CY2015 Call Letter and Part D Final Rule

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If you have any questions about this Call Letter or the Proposed Rule, send an email to govaff@ascp.com.

Each year insurance plan companies and organizations wishing to offer to eligible Medicare beneficiaries the Medicare Prescription Drug Benefit, commonly referred to as the Part D drug benefit, must submit a contract bid to the Centers for Medicare & Medicaid Services (CMS). Contracts for providing Part D plan coverage to beneficiaries are awarded to companies and organizations whose bid submissions are reviewed and approved by CMS annually. The benefit is offered through Part D Plans (PDPs), Medicare Advantage-Part D (MA-PD) plans, PACE organizations and cost plans. As part of this yearly process, CMS will release several regulatory guidance documents, which are a matter of particular importance to companies and organizations interested in providing the Part D benefit to those patients who receive coverage.

CY2015 Part D Proposed Rule

CMS published a proposed rule to make several changes to Medicare Part D in the January 10, 2014 Federal Register. This document outlines CMS’s potential regulation changes to coverage and benefits for patients, and guidelines for Part D plan sponsors. It often contains fundamental policy shifts to this portion of Medicare. ASCP submitted comments March 7, 2014.

CY2015 Call Letter

The Announcement for Medicare Advantage-Part D Payment Policies and Call Letter contains annual adjustments and parameters for the defined standard Part D benefit for the upcoming plan contract year. The Call Letter provides guidance to PDP sponsors in preparation for the bid and contract for the upcoming contract year. It is issued in the spring of each year in advance of the bid submission deadline in June and contains important new information and operational requirements for Part C, Part D, and cost plan contractors. The draft CY2015 Call Letter was released February 21, 2014. The final Call Letter was published April 7, 2014.  

What does this mean?

Due to the high population of Part D beneficiaries residing in LTC settings, existing policies or new adjustments to the standard Part D benefit for a particular contract year often have direct and indirect impact on LTC pharmacies, consultant pharmacists, and LTC facilities. Since Part D is a common prescription drug benefit for older adults in the community and LTC facility residents, ASCP reviews any proposed regulations, and the annual draft Call Letter published prior to March 1, to determine which if any changes imposed on PDP sponsors will create new policy changes for LTC pharmacies, consultant pharmacists, or LTC facilities. All industry stakeholders are able to submit comments to CMS during a comment period prior to the publication of any final regulations. The final Call Letter is published the first Monday in April of each year.

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January 2014

Advocacy for Hospice Enrollee Medication Access Continues

ASCP has met with officials from the Centers for Medicare & Medicaid Services (CMS), as well as representatives from the Senate Finance and House Ways & Means committees, to address ongoing problems related to the CMS hospice drug-coverage guidelines published March 10, 2014. CMS officials have signaled a willingness to consider further clarification of their guidance or a complete withdrawal in favor of an interim replacement policy. ASCP is working closely with other stakeholder organizations such as the National Hospice and Palliative Care Organization and the Pharmaceutical Care Management Association. In addition, ASCP submitted comments (PDF). July 1, 2014 in to CMS. ASCP used the opportunity to document prior authorization processing and medication access barriers observed in the field as a result of the current guidance. The Society reiterated its request to suspend the guidance until a more appropriate policy can be established.

ASCP Advocacy for Hospice Enrollee Medication Access

ASCP Policy & Advocacy staff have received a number of reports from members regarding problems related to coverage of Part D drugs for hospice enrolled beneficiaries. The problems are related to a new guidance document published by CMS March 10 and involve a blanket prior authorization policy for all Part D claims submitted for hospice enrollees. The new policy has created access barriers for these patients as well as difficulty getting claims paid for enrollees in long-term care facilities. Staff and leaders have met with officials from the Centers for Medicare & Medicaid Services (CMS), as well as representatives from the Senate Finance and House Ways & Means Committees, to address ongoing problems related to the CMS hospice drug coverage guidelines published March 10. ASCP is working closely with other stakeholder organizations such as the National Hospice and Palliative Care Organization and the Pharmaceutical Care Management Association.

Additionally, ASCP submitted comments (PDF) July 1 in response to a CMS public solicitation for comments on the guidance in contemplation of a future rulemaking.  ASCP used the opportunity to document prior authorization processing and medication access barriers observed in the field as a result of the current guidance.  We also reiterated our request to suspend the guidance until more appropriate guidance can be established."

CMS Releases CY2015 Part D Final Rule

The Centers for Medicare & Medicaid Services (CMS) on May 23rd published the Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program (a.k.a. Part D Final Rule) in the Federal Register. 

CMS has withheld several of those sections from the final rule. During the comment period for the proposed rule, ASCP submitted feedback to CMS’ public docket regarding the following sections: Drug Categories or Classes of Clinical Concern and Exceptions (six-protected classes), Medication Therapy Management Program (MTMP) Under Part D, Efficient Dispensing in Long Term Care Facilities and Other Changes, Prescription Drug Pricing Standards and Maximum Allowable Cost (MAC transparency), Any Willing Pharmacy Terms and Conditions and Enrollment Requirements for the Prescribers of Part D Covered Drugs. CMS finalized the MAC transparency provision and the prescriber enrollment requirement in the final rule.

ASCP is evaluating other sections of the final rule that may impact LTC pharmacists. A full analysis of the final rule will be posted on this page as it becomes available.

CMS Publishes Final CY2015 Call Letter

On Monday, April 7, CMS published the final CY2015 Announcement for Medicare Advantage-Part D Payment Policies and Call Letter (PDF)  in the Federal Register. In the document, CMS addresses sections regarding access to preferred cost sharing, appropriate utilization of prior authorization requirements, the MTM benefit, and antipsychotic drug use data. ASCP is reviewing the document to determine the impact on ASCP members and the patients we serve. We will keep you informed as we learn more.

CMS Issues Revised Guidance Regarding Payment of Part D Drugs for Patients Enrolled in Hospice

On March 10, 2014 the Centers for Medicare and Medicaid Services (CMS) issued revised, final guidance (PDF) regarding Medicare Part D payment of drugs for beneficiaries enrolled in hospice. This memo provides clarification regarding coverage and payment responsibility for Part D beneficiaries enrolled in hospice. The clarifications included in this revised memo are: the inability of CMS to allow a transition period to establish consistency in payment for patients moving from Part D coverage to hospice; the interaction needed between the prescriber-hospice provider-beneficiary-plan sponsor in the prior authorization process; the lack of a process for dispute resolution (independent reviewer) in 2014; and the non-inclusion of hospice-related complaints in determining a plan’s star rating. As these are new clarifications to existing CMS policy, the agency has decided to change the effective date of this guidance to May 1, 2014. CMS indicated that some provisions in this guidance will be promulgated in a forthcoming rulemaking and comment period. In preparation of this action, members are encouraged to ask questions or provide feedback on this new guidance to govaff@ascp.com.

CMS Releases Draft 2015 Medicare Advantage (MA) Call Letter

On Friday, February 21st, CMS released the draft 2015 Medicare Advantage (MA) Call Letter (PDF) via their HPMS system. ASCP staff has begun reviewing the document to determine the impact it will have on our members. As we move forward in crafting a response by the March 7th deadline, we will keep our members informed of the sections that may be particularly pertinent.

MTM beneficiary pool to be expanded under CMS Proposed Rule

On January 10, 2014, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that outlines many changes to Medicare Part D for 2015. ASCP has been reviewing the 678-page document for provisions that may affect our members.

One section of importance would expand the pool of eligible medication therapy management (MTM) beneficiaries by relaxing certain prerequisites. CMS proposes that Part D plans target beneficiaries who have two or more chronic conditions. At least one of those diseases must be from the following list: cardiovascular disease, diabetes, high cholesterol, respiratory diseases, arthritis, mental health, Alzheimer's disease, and end stage renal disease. Previously, CMS said plans could require three chronic diseases before a beneficiary was targeted for MTM. CMS also proposes to lower the cost requirements for beneficiaries from $3,144 per year on medications per year down to $620 per year - the estimated cost of a year's supply of two generic drugs. The beneficiary must also be taking any two Part D drugs.

It is expected that up to 55 percent of Part D beneficiaries could now have access to such services under these changes.

Proposed Rule on Changes to Part D for 2015

An expansion of the medication therapy management (MTM) beneficiary pool and changes in Medicare Part D formularies' six protected drug classes are among the modifications proposed by the Centers for Medicare & Medicaid Services to Medicare Part D starting in 2015.

ASCP is reviewing the document, outlining the changes, and will submit comments by the March 7, 2014 regulatory deadline.

Other CMS proposals would modify plan sponsor audit and inspection authority, prescriber enrollment requirements for Medicare, identification of improper prescribing practices, access to mail-order prescription services, and guidance on the efficient dispensing of medication in long-term care facilities. Notably, the MTM modifications would relax coverage prerequisites. Experts say that if the proposed rule goes into effect, up to 55% of Part D beneficiaries would have access to such services.

ASCP Staff Reviewing CMS Proposed Rule on Medicare Part D

On January 10, 2014, CMS released a proposed rule on "Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs," which contains many changes to Medicare Part D. ASCP Staff has already begun reviewing the 678-page document for sections that have significance to pharmacy and may impact our members. More information will be shared over the next month as we evaluate the rule more thoroughly.

CMS Releases Medicare Part D Proposed Rule

On January 7, 2014, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule (PDF) that outlines many changes to Medicare Part D for 2015. ASCP Policy and Advocacy staff has been reviewing the 678-page document for provisions that may affect our members. We will keep our members apprised of the sections of particular merit as we begin to craft our response.

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