CMS held the 2016 Medicare Advantage & Prescription Drug Plan Fall Conference and Webcast on Thursday September 8th, 2016. In case you missed the conference, here is a brief overview of some of the topics covered.

Options for Adjusting Star Ratings for Audits and Enforcement Actions

CMS is re-evaluating the connection between audits, Civil Monetary Penalties (CMP), and sanctions and the Star Ratings. CMS is seeking early feedback from industry stakeholders on potential options including re-instating the reduction of overall Star Rating for sanctioned plans, developing a Star Rating measure specific to audits, and revising the current BAPP Star Rating measure to reflect the sizes of CMPs. Feedback should be submitted to CMS via email no later than September 23rd. Consideration of industry feedback will be included in the upcoming release of the Fall Star Ratings Request for Comments and the 2018 Draft Call Letter. Plans are strongly encouraged to provide feedback at each of these various stages, as CMS anticipates finalizing any changes in the 2018 Call Letter.

CMS also previewed upcoming changes to Medicare Plan Finder that will allow all Medicare beneficiaries to view plans under sanction. A sanction button will be available for beneficiaries to view more information about the details of the sanction and further explain the inability of the sanctioned plan to accept enrollments. However, beneficiaries who are not enrolled in the sanctioned plan will not be able to select a sanction plan for comparison, view pricing-related information, or view the plan’s overall Star Rating.

Improving Operations Through Audits

United Healthcare (UHC) shared insights from their most recent experience with CMS audits. It is important for plans to move toward proactivity when it comes to CMS audits. Strategies governing universe pulls to facilitate timely and accurate universes are of paramount importance. Overcoming the significant challenge of merging data from multiple sources into complete universes is a key element of successful universe submissions. A thorough universe QA process to identify and correct errors prior to submission is also critical. Business owner identification and accountability for accurate and timely universe submissions as well as engaging all impacted delegates helps ensure fulfillment of requirements and a smoother audit process overall. Achieving and sustaining an ongoing state of audit readiness can enable a plan to avoid “being brought to its knees” when CMS knocks on the door.

Overview of the Comprehensive Addiction and Recovery Act (CARA)

The Comprehensive Addiction and Recovery Act (CARA) became law on July 22, 2016. This Act allows Part D Plan Sponsors to establish drug management programs that limit “At Risk” beneficiaries regarding abused or diverted controlled substances to selected prescriber(s) and selected pharmacy(ies). This new functionality, which has long been used in commercial drug claim processing, will be effective on or after January 1, 2019. The process for this new functionality is similar to the current overutilization program with beneficiaries being identified as “At Risk” followed by an Initial Notification to the beneficiary, which provides information regarding their prescription drug use, a list of organizations that can assist with drug management programs and a request for preferences on prescribers and pharmacies. The Second Notification must be sent within 30 days of the Initial Notification. This notification indicates it has been confirmed that the beneficiary is “At Risk” and therefore the Plan Sponsor must have already completed the outreach to prescribers and pharmacies to confirm this decision. The Second Notification includes the selected pharmacies and prescribers to which the beneficiary will be limited for access for the identified controlled substances and the effective date. Once effective, if a beneficiary attempts to purchase the controlled substance at a non-selected pharmacy or has a prescription from a non-selected prescriber, they will receive a notification message from the pharmacy indicating why the beneficiary cannot obtain their drug. CMS announced that a Stakeholder Meeting would be scheduled no later than January 1st, 2017 for the industry to provide input on details of this program.

If you would like help assessing the information provided by CMS as it relates to your business or help assessing your associated risk, please feel free to contact us at


Share this on Twitter: