Comment: We received many comments, primarily from plans, expressing support for the proposed change to the payment adjudication timeframe from 7 to 14 calendar days at the redetermination and reconsideration levels. Commenters noted that, because payment requests involve an enrollee who has already received the medication, allowing the plan 14 calendar days (instead of 7 calendar days) to process the payment request would allow the plan to prioritize requests for coverage where the enrollee has not yet accessed the prescription drug, particularly during times when the plan sponsor is experiencing a high volume of requests. Commenters noted that this would ensure adequate resources are directed to processing more time-sensitive pre-service requests where the beneficiary has not yet obtained the drug. Commenters also expressed support for this proposal for the reason that it could reduce the number of unfavorable decisions made due to insufficient information to support the request. Some of these commenters requested that CMS consider lengthening the timeframe for other decisions, such as coverage determinations.
Drug, supplement, and vitamin information on the go. Download Medicare Part D is Medicare’s prescription drug benefit. It covers insulin, diabetes drugs and certain supplies. There are times when Medicare Part D does not cover insulin, diabetes drugs and supplies. For example, Medicare Part B, not D, covers external insulin pumps and the insulin used in them.
Advance Care Planning We believe the proposed change to a 14 calendar day timeframe is an appropriate balance between plan sponsors’ need to obtain information to thoroughly evaluate a payment request and the interest of enrollees in receiving prompt notