CMS compliance Archives • Tier 1 Pharmacy Consulting

2020 Readiness Checklist for Medicare Advantage Organizations & Prescription Drug Plans

November 27, 2019

Last month, HPMS released a memo outlining its 2020 Readiness Checklist for Medicare Advantage Organizations and prescription drug plans.

The Centers for Medicare and Medicaid Services recommends all Medicare Advantage and prescription drug plans review the checklist – and take the appropriate action to meet the requirements next year. Health plans should closely review the entire checklist to ensure compliance. Remember, the checklist isn’t a compilation of suggestions from the government. Instead, it’s a summary of the most critical requirements.

Here’s a few examples of what’s in the readiness checklist for 2020:

Medicare Plan Finder Data. Part D Sponsors must provide access to the Health Plan Management System Part D Pricing File Submission Module.

Prescription Drug Event Requirements. Part D Sponsors must submit the data CMS needs to carry out payment provisions through the Prescription Drug Front-End System and processed by the Drug Data Processing System.

Coverage Gap Discount Program. The agency is asking Part D Sponsors to understand their responsibilities to participate in the CGDP, and provides information about the CGDP portal, onboarding training and more.

Precluded Providers and Prescribers. CMS has bigger expectations for 2020 when it comes to managing precluded providers and prescribers. Moving forward, MAOs/Part D Sponsors must, when when a prescriber is on the Preclusion List, deny payments for reject a pharmacy claim, deny a beneficiary request for reimbursement, or deny a health care service.

What Can Your Health Plan Do Next Year?

Tier 1 Pharmacy Consuting can make a readiness assessment for your health plan or prescription drug plan to ensure you are prepared and identify potential problems before they begin.

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Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program.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 Seeks Comments on Proposed Audit Protocol Changes for 2020

August 27, 2019August 27, 2019

The Centers for Medicare and Medicaid Services (CMS) announced in a recent memo that officials are seeking comments to their proposed audit program protocol changes. This blog will outline some of the most important changes and a reminder of steps health plans can take if they receive a CMS audit notification.

Key Proposed Changes Through 2020

Formulary Administration “‘Website” section removal of the Audit Process and Data Request
Transition sample size from 15 to 30
Removal of the CPE Self-Assessment Questionnaire and the ODAG Supplemental Questionnaire
Removal of ‘Dismissals’ from the data integrity sampling
Removal of OD approved cases from the Clinical Decision Making section
Increased the Grievance sample size
Removal of ‘Enrollment Verification’ audit element for SNP MOC
Removal of the Medication Therapy Management audit area

For the full list and a closer look at all of the proposed changes to audit protocols, check out the memo here. CMS is accepting comments through Oct. 15.

Many of the changes would reduce the burden on health plans. Even so, health plans should review any and all changes. The chance of a plan getting a program audit has increased and continues to grow. CMS is now reaching out to nearly 100% of plans every four via plan audits. Audit notice letters are typically sent March through July.

Plans should take steps sooner rather than later to address the changes and anticipate an audit in the future. The best way to deal with a CMS audit is to be prepared.

We can help.

The team at 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, create corrective action plans and more. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions and help you through the process from start to finish.

Tier 1 CEO Brent Hiley has been both the lead for CDAG (coverage determinations, appeals and grievances), the lead for FA (formulary administration) and even overall audit director, ensuring coordination of all elements related to data requests, deliverables, impact analysis and root cause summaries. He can provide onsite audit support for teams to ensure they are prepared for various questions that might be asked and coach them on how to approach certain aspects of the audit.

About Tier 1

CEO Brent Hiley 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.

Drop us a note at info@tieronepc.com. We’re here to guide your health plan every step of the way.

The Biggest Takeaways from CMS’s Annual Spring Conference

June 28, 2019

This spring, the Centers for Medicare and Medicaid Services (CMS) held an event that you and your health plan will want to know about. Each year, CMS’s annual Medicare Advantage & Prescription Drug Plan Conference provides important information to health plan provider staff, management, and executives regarding updates to existing Medicare policies, technology, and much more. This year proved to be no different—and we want to share with you some key updates that may impact you and your business now and into the future.

The one-day conference provided a number of important takeaways regarding All Payer Policies, Medicare Advantage Qualifying Payment Arrangement Incentives (MAQI), eMedicare, and more. Below, we outline two topics that we believe will have a significant impact on you and your health plan.

Medicare Advantage Value Based Insurance Design Update

In order to succeed in the health care space, health plans must shape their priorities based on the most up-to-date information available to them. CMS’s spring conference offered the opportunity to not just receive the latest news, but to peer into the future and prepare for what’s to come in the industry over next several years. Of particular interest was CMS’s overview of the future of its Value Based Insurance Design model. Starting in 2020, this model will begin incorporating significant innovations, from allowing health plans and other organizations to design targeted benefits for enrollees based on chronic condition or socioeconomic characteristics to providing meaningful rewards and incentive programs. In 2021, CMS will be testing the possibility of adding a Medicare hospice benefit to this program as well. CMS’s stated goal is to promote patient-centered care and increase access through innovative means. We are certainly excited about these what these future benefits might mean for our health plan clients.

