First Name (1) Reward factor. This rating-specific factor is added to both the summary and overall ratings of contracts that qualify for the reward factor based on both high and stable relative performance for the rating level.
Find It Fast! Response: Such outreach is no longer required. CMS' previous guidance in this regard was based upon the prior requirement—which the modifications to § 423.120(c)(5) are removing—for sponsors to pay pharmacy claims with inactive and invalid NPIs when the pharmacy either could not or did not correct the prescriber NPI and then obtain the active and valid ones afterward.
Help Sign in with Facebook MedPulse News App Previous: Medicare Advantage 72. Pew Research Center, May 2017, “Tech Adoption Climbs Among Older Adults”, http://www.pewinternet.org/2017/05/17/tech-adoption-climbs-among-older-adults/.
Contact Department Staff (a) Measure Star Ratings—(1) Cut points. CMS will determine cut points for the assignment of a Star Rating for each numeric measure score by applying either a clustering or a relative distribution and significance testing methodology. For the Part D measures, CMS will determine MA-PD and PDP cut points separately.
SEP—CMS/State Assignment Within 3 months * of assignment or notification of assignment, whichever is later Upon application date. Accountable Care Organizations (ACOs)
to allow practitioners to choose to document office/outpatient E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively practitioners could continue using the current framework;
Acquisition Cost of Equipment [Education] § 423.180 You have worked long enough in a federal, state, or local government job to be eligible for Medicare. You get Medicare Part A premium-free if you’ve worked at least 10 years, or 40 quarters, while paying Medicare taxes.
More service providers to choose from Effective June 3, 2016. (g) Data integrity. (1) CMS will reduce a contract's measure rating when CMS determines that a contract's measure data are inaccurate, incomplete, or biased; such determinations may be based on a number of reasons, including mishandling of data, inappropriate processing, or implementation of incorrect practices that have an impact on the accuracy, impartiality, or completeness of the data used for one or more specific measure(s).
The correcting document is effective January 1, 2015. Learn everything you need to know about Medicare Supplement user rights and enrollment periods. [...] Comment: Overall, commenters supported the continued use of the CAI, but the majority of commenters suggested some enhancements to the current methodology (which we would continue to use under our proposal). Many commenters believe that the selection rules for adjusted measures are somewhat arbitrary or restrictive and result in a small subset of adjusted measures. These commenters suggested expanding the number of measures for adjustment. The suggested enhancements for increasing the number of adjusted measures focused on modifying the selection rules. Commenters suggested revising the second set of selection criteria that are based on the within-contract disparity analysis across contracts, which would result in a larger set of adjusted measures. The suggested modifications included a revision of the percentage used for the median absolute difference between LIS/DE and non-LIS/DE beneficiaries for all contracts analyzed. Some commenters suggested changing the currently employed value of 5 percentage points to a lower values, such as 1 or 2 percentage points. A commenter suggested that the percentage for the rule vary based on the measure, such that the number is meaningful for the particular measure. A commenter suggested modifying the selection rule from the proposed one that uses the entire range of the within-contract disparities to instead identify the measures where the LIS/DE subgroup performed better or worse than the non-LIS/DE subgroup (basing the second selection rule to the middle 90 percent of the differences in the distribution of the within-contract disparity analysis).
Comment: We solicited comments on potentially adding measures in the future that evaluate quality from the perspective of adopting new technology. Many commenters supported adding a measure related to the use of technology, but multiple commenters cautioned that CMS rely on and use evidence that technology impacts health outcomes or improves the experiences of beneficiaries in order to adopt specific measures of that type. A number of commenters cautioned CMS to move carefully and slowly on promoting technology due to the potential for unintended consequences. A few commenters did not support measuring the adoption of technology, because such adoption may not always be in the best interest of the patient or enrollee. A few commenters did not support such measurement because adoption of technology is hard to measure well and may not lead to greater member satisfaction or correlate with other measures of plan performance. Those commenters discouraged such a focus, believing that beneficiaries will vary in their interest in whether plans and providers adopt new technologies, so measures of such adoption many not inform plan choice. A few commenters also feared that measures of adoption of technology may end up reflecting geographic differences and the socioeconomic status of members enrolled in the plan rather than the quality or performance of the plan itself. With respect to CMS' proposal to possibly add new measures that address the issue of new technology in the future, such as telemedicine, a commenter pointed out that “Use of new technologies” is not clearly defined and can span a number of technologies implemented across plans but not in a uniform manner or across all service areas. A commenter recommended that CMS continue to look at the incorporation of new technologies into Star Ratings measures but withhold any proposals for CY 2019 and CY 2020 until more formal proposals can be put forth for notice and comment prior to adoption. A commenter specifically urged measures of e-prescribing and e-prior authorization in Star Ratings. Another commenter urged CMS to explicitly capture in CAHPS composites (that is, the combination of two or more survey items into a measure) the use of telemedicine, as current survey wording may not do so.
