2016 CMS Applications: Highlights and Basics

This week’s CMS industry training on applications was quite informative, and contained many audience questions that you will want to hear.   The recording is already available to registrants for those who missed it.  There was way too much information for me to summarize, so I have included here a few highlights from the call and some basics that are easily overlooked.

Highlights

All new Part D applicants (MA-PD and PDP) who do not have a Part D contract with CMS that has been in effect for one year prior to application submission, must use a contracted first tier, downstream, or related entity (FDR) that has one year experience in the last two years performing functions in support of another Part D contract.  Also, new PDP applicants must have two continuous years’ experience offering health insurance immediately prior to submitting the application or five continuous years actively managing prescription drug benefits.  CMS confirmed that the applicant can use the experience of a parent or subsidiary of its parent to comply with these requirements.

CMS also highlighted that applicants must validate their home infusion (HI) and long term care (LTC) pharmacies prior to submission.  They must have valid NPIs.  If you upload invalid information, the application will be considered deficient.  This reminder is certainly a result of last year’s CMS exercise of calling HI pharmacies directly to ask them about the services they perform.  Based on the tone of yesterday’s call, there is low tolerance for applicants that do not verify this information.  They further mentioned that applicants must make sure their ITU file matches ITU reference file. “Even if the spelling is wrong, please use the wrong spelling.”  You will need to listen to the entire call recording to catch all the information provided, but the slides are a good start. 

Nail down the basics.

• It may seem trivial, but make sure you have the right contact name in the Part C Application Contact and Part D Application contact fields.  Earlier last year when CMS sent their first round of deficiency notices, only the application contacts received the emails at the plan — no one else.  With only one week to address deficiencies or gaps after that first notice is received, it is imperative that the right contact is in place and that they are aware that they need to monitor notices from CMS quite closely.
• Cross-walk documents using pdf page numbers.  CMS has quite a bit of information to review so point them directly to the requirement in your document, be it the Quality Improvement Plan or the PBM contract.
• CMS stresses to follow instructions and use the new templates for the Part D application; do not use anything from previous years.  Also, do not submit such a thin application that is indicative that it is simply a placeholder for more time.

Make sure your effective dates are in line with the application requirements.  

·        Consider your licensure and contract effective and end dates.  For example, your state license or certificate of authority needs to be in effect to cover the entire 2016 plan year.  If yours expires mid-year, you can expect a deficiency unless you upload documentation showing the certificate covers the entire plan year, or other documentation such as proof of payment for the renewal.

·        If you have a subcontract of an FDR that you must upload to CMS based on the fact they are performing a key Part D function, ensure that the effective date is appropriate.  For example, one key Part D function is enrollment processing.  Enrollment functions must be in place and operational during the AEP.  Therefore, ensure that the effective date of a contract is in line with the time frame for which they will begin working with Part D beneficiaries on your behalf.  (Remember: if delegating this or other key Part D functions to a parent organization, that executed subcontract must be uploaded.  As mentioned in last week’s call, the Part C agreements are not required this year for upload. )

In a couple days, I’ll post some interesting things that our team has encountered along the way that may help shed light on the application documentation.  For example: is there an upload missing from the Part D readme file?  There sure is.  Is there something in the PDF application that doesn’t quite match HPMS?  A couple things, actually.  If you have questions, by all means follow CMS’ instructions for questions!  However, if you find anything that doesn’t quite make sense that you’d like to share, we’d love to hear from you.

Resources

The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow up questions. Visit our website to learn how GHG can help >>

Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>