Part D sponsors. We’ll tackle social media and mobile rules in a future post, because there are rules there, too.

Tier 1 Pharmacy Consultants can help you update your website and ensure all of your marketing materials are CMS compliant.

What Health Plans Must Do

Build a website that is easy to understand and navigate.
Maintain the current website content through Dec. 31 of each year.
Notify visitors if there is a link that will take them to a non-Medicare information webpage or to a different website altogether.
Include applicable disclaimers on every page of the site.
Build a separate section for Medicare information covered by the guidelines if the health plan also markets other lines of business.
Review and update website content as needed, including ever-changing prescription drug prices and information.
Include the date of the last update on each page.
Label all links.
Comply with Section 508 of the federal Rehabilitation Act, which requires agencies to make their electronic and information technology comply with the Americans with Disabilities Act, which prohibits discrimination against people with disabilities.

Document Requirements

Health plans also are required to post a handful of downloadable documents, such as marketing materials and communication materials. The documents must be accurate and up-to-date at all times.

Some documents, such as the Summary of Benefits, Annual Notice of Change, Evidence of Coverage, Provider Directory, and Formulary all needed to be in place by Oct. 15 of last year. Others needed to be posted all year and had Jan. 1 deadline for updates.

The Privacy Notice under the HIPAA Privacy Rule; Exception Request Forms for Physicians; Utilization Management Forms for Physicians and Enrollees; the Prescription Drug Transition Policy; Prior Authorization Forms for Physicians and Enrollees; and Part D Model Coverage and Redetermination Request Forms needed to be post on a plan’s website by New Year’s Day.

If it was a struggle, we can make it easier next time around.

What Health Plan Websites Can’t Do

Just like there are rules outlining what plans must do, CMS also has put forth actions they are prohibited from doing, including:

Plans cannot link to foreign drug sales, including links from advertisements, on their websites.
Plans cannot instruct users to input personal information other than a zip code, county, and/or state for access to non-beneficiary specific website content.
Plans cannot claim that they are not responsible for the content of their social media pages, as well as the websites of any related party that provides information on the plan’s behalf, such as a public relations representative or social media specialist.

Plans Cannot Forget to Include

A toll-free customer service number, days and hours of operation and TTY number address.
Member rights and responsibilities upon disenrollment.
Instructions on how to appoint a representative along with a link to the downloadable version of the CMS Appointment of Representative Form.
Instructions on how to file a grievance and an appeal, including procedures for filing, a link to the webpage, the 1-800 MEDICARE number, mailing address, fax number, any forms created by the health plan for appeals and grievances and more.
The statement, “You must file Form 1040, ‘US Individual Income Tax Return,’ along with Form 8853, ‘Archer MSA and Long-Term Care Insurance Contracts’ with the Internal Revenue Service (IRS) for any distributions made from your Medicare MSA account to ensure you aren’t taxed on your MSA account withdrawals. You must file these tax forms for any year in which an MSA account withdrawal is made, even if you have no taxable income or other reason for filing a Form 1040. MSA account withdrawals for qualified medical expenses are tax free, while account withdrawals for non-medical expenses are subject to both income tax and a fifty (50) percent tax penalty.”
The statement, “Tax publications are available on the IRS website at http://www.irs.gov or from 1-800-TAX-FORM (1-800-829-3676).”
Enrollment instructions and forms.
Medication Therapy Management program requirements.

Remember, CMS has the right to directly enforce its provisions to ensure compliance. Don’t let it get to that point. Make sure your website is up to par.

How we can help

The team at Tier 1 Pharmacy Consulting can be the liaison between the health plan and the pharmacy benefit manager to help oversee the steps needed to ensure CMS compliance, including regular website updates. The Tier 1 team can offer solutions on how to properly and effectively institute the appropriate process for oversight and ensure health plan information and marketing is compliant, accurate and up-to-date all year.

We are experts in Medicare. Even the best health plans need CMS guidance. That’s why we’re here.

About Tier 1

Drop us a note at info@tieronepc.com. Let’s get connected.