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MA Plans, Are You Ready for 2024?

by Yvonne Tso, PharmD, MBA

Every year in October, the Centers for Medicare & Medicaid Services (CMS) publishes a readiness checklist for Medicare Advantage and Prescription Drug Plans (MAPDs) [1] to assist in the preparation for the new contract year. On October 13, 2023, the CY 2024 Readiness Checklist was released. In addition to the usual critical requirements, there are changes and revised regulations for CY 2024. Highlighted below are some of the aforementioned to which particular attention should be paid.


1. Customer/Member Service Representatives (CSRs) – CSRs in call centers will be very busy during the Annual Election Period (AEP, October 15 to December 7). They should be well-versed with the changes in benefits in 2024 to answer questions from incumbent members but they should also be able to answer some questions from prospective enrollees. Provide them with job aids so that they know what to say to the callers and when they should transfer the call to the appropriate department. CSRs should be trained in Part C and Part D processes.[2] Moreover, the call center should be ready to provide language support service to callers with limited English proficiency (LEP—not to be confused with the Late Enrollment Penalty!). Check the TTY platform to make sure it is functioning as intended. Be prepared for both secret shopping calls and inquiring beneficiaries.


2. Agents and brokers – Agent and broker training and testing is a key component of a successful MAPD plan. Agents and brokers must possess in-depth knowledge of Medicare health and drug plans, benefits and operations, and CMS regulations in order to ensure that they do not enroll beneficiaries inappropriately or provide misinformation about plan benefits. CMS publishes training and testing guidelines annually to ensure consistency and quality across all agent and broker training and testing programs.[3] Take advantage of these training materials to stay compliant.


3. Utilization Management – The CMS 4201 F final rule (effective June 5, 2023) requires coordinated care plans to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require prior authorization for the active course of treatment. To ensure prior authorization is being used appropriately, CMS requires all MA plans establish a Utilization Management Committee to review policies annually and ensure consistency with traditional Medicare’s national and local coverage decisions and guidelines. The final rule also requires that approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.[4] Beginning January 1, 2024, an MA plan may not use any utilization management policies for basic or supplemental benefits unless those policies and procedures have been reviewed and approved by the Utilization Management Committee.[5]


4. Pharmacy and Pharmacy Benefit Manager (PBM) – Benefits from the Inflation Reduction Act 2022 continue to be phased in in CY 2024. The Pharmacy Department should ensure that the PBM correctly configures the adjudication system not to charge any coinsurance or co-payments by enrollees who fall into the catastrophic phase of the prescription drug benefit. Starting July 1, 2024, the Part B payment limit for new biosimilars when average sales price (ASP) data is not available will not exceed the payment limit of its reference biological.[6] If the PBM is not responsible for adjudicating Part B drugs, Pharmacy should work with the Claims Department to make sure the fee schedule[7] for Part B drugs is compliant with the guidance. CMS reminds plan sponsors again to use available information to coordinate Part B and D drug benefits.[8]


Effective January 1, 2024, CMS requires the application of all pharmacy price concessions at the point of sale[9]. If the payment to a pharmacy may be reduced by up to a certain amount, the maximum possible reduction in payment must be treated as a pharmacy price concession and reflected in the negotiated price available at the point of sale and reported to CMS on a PDE record.[10]


Effective January 1, 2025, CMS is expanding the PDE File Layouts. All Part D sponsors will be required to submit certification (CERT) test files prior to submitting production PDE files. CERT Testing is planned to begin on July 1, 2024.[11]


5. Drug Management Program (DMP) – Implementing a DMP to include beneficiaries with a history of opioid-related overdose became effective on January 1, 2022 pursuant to the SUPPORT Act[12]. However, some Part D plan sponsors may not have had the experience in placing a “potential at-risk” or “at-risk” beneficiary in the DMP. To effectively support the DMP requires collaboration of Pharmacy, case management, the team responsible for system processes, Appeals & Grievances and even network management.[13] Sponsors should also develop and provide opioid information to beneficiaries in accordance with 42 C.F.R. § 423.128(b)(11).[14]


It is a best practice for Compliance Officers to request the plans’ business owners and delegated entities to attest their readiness for a new contract year, which is a time-consuming activity but can supplement the Compliance Officers’ year-end risk assessment and Compliance Program Effectiveness evaluation.


Over the years, Integritas Medicare professionals have assisted MAPD plans in developing processes and tools to review and validate readiness and compliance with elements on the readiness checklist. It is a valuable investment to identify and remediate any gaps before they become deficiencies in the new year that may disrupt workflow or adversely affect members or be identified in a CMS audit. If you would like a copy of the readiness checklist or need assistance with completing the checklist, please contact us at 415-596-5277 or info@integritasmedicare.com

[1] The Readiness Checklist also applies to All Medicare Advantage Organizations (MAOs), Prescription Drug Plan Sponsors, 1876 Cost Plans, and Medicare-Medicaid Plans (MMPs). [2] CY 2024 Readiness Checklist Section IV, pg. 37 [3] Guidelines for Agent Broker Training and Testing for Contract Year 2014, July 8, 2013 [4] CMS Final Rule 4201F April 5, 2023 [5] CY 2024 Readiness Checklist Section Q, pg. 38 [6] Inflation Reduction Act: CMS Implementation Timeline published by CMS [7] ASP Pricing for Part B drugs is published quarterly and posted on CMS Medicare website. [8] 2024 Readiness Checklist Section V. Drugs Available Under Part A or Part B – Medicare Advantage Organizations and Part D Sponsors, pg. 34 [9] CMS Final Rule 4192 F [10] Id Section IX, pg. 15 [11] Id Section IX, pg. 14. PDE = Prescription Drug Event [12] Support Act was passed in 2018, re-authorized in 2023 [13] ID Section VI, pg. 11 [14] Id Section VI, pg. 23

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