CMS releases final Medicare audit protocol updates

The Centers for Medicare and Medicaid Services (CMS) has released the final protocols for 2017 audits of Medicare Parts C and D plans. This is the latest step in a process RegPulse has reported on during the initial release and as draft protocols underwent updates during the last year.

The audit protocol revisions affect the ways in which plan sponsors—such as Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), and Medicare-Medicaid Plans (MMPs)—prepare and present information about their data universes to CMS. Sponsors that take part in these programs should review the changes and continue or update their programs assessments to identify the changes that affect them and plan appropriate responses.

Here is a summary of the relevant changes to the audit protocols in the final release, listed by program type:

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CY 2018 changes and policy updates for Medicare health and drug plans

Summary of provisions and impacts

The Centers for Medicare and Medicaid Services (CMS) released its Advance Notice of Methodological Changes for Calendar Year (CY) 2018 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2018 Draft Call Letter on February 1, 2017.

The purpose of the Advance Notice and draft Call Letter was to notify Medicare Advantage Organizations (MAO) and Part D sponsors of proposed changes to the Part C and Part D programs for the following plan year, including but not limited to:

  • Planned changes in the MA capitation rate methodology and risk adjustment methodology applied under Part C for CY 2018
  • Proposed changes in the Part D payment methodology for CY 2018
  • Proposed changes to the quality rating system and information the MAOs and Part D sponsors should consider while preparing their 2018 bids

CMS received many submissions in response to the request for comments on the Advance Notice and released final updates to MA and Part D Prescription Drug Programs for 2018 on April 3, 2017.
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President Obama signs 21st Century Cures Act, including provisions with significant implications for health plans and health care providers

President Obama on Tuesday, December 13, 2016, signed into law H.R. 34, the 21st Century Cures Act. Although the law focuses largely on the Food and Drug Administration, the National Institutes of Health, and issues of primary interest to life sciences companies, the new law includes provisions with significant implications for health care providers and health plans, especially those offering Medicare Advantage products. The provisions in some cases will affect compliance plans, Medicare payments, and strategic opportunities for organizations, making it imperative that provider and plan leaders take time to review how the 21st Century Cures Act might affect their organization.

Highlights of key provisions affecting health plans and health care providers are provided below.

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New file layouts, test procedures call for vigilance in preparing for CMS audits

Posted by Tom Delegram, Advisory Managing Director, Deloitte & Touche LLP,  and Jack Scott, Advisory Managing Director, Deloitte & Touche LLP on August 1, 2016

Health plans that participate in the Medicare Advantage (MA) and Part D programs should already be preparing to adapt to a large number of potential changes to the data and testing protocols the Centers for Medicare and Medicaid Services (CMS) uses during its audit process. CMS released the draft 2017 audit protocols in June 2016 and the comment period for the proposed changes extends until August 12, 2016. The rules may not become final until late in the calendar year, but there are steps plans can take now that will help them prepare for the 2017 audit season. Continue reading “New file layouts, test procedures call for vigilance in preparing for CMS audits”

Making Progress on Health Insurance Exchanges Without Definitive Guidance

Making Progress on Health Insurance Exchanges Without Definitive GuidancePosted by Kelly Sauders, Partner, Deloitte & Touche LLP

Health plans are waiting for CMS (The Centers for Medicare and Medicaid Services) to provide detailed requirements and guidance about participating in federal health insurance exchanges. In the meantime, we believe their leading bet is to refer to the managed care manuals for Medicare Part C and D. Or in the case of a state-run exchange, it probably makes sense to follow the state’s Medicaid guidelines.

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