Wireless We proposed to update annually the performance and variance thresholds for the reward factor based upon the data for the Star Ratings year, consistent with current policy. A multistep process would be used to determine the values that correspond to the thresholds for the reward factors for the summary and/or overall Star Ratings for a contract. The determination of the reward factors would rely on the contract's ranking of its weighted variance and weighted mean of the measure-level stars to the summary or overall rating relative to the distribution of all contracts' weighted variance and weighted mean to the summary and/or overall rating. Under the proposal a contract's weighted variance would be calculated using the quotient of the following two values: (1) The product of the number of applicable measures based on rating-type and the sum of the products of the weight of each applicable measure and its squared deviation  and (2) the product of one less than the number of applicable measures and the sum of the weights of the applicable measures. A contract's weighted mean performance would be found by calculating the quotient of the following two values: (1) The sum of the products of the weight of a measure and its associated measure-level Star Ratings of the applicable measures for the rating-type and (2) the sum of the weights of the applicable measures for the rating type. The thresholds for the categorization of the weighted variance and weighted mean for contracts would be based upon the distribution of the calculated values of all rated contracts of the same type. Because highly-rated contracts may have the improvement measure(s) excluded in the determination of their final highest rating, each contract's weighted variance and weighted mean would be calculated both with and without the improvement measures.
Not all MA plans may be willing to contract directly with individual palliative care programs or providers. Plans are likely to add home-based palliative care as a supplemental benefit by contracting with a larger commercial or vendor entity (such as Aspire Health or Landmark Health). Those vendor entities providing home based palliative care services will need strong clinical partners in local markets. To effectively subcontract with these larger vendor entities, the same capabilities are needed – an efficient staffing model, strong and responsive enrollment, processes and population stratification and dosing capabilities.
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Uniform laws Check to see if your doctor, clinic, hospital or other medical provider is included in the plan network. Response: We are committed to partnership with state Medicaid agencies to pursue integrated care approaches that work for each state. We believe that the proposed regulatory language requiring state approval for default enrollment into D-SNPs provides an appropriate safeguard that ensures any default enrollments are consistent with the state's Medicare-Medicaid integration goals.
Getting Started PROPOSED CHANGES TO THE COVERAGE GAP Response: Section 507 of MACRA amends section 1860D-4(c) of the Social Security Act (42 U.S.C. 1395w-104(c)) by requiring that pharmacy claims for covered Part D drugs include prescriber NPIs beginning January 1, 2016 that are determined to be valid under procedures established by the Secretary in consultation with appropriate stakeholders. MACRA does not address the issue of which NPI a pharmacy must use on a claim for a prescription written by a resident—only that is be active and valid. In addition, the modifications to (c)(5) are technical to make the regulatory text consistent with exiting law and guidance.
Kentucky First slide details.Current Slide Second slide details. How Can You Pay for Senior Living? More In Stay Healthy
Medicare well care visits (iii) If a Part D plan sponsor maintains a specialty tier, as defined in § 423.560, the sponsor may design its exception process so that Part D drugs and biological products on the specialty tier are not eligible for a tiering exception.
home Health Care Database Advisory Committee (HCDAC) Comment: A number of commenters suggested CMS should codify its existing guidance regarding specialty drugs.
In 2007, we estimated that 7 percent of enrollees were receiving services under capitated arrangements. Although we do not have more current data, based on CMS observation of managed care industry trends, we believe that the percentage is now higher, and we assume that 11 percent of enrollees are now paid under global capitation. There are currently 18.6 million MA beneficiaries. We estimate that about 18.6 million × 11 percent = 2,046,000 MA members are paid under some degree of global capitation. Accordingly, using our revised stop loss insurance requirement in this final rule, we estimate the total aggregate projected annual savings, reflecting a reduction in reinsurance services will be roughly $100 PMPY × 2,046,000 million beneficiaries paid under global capitation = $204.6 million.
Comments with web links are not permitted. Shelly Winston, (410) 786-3694, Part D E-Prescribing Program. c. Actuarially Equivalent Arrangements
Genome Data Viewer Stay connected Case 4: The physicians/physician groups have an ownership stake in the intermediary. The intermediary shares additional payments based on use and costs of referral services with the contracted physicians/physician groups. The amount of the additional payment paid to each physician/physician group is related to the referral services associated with that individual physician/physician group. In this case, the physicians/physician groups are at financial risk based on their referral patterns. The analysis must be performed at the physician/physician group level to evaluate whether that risk is a substantial financial risk of 25% or more of potential payments for each physician/physician group.
Nursing home care You may be eligible for financial assistance to cover your health care expenses—many people who could qualify never sign up. So don’t hesitate to apply. Income and resource limits vary by program.
Response: The proposed rule stated that all of the changes related to Star Ratings would go into effect for performance periods in 2019 (thus, for the 2021 Star Ratings and 2022 QBPs). However, in light of the passage of the Bipartisan Budget Act provision which requires enrollment-weighted adjustments to the Star Ratings for contract consolidations approved on or after 1/1/19, we are finalizing the regulation text on this policy to be applicable to consolidations that occur on or after the same date. The final regulations at §§ 422.162(b)(3) and 423.182(b)(3) will apply to the star ratings of surviving contracts from contract consolidations that are approved on or after January 1, 2019. Thus, the policy will be implemented for the 2020 Star Ratings and the 2020 QBPs. We note that while the statute is specific to MA ratings, we are finalizing the same policy for Part D Ratings on the same timeframe to have consistent methodology across Part C and D for beneficiaries choosing a contract.
Comment: A commenter suggested that CMS require plans/PBMs to report the percentage of times when beneficiary preference is/is not considered and to track which pharmacy the plan/PBM utilizes to override patient preference.
Response: We clarify that under the Financial Alignment Initiative capitated model demonstrations, MA regulations—including those governing SEPs—apply to MMPs unless waived. As has been the case to date under the demonstrations, we will continue to use our demonstration authority to waive applicable MA regulatory requirements in three-way contracts as necessary, and in partnership with each state, to achieve each individual demonstration's objectives.
However, after implementation of the new CMS training, we continued to receive hundreds of inquiries and concerns from sponsors and FDRs regarding their difficulties with adopting CMS' compliance training to satisfy the compliance program training requirement. While CMS' previous market research indicated that this provision would mitigate the problems raised by FDRs who held contracts with multiple sponsors and who completed repetitive trainings for each sponsor with which they contract, in practice, we learned that the problems persisted. Many sponsoring organizations required their own plan specific training, as part of their contract with their FDRs, in addition to the CMS training. Also, sponsoring organizations were unwilling to identify which critical positions within the FDR were subject to the training requirement. As a result, FDRs were still being subjected to multiple sponsors' specific training programs. Furthermore, stakeholders have indicated that the requirement has increased the burden for various Part C and Part D program stakeholders, including hospitals, suppliers, health care providers, pharmacists and physicians, all of which may be considered FDRs. Since the implementation of the mandatory CMS-developed training has not achieved the efficiencies intended, we proposed to delete the provisions from the Part C and Part D regulations that require use of the CMS-developed compliance training.
Submit a News Tip Data Security Louisiana In paragraph (c)(6)(i), we proposed to state: “Except as provided in paragraph (c)(6)(iv) of this section, a Part D sponsor must reject, or must require its PBM to reject, a pharmacy claim for a Part D drug if the individual who prescribed the drug is included on the preclusion list, defined in § 423.100.” This will ensure that Part D Start Printed Page 16642sponsors comply with our proposed requirement that claims involving prescribers who are on the preclusion list should not be paid.
