| Centers for Medicare & Medicaid Services (CMS) Resources Click here for: CMS Guidance on Medicare Prescription Drug Benefit Recent News June 19, 2008 Advocates Settle BAE Lawsuit Addressing Low-Income Subsidy Eligibility Issues On June 19, 2008, the Centers for Medicare Advocacy and the National Senior Citizens Law Center announced a settlement in Situ, et al. v. Leavitt, a class action lawsuit filed on behalf of full benefit dual eligibles (FBDEs) in Medicare Part D against the Centers for Medicare and Medicaid Services (CMS). Many FBDEs have been unable to fully access their benefits due to enrolment problems that have lead to coverage gaps. FBDEs also have been assessed co-payments that they do not owe due to inaccuracies in CMS’ data base. The settlement agreement is designed to resolve these problems by getting FBDE’s enrolled into Part D plans and by resolving low-income subsidy eligibility issues more quickly without burdening beneficiaries or pharmacies. The settlement does not address payment issues between Part D plans and pharmacies, although it is expected that the settlement terms may help reduced the volume of disputed claims.[1] The settlement covers virtually all full benefit dual eligible beneficiaries who have been unable to access benefits or who have been assessed copayments, incorrectly. Beneficiaries covered by the terms of the settlement include beneficiaries who live in the community as well as those who are institutionalized. Notably, to be considered a member of the class, a beneficiary must contact their plan, CMS or the State Medicaid agency to complain of an auto enrollment or subsidy problem. Click here for a summary of the settlement agreement. Click here for a copy of the settlement. [1] CMS does not have authority to intervene in payment disputes between Part D plans and pharmacies. June 9, 2008 CMS Discontinues the original E1 eligibility query. Effective April 1, 2009, CMS will discontinue support for the original E1 eligibility query and continue to support only the “enhanced E!” moving forward. The Enhanced E1 was implemented in December 2006 to provide enhanced search capability, additional data elements in the response, and more explicit messaging when the TrOOP facilitator is unable to identify the plan enrollment. Pharmacists may need to work with their software vendors to upgrade/reprogram the pharmacy’s software or amend existing contractual arrangements to request and receive the enhanced version of E1. CMS recommends implementing the enhanced E1 by November 15, the beginning of the Medicare Part D open enrollment period for 2009. For a copy of CMS’ Announcement, click here. June 9, 2008 CMS increases frequency of accepting and processing State Medicaid eligibility files. Beginning on or about June 15, 2008, State Medicaid Agencies will be able to submit multiple dual eligible files throughout the month and on any day of the month and CMS will process files submitted by the State Medicaid Agencies and perform LIS deeming and auto-/facilitated enrollment on a daily basis, absent any unforeseen circumstances. Part D sponsors will receive information about the results of LIS deeming on the weekly Transaction Reply Reports (TRRs) released throughout the month, not just on the first weekly TRR of the month, as is currently the case. In addition, PDPs that qualify for auto-/facilitated enrollment will receive the PDP notification File for Auto-and Facilitated Enrollments on a flow basis throughout the month beginning on or about June 15, 2008. For a copy of CMS’ Memorandum for Part D Plans, click here. June 5, 2008 New CMS Hospice Regulations The Centers for Medicare & Medicaid Services (CMS) released revised Conditions of Participation (CoP) for hospice programs that participate in the Medicare and Medicaid programs. In the revised CoPs, new medication-related services are required, above and beyond what was required in the previous (current until December) regulations. Consultant pharmacist services were previously required only for inpatient hospice facilities. The new requirements are broadened to include all hospice programs, which presents a new opportunity for consultant pharmacists to market their services and skills to hospices. Dispensing pharmacies who provide medications and/or durable medical equipment to hospice patients, should also be aware of the new requirements. Click here for the CMS Final Rule that outlines the new Hospice Regulations. Click here for ASCP's Summary of the Medication Management Requirements in the New Hospice Regulations. May 30, 2008 USP's Medicare Part D Model Formulary Guidelines Move to Three Year Revision Cycle In response to a request from the Centers for Medicare and Medicaid Services (CMS), the United States Pharmacopeia (USP) announced on May 20, 2008, it will no longer revise the Medicare Model Guidelines on an annual basis. Instead, “based on the success and stabilization of recent versions of the Model Guidelines, the Centers for Medicare and Medicaid Services (CMS) and USP have agreed to move from an annual timeline for revision to a three-year cycle.” The MMA designates USP to develop the Medicare Model Guidelines and to revise the Guidelines from time to time to reflect changes in therapeutic uses of covered Part D drugs and additions of new covered Part D drugs. Plans that design to conform to the categories and classes in the Model Guidelines may not be found “likely to substantially discourage enrollment” by certain Medicare beneficiaries. (MMA, Section 1860D-11(e)(2)(D)(i) and (ii)). USP’s press release states that CMS will use the current Medicare Model Guidelines Version 4.0, without changes, through plan year 2011. In 2010, USP intends to begin work on Version 5.0, which will be utilized during the Part D formulary review process for plan year 2012. Version 4.0 and related information are available on USP’s Web site. May 20, 2008 CMS list of poorest-performing nursing facilities nationwide, also known as special focus facilities (SFFs) Updated October 31, 2007 Continuity Assessment Record and Care Evaluation (CARE) Instrument The Medicare Continuity Assessment Record and Evaluation (CARE) is a uniform patient assessment instrument designed to measure differences in patient severity, resource utilization, and outcomes for patients in acute and post-acute care settings. This tool will be used by the Centers for Medicare & Medicaid Services (CMS) to: (1) standardize program information on Medicare beneficiaries' acuity at discharge from acute hospitals, (2) document medical severity, functional status and other factors related to outcomes and resource utilization at admission, discharge, and interim times during post acute treatment, and (3) understand the relationship between severity of illness, functional status, social support factors, and resource utilization. The CARE instrument will be used in the Post-Acute Care (PAC) Payment Reform Demonstration program mandated by Section 5008 of the Deficit Reduction Act of 2005 to develop payment groups that reflect patient severity and related cost and resource use across post acute settings. July 16, 2007 ASCP Letter to CMS About Requirement for Tamper-Resistant Prescriptions for Medicaid Recipients July 2007 CMS Proposes to Remove Exemption of FAX Prescriptions from e-Prescribing Requirements Links to Key CMS Web Pages
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