Early each year, the Centers for Medicare & Medicaid Services (CMS) releases their Call Letter containing information on Part C and Part D programs that Medicare Advantage organizations and Part D sponsors need to take into consideration when preparing their 2015 bids.
According to CMS, policies in the 2015 Call Letter have been designed to improve the overall management of the Medicare Advantage and Prescription Drug Programs using 4 major outcomes: (1) vibrancy and stability, (2) value for the beneficiaries and taxpayers, (3) quality improvement, and (4) compliance improvement.1
“This year, to achieve these overlapping outcomes, CMS’ Call Letter activities follow 4 major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections,” according to the Call Letter.1
The process used to create the Call Letter consists of a culmination of feedback from payers, providers, and beneficiaries. Although some suggested that changes from year to year may place plans, providers, and/or beneficiaries in direct conflict, it does provide a channel for comment and change.
It is critical for all stakeholders to actively participate in the dialogue with CMS, which will shape the plan offering each year. Adoption of a final Call Letter is a transparent process whereby all comments are read and taken into consideration. I believe that failure to participate as a stakeholder may lead to policies and rules unfriendly to your environment.
In their draft letter, CMS proposed requiring Part D plan sponsors to offer terms and conditions for every level of cost-sharing, including preferred cost-sharing, to any willing pharmacy that will accept the terms. This proposal would benefit seniors by giving them more choice among pharmacies in their drug plan and lead to increased competition in the marketplace.
In particular, CMS has awarded a contract to study beneficiary access to preferred cost-sharing and assess beneficiaries’ geographic access to pharmacies offering preferred cost-sharing plans’ networks. The results of the study would allow them to decide whether standards should be set for network adequacy for pharmacies offering preferred cost-sharing, similar to current standards for retail network adequacy.
CMS plans to continue to review retail networks for the 2014 and 2015 plan years, and states it will take “appropriate action regarding any plan whose network of pharmacies offering preferred cost sharing appears to offer too little meaningful access to the preferred cost sharing.”1
Prior to release of the final Call Letter, CMS withdrew parallel rules being proposed, which would also address preferred cost-sharing. In the final Call Letter, the CMS indicated that they will continue to review the retail networks of plans offering cost-sharing for the 2014 and 2015 plan years.2
Medication Therapy Management
Medication therapy management (MTM) services are critical to patients’ understanding and adherence to their medication regimens and provided by pharmacists. Here, the agency expands access to these critical services and positions MTM service as a critical component of the Prescription Drug Benefit.
Monitoring and Compliance
CMS has been assessing Part D sponsors’ ability to implement their CMS-approved MTM programs in accordance with statutory requirements and related CMS guidance. Performance has been below standard for MTM targeting, comprehensive medication review (CMR) offers and providing patient written summaries, and meeting standards for targeted medication reviews.
In the future, sponsors identified as noncompliant with MTM program requirements may be subject to compliance actions, according to the draft letter. In addition, CMS is exploring new audit performance elements for MTM programs, which may be piloted in 2014 and fully implemented in 2015. Findings from the audits may also impact sponsors’ Part D Star Ratings for MTM.
In the final Call Letter, findings from the MTM monitoring project suggest that sponsors identified as noncompliant with MTM program requirements may be subject to compliance actions. In addition, CMS plans to develop new audit performance elements for MTM programs. Findings from the audits may also impact sponsors’ Part D Star Ratings for MTM for 2016 or beyond. Prior to piloting this audit area, CMS will publicly release the audit protocols. CMS may pilot MTM program audits as early as the 2014 or 2015 audit season.2
Health Information Technology Standards
CMS continues to encourage standards for Health Information Technology (HIT) for MTM service documentation. It also encourages consensus on more robust definitions for MTM, CMRs, and drug therapy recommendations and resolutions for service delivery and performance measurement.