Medicare-Medicaid Integration Policies

One of the great benefits of CMS’s annual conference is the clarity experts provide on some of the most complex policies and rules that health plans must abide by. A panel dedicated to explaining new integration related to Parts C and D Rules for Dual-Eligible Special Needs Plans (D-SNPs) provided several valuable takeaways. These Rules address both policy and technical changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PASE), Medicaid Fee-for-Service, and Medicaid Managed Care Programs for 2020 and 2021. This session highlighted important contexts for making updates to the regulations, specific regulation changes, and various operational considerations.

About Tier 1

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

CMS Draft Call Letter Released; Opioid Use Worrisome

March 25, 2019

Opioids remain a concern for officials at the Centers for Medicare and Medicaid Services (CMS). The agency has announced that addressing the epidemic – addiction, misuse, overdose and death – is one of its top priorities, and that officials have made big changes to 2019 Medicare Part D Opioid Prescribing Policies as a result.

More recently, CMS included in its Medicare Advantage (MA) and Part D draft call letter for 2020 a proposal to implement provisions of the federal SUPPORT for Patients and Communities Act that that require coverage of opioid addiction treatment programs, including medication-assisted treatment. The letter also encourages health plans to lower the out-of-pocket cost of Naloxone, which can quickly treat a narcotic overdose in an emergency, and, just as importantly, encourage doctors to prescribe the drug alongside opioids just in case. Alternative therapies also are encouraged. CMS says it plans to increase surveillance of opioid misuse with its overuse and misuse monitoring system.

The final version of the call letter will be released in early April. The initial draft also includes:

Changes to Supplemental Benefits

CMS is proposing that Medicare Advantage plans offer supplemental benefits outside the primary health plan to patients that suffer from a chronic illness. Those benefits would include things like transportation to and from medical appointments and other help.

Changes to Star Ratings

CMS wants opioid and benzodiazepine misuse measures included in the star ratings for MA plans. The idea is to track use and prevent prescriptions being handed over from several providers to patients who have developed an addition – or at the very least are misusing the drug.

Generic and Brand Formulary Tiers

CMS is looking at provisions that would prevent Part D plan formulary tiers from including both generic and brand formularies. Instead, generics and brands would be kept separate.

CMS changes can be difficult to navigate and keep track of. Need help? That’s why we’re here. The team at Tier 1 Pharmacy Consulting are pharmacy benefit plan experts, providing support and consultation for all types of CMS changes. Remember, plans that fail to abide will be subject to a CMS audit. Agency officials are watching health plans very closely this year.

Tier 1 can review changes to ensure accuracy and compliance. In the event of an audit, we will interpret data to identify potential issues, craft responses and create corrective action plans.

About Tier 1

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

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.

CMS Changes to 2019 Audit Protocol: What You Need to Know

January 19, 2019January 21, 2019

Pharmacy teams can now expect their drug management programs to fall under considerable audit scrutiny by the Centers for Medicare and Medicaid Services regarding a new federal law that aims to prevent prescription opioid misuse and addiction.

For the first time, CMS will look at health plans’ implementation of the Comprehensive Addiction and Recovery Act throughout the program audit process.

The agency released the change as part of its 2019 audit protocols.

CMS releases changes and updates to its program audit process every year so health plans know what to expect in the event they are audited. Such probes include CMS program audits, PDE audits, one-third Financial audits, BID audits, Formulary Administration audits, Transition Monitoring Program Analysis, Coverage determination/redetermination Timeliness audits and Data Validation audits.

Medicare plans are increasingly subject to closer CMS monitoring and review. An audit is more likely now than ever before.

Be Prepared

The next audit notifications will be sent between March and July.

Fewer Deliverables

The CMS changes to audit protocols include some positive news for health plans – including a reduction in audit deliverables. For example, health plans are no longer required to submit Call Logs and answers to supplemental questions during a program audit. CMS has suspended:

The collection of CDAG, ODAG, and SARAG Supplemental Questions at the time an audit engagement letter is drafted. Instead, CMS is encouraging plans to use the questions as a guide to determine non-compliance.
The collection of Call Logs, which help identify misclassification of coverage requests during the Compliance Program Effectiveness portion of an audit. The agency plans to use other ways to look at requests that are filed incorrectly, such as reviewing how well a plan oversees the call-routing process.
The collection of certain CPE data and documentation that can be obtained elsewhere.
The collection of Formulary and Benefit Administration and Special Needs Model Plan of Care enrollment verification evaluation.

CMS also has decided to make three CPE universe data fields optional: CPE FTEAM Column C, FTE Contract Effective Date; and CPE ECT Columns I and J, “Medicare Compliance Department Employee” and “Compliance Department Job Description.” The agency determined each played an insignificant role in determining non-compliance.

CMS also says it will take a broader look into the misclassification of calls as well as compliance and oversight of call routing.

The Bottom Line

Many of the changes for 2019 will reduce the burden on health plans. Others are challenging. Plans should take steps to address the changes and plan for an audit that is likely coming – this year or down the road. We can help.

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.