by Yvonne Tso, PharmD, MBA
Annually, the Centers for Medicare & Medicaid Services (CMS) distributes a Readiness Checklist to Medicare Advantage and Prescription Drug Plan (MAPD) Sponsors (“Sponsors”) as a reminder for readiness prior to open enrollment. Although CMS has stopped requiring Sponsors to submit assessment attestations, the expectation remains that Sponsors review the checklist to ensure their enrollees receive effective medical and drug coverage in the new contract year. As a managed care organization, an MAPD Sponsor should ensure that every functional department within the plan reviews the Checklist and reports to the Compliance Officer its readiness or areas at risk (i.e., “not ready”) for the new contract year.
For CY 2022, there are new requirements for MAPD other than preparedness for the customary benefit changes. The 2022 Readiness Checklist highlights some of these new requirements and resources:
1. In alignment with Executive Order 13985 (Advancing Racial Equity and Support for Underserved Communities Through the Federal Government), the CMS Office of Minority Health offers different tools via the Health Equity Technical Assistance Program to health plans that have identified deficiencies and needs among the underserved and minority groups in their communities. CMS has a website offering resources for health plans and their health equity initiatives. Addressing health inequity within its enrolled population is economically sound practice because treating conditions before their progression can mitigate subsequent costly procedures or long-term treatments and accelerate recovery and preserve well-being for the afflicted. Examples include preventive screening services, early diagnostic tests and immunization and medication adherence to manage chronic conditions. As the saying goes, a stitch in time saves nine.
2. Beginning January 1, 2022, Part D Sponsors are required to implement a Drug Management Program (DMP) to comply with regulations codified through CMS 4190-F2.
A DMP should be designed to address overutilization of frequently abused drugs (FADs)[1] while maintaining access to such drugs as medically necessary. The DMP should identify potential at-risk beneficiaries (PARBs)[2], engage them in case management through contact with their prescribers to determine if the member is at risk. Access to coverage of FADs may be limited for the at-risk beneficiaries (ARB) following notification and implementing member-specific point-of-sale claim edits. In general, the member may select the prescriber and pharmacy.
Identified PARBs and ARBs in the DMP who are Low Income Subsidy-eligible are limited in their ability to change plans using Special Enrollment Period (SEP). CMS provided guidance for Sponsors to identify PARB/ARB and the procedures to implement a DMP in a recent HPMS memo published on September 30, 2021. Administration of the Drug Management Program is one of the audit elements in the 10727 CMS program audit protocol to be implemented in CY 2022. Getting DMP ready for 2022 also helps prepare for a potential CMS audit in the new year.
3. For CY 2023 (data collected in CY 2022), member experience measures collected in CAHPS[3] will have a weight value of 2 for the STAR measures, up from 1 in previous years. Investing in additional training for staff in Customer Service and Call Centers is not only helpful during the open enrollment period but can also leave a good impression with callers who might participate in the CAHPS. Call volume is typically heavy during Annual Enrollment Period (AEP) from October 15 to December 7, followed by the Medicare Advantage Disenrollment Period (MADP) from January 1 to February 15. The Medicare Advantage Open Enrollment Period (MA OEP) begins on January 1 and ends on March 31. During this time, MA plan enrollees may disenroll or switch to another MA plan (either with or without Part D coverage) or switch to Original Medicare and enroll in a stand-alone PDP. The data collection timeframe for CAHPS is from March to May. The above activities can keep a call center very busy from October to March and call center staff are the front-line workers. First impressions matter. A call ending satisfactorily could influence enrollment or disenrollment. A positive first impression can be long-lasting.
Training should include benefit changes (they are described in the Annual Notice of Change), Part D formulary changes (impacted members are notified in advance of the changes), how the Senior Savings Program works for participating Sponsors, and how a new enrollee can get more than a 7-dayseven 7 supply of an opioid pain medication when waiting at the pharmacy.
4. Part D Sponsors should develop and provide opioid information to enrollees in accordance with 42 C.F.R. § 423.128(b)(11). The information should cover risks associated with prolonged opioid use and coverage of non-pharmacological therapies, devices, and non-opioid medications.
5. Coordination of benefits – it is best to coordinate Part D and Part B benefit accumulations at the beginning of a new year, if the Pharmacy Benefit Manager (PBM) processes diabetic supplies or nebulized inhalation drugs dispensed by retail pharmacies. Sponsors that have gone through a one-third financial audit in 2021 will recall the focus on drugs dispensed to members in hospice or in skilled nursing facilities that are not eligible for Part D. To adjudicate the drug benefits between Part B and Part D requires accurate member demographic data and data interface internally (between departments that process enrollment data, Daily Transaction Reply Reports and Claims) and externally (with the PBM). If these processes are established and validated for the new contract year, Sponsors are also prepared for the one-third financial audit that may beckon in 2022.
Sponsors bear the sole responsibility for the accuracy of the readiness assessment, not their subcontractors or related entities, and CMS will continue to monitor the operations of the Part C and Part D programs and Sponsors are compliant with the programs’ requirements using various mechanisms.
We, at Integritas Medicare, have supported MAPD Sponsors in implementing new programs (such as changing the PBM) and starting a new plan. The above is not a comprehensive list of all the items in the Readiness Checklist CY 2022. We would be glad to respond to any questions related to the above or any items on the 37-page checklist. Contact us at 415-596-5277.
[1] CMS has determined that opioids (except buprenorphine for medication-assisted treatment and injectables) and benzodiazepines are FADs for purposes of Part D DMPs. [2] CMS has defined PARB and ARB in the 2022 Part D Drug Management Program Guidance [3] Consumer Assessment of Health Plans and Systems.