The Call Letter mentions that the CMS will work with the industry to convene technical expert panels and develop additional standards and definitions, which will be proposed in future rulemaking for adoption by all Part D sponsors.1
In the final letter, the CMS encourages industry to develop and use standards for HIT for MTM service documentation, including more robust definitions for MTM, CMRs, and drug therapy recommendations, as well as resolutions for service delivery and performance measurement.
In addition, the CMS suggests that it will coordinate with the Office of the National Coordinator for Health Information Technology (ONC), and work with the industry to develop additional standards and definitions. The latter will be proposed in future rulemaking for adoption by all Part D sponsors.
“Commenters overwhelmingly supported the development and use of HIT standards for MTM and working towards reaching consensus on service-level definitions to streamline delivery, documentation, and reporting,” according to the final Call Letter.2
Administrative Costs in Bids
In its draft letter, the CMS stated that it considers MTM program services provided to targeted beneficiaries as an administrative cost to be included in the plan bid, incident to appropriate drug therapy, and not an additional benefit. In addition, an MTM program is based on the contract year. The plan’s bid should take into account MTM costs for the applicable contract year, as MTM programs can change from year to year. These proposals were all confirmed in the final Call Letter.
CMS also stated in their draft letter that eligibility targeting requirements are established as the minimum threshold and believes that as part of their broader efforts with respect to drug utilization management and quality assurance, sponsors may also elect to offer MTM services to an expanded population of beneficiaries who do not meet the statutory eligibility and may incorporate these additional costs of providing MTM services to an expanded population in the administrative costs in their bids.
However, the final Call Letter indicates that the CMS eligibility targeting requirements are established as the minimum threshold. Therefore, they believe that as part of broader efforts with respect to drug utilization management and quality assurance, sponsors may also elect to offer MTM services to an expanded population of beneficiaries who do not meet the eligibility criteria under section 423.153(d). Sponsors may incorporate these additional costs of providing MTM services to an expanded population in the administrative costs in their bids.2
CMS is encouraging sponsors to also offer MTM services to beneficiaries who meet the sponsors’ internal criteria for retrospective identification of opioid overutilization, but do not otherwise qualify for MTM. These beneficiaries may benefit from MTM services, including CMR, targeted medication reviews, and interventions with their prescribers.
In the final Call Letter, the CMS states that offering MTM to this population could complement the current drug utilization management requirements to reduce overutilization of opioids, assist in coordination of care, and improve pain management. “Commenters were mixed with regard to their support for this proposal,” they added. “Sponsors who were opposed generally agreed with the goals, but questioned the benefit and effectiveness of providing MTM services to engage this patient population to address overutilization of opioids.”
Most recently, the CMS finalized 1 provision opposed by the Academy of Managed Care Pharmacy (AMCP).3 Plans will have to provide advance notice to pharmacies regarding changes in maximum allowable prices starting in 2016. Several provisions listed as important by AMCP include preferred networks and any willing provider terms and conditions, integration of the noninterference clause of the Medicare Modernization Act, expansion of MTM, as well as requirements for mail-order pharmacies to require fulfillment within 3 to 5 days after receipt of a prescription.
Because adoption of the final Call Letter is a transparent process, I encourage all stakeholders to actively participate in a dialogue with the CMS. Failure to do so may lead to policies and rules counter to your needs. From year to year, the Call Letter has been a vehicle to apply innovation to plan benefits and provider services. It is important to understand the process—how comments are viewed by CMS.
- CMS, Advance Notice of Methodological Changes for Calendar Year (CY) 2015 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter, February 21, 2014.
- CMS, Advance Notice of Methodological Changes for Calendar Year (CY) 2015 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2015 Final Call Letter, April 7, 2014.
- Academy of Managed Care Pharmacy. CMS’ Final Medicare Part D Rule: CMS’ Final Medicare Part D Rule delays many provisions opposed by AMCP and others, but implements MAC Pricing Standards in 2016. www.magnetmail.net/actions/email_web_version.cfm?recipient_id=1030745711&message_id=4497191&user_id=AMCP&group_id=872545. Accessed May 22, 2014.