Need more help? in Providence In addition, Carter’s Medicare expansion created coverage for in home health services. These services include any medical care offered to a patient in that patient’s home, from nursing costs, to qualifying equipment, and more. The changes allowed patients to seek care for long-term and end of life illnesses in the comfort of their own homes, instead of in a hospital, hospice or nursing home.
PubChem Substance Twins Insider Evidence-Based Oncology Document Viewers - Medicare The discussion noted that the rulemaking process will generally be used to retire, replace, or adopt a new e-prescribing standard, but it also provided for a simplified “updating process” when a non-HIPAA standard could be updated with a newer “backward-compatible” version of the adopted standard. In instances in which the user of the later version can accommodate users of the earlier version of the adopted non-HIPAA standard without modification, it noted that notice and comment rulemaking could be waived, and the use of either the new or old version of the adopted standard would be considered compliant upon the effective date of the newer version's incorporation by reference in the Federal Register. We utilized this streamlined process when we published an interim final rule with comment on June 23, 2006 (71 FR 36020). That rule recognized NCPDP SCRIPT 8.1 as a backward compatible update to the NCPDP SCRIPT 5.0 for the specified transactions, thereby allowing Start Printed Page 16636for use of either of the two versions in the Part D program. Then, on April 7, 2008, we used notice and comment rulemaking (73 FR 18,918) to finalize the identification of the NCPDP SCRIPT 8.1 as a backward compatible update of the NCPDP SCRIPT 5.0, and, effective April 1, 2009, retire NCPDP SCRIPT 5.0 and adopt NCPDP SCRIPT 8.1 as the official Part D e-prescribing standard for the specified transactions. On July 1, 2010, CMS utilized the streamlined process to recognize NCPDP SCRIPT 10.6 as a backward compatible update of NCPDP SCRIPT 8.1 in an interim final rule (75 FR 38026). We finalized the NCPDP SCRIPT 10.6 as a Backward Compatible Version of NCPDP SCRIPT 8.1, and retired NCPDP SCRIPT 8.1 and adopted the NCPDP SCRIPT 10.6 as the official Part D e-Prescribing Standard for the specified transactions in the CY 2013 Physician Fee Schedule, effective November 1, 2013. For a more detailed discussion, see the CY 2013 PFS final rule (77 FR 69329 through 69333).
Account Information Independent Living 1998: 38 60. Section 423.40 is amended by revising paragraph (d) and adding paragraph (e) to read as follows:
Low privacy 0.11 (0.23) −0.41 (0.23) A separate POS issue—though in a different context—came up in the context of the new drug management programs (DMPs) Part D plans are expected to adopt in 2019. These DMPs are the result of a provision in the 2016 Comprehensive Addiction and Recovery Act meant to address the opioid crisis.5 Adoption of DMPs will be voluntary, but the CMS expects plans to implement them for a variety of reasons. The programs will allow plans to limit an at-risk beneficiary’s (there is a definition for that in the final rule) access to coverage of frequently abused drugs beginning in 2019 through a beneficiary-specific POS claim edit and/or by requiring the beneficiary to obtain frequently abused drugs from a selected pharmacy and/or prescriber(s) after case management and notice to the beneficiary. To do so, the beneficiary will have to meet clinical guidelines that factor in that the beneficiary is taking opioids over a sustained time period and that the beneficiary is obtaining them from multiple prescribers and/or multiple pharmacies. The P&T committees in each plan will be responsible for approving the DMP, which must include at least (as a minimum): 1) the appropriate credentials of the clinical staff conducting case management; 2) the necessary and appropriate contents of files for case management, which must include documentation of the substance of prescriber and beneficiary contacts; and 3) monitoring reports and notifications about incoming enrollees who meet the definition of an at-risk beneficiary or a potential at-risk.
You should take Medicare Part A when you are eligible. However, some people may not want to apply for Medicare Part B (Medical Insurance) when they become eligible.
PubMed Clinical Queries Applying for LIS & MSP The General Enrollment period is January 1 through March 31 of each year. Your Medicare coverage will begin July 1 of that year. You will pay a Part B Late Penalty: 10% surcharge for each year you are late in enrolling. This penalty continues forever. For example, if you enrolled four years late, then you will pay a 40% surcharge for every year that you buy Part B.
CAHPS: Summary of Additional Comments Received and CMS's Responses Click Here to Learn More Comment: Many commenters in favor of the proposed changes to Subpart V asked CMS to provide more information on what materials would fall under the definition of marketing and what materials would fall under the definition of communications, but not marketing. Moreover, commenters requested additional information on Start Printed Page 16629whether or not communication materials that are not marketing materials would still be submitted to CMS for review. Several commenters suggested materials, such as standardized models, be considered communications, but not marketing. Many of these comments acknowledged that they expected such detail to be captured in sub-regulatory guidance, such as the MMG. Additionally, a subset of commenters reiterated the importance of CMS working with industry to develop updated sub-regulatory guidance for marketing and communications.
Username If the time comes when you can no longer manage daily living in your own home or with family members, an apartment in an assisted living facility could be the next best thing.
§ 422.224 Medicare Savings Program (MSP) Apply for Medicare online Laws & Regulations (2) Sports Podcasts Licensee Lookup
19 Documents Open for Comment RN Case Manager Amazon Stock (AMZN)
If you qualify for Tricare for Life, which is an insurance program for service veterans, you would need Medicare when you turn 65.
Business of Medicine Financial Tips Statutory Laws XYZ, LLC S4321 84.8 17,420
Conserved Domain Database (CDD) Medicare coverage for breast cancer screening Orthopedics Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)
People who are already enrolled in Cost plans can stay on their plan throughout 2018. (B) To determine a contract's final adjustment category, contract enrollment is determined using enrollment data for the month of December for the measurement period of the Star Ratings year. The count of beneficiaries for a contract is restricted to beneficiaries that are alive for part or all of the month of December of the applicable measurement year. A beneficiary is categorized as LIS/DE if the beneficiary was designated as full or partially dually eligible or receiving a LIS at any time during the applicable measurement period. Disability status is determined using the variable original reason for entitlement (OREC) for Medicare using the information from the Social Security Administration and Railroad Retirement Board record systems.
Anderson, Wayne L., Zhanlian Fen, and Sharon K. Long, RTI International and Urban Institute, Minnesota Managed Care Longitudinal Data Analysis, prepared for the U.S. Department of Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE), March 2016, available at: https://aspe.hhs.gov/report/minnesota-managed-care-longitudinal-data-analysis.
Comment: We received several comments related to how to determine which drugs should be considered alternatives for treating the enrollee's health condition. Some of these commenters were supportive of the additional information we provided in the preamble to the proposed rule about how to determine alternative drugs. Most of the commenters stated that a more specific regulatory definition of alternative drug is needed. Some commenters recommended that the definition specify that alternative drugs must be one or more of the following: supported in drug compendia or treatment guidelines for use in the same place in therapy, FDA-approved for the same indication as the requested drug, in the same therapeutic class and/or category as the requested drug, use the same route of administration as the requested drug, and/or have the same mechanism of action as the requested drug.
(1) An explanation that the beneficiary's current or immediately prior Part D plan sponsor has identified the beneficiary as a potential at-risk beneficiary.
DEALS Section 1860D-4(c)(5)(B)(i)(I) of the Act requires Part D sponsors to provide a second written notice to at-risk beneficiaries when they limit their access to coverage for frequently abused drugs. We proposed to codify this requirement in § 423.153(f)(6)(i). As with the initial notice, our proposed implementation of the statutory requirement for the second notice will also permit it to be used when the sponsor implements a beneficiary-specific POS claim edit for frequently abused drugs. Specifically, we proposed to require the sponsor to provide the second notice when it determines that the beneficiary is an at-risk beneficiary and to limit the beneficiary's access to coverage for frequently abused drugs. We further proposed to require the second notice to include the effective and end date of the limitation. Thus, this second notice will function as a written confirmation of the limitation the sponsor is implementing with respect to the beneficiary, and the timeframe of that limitation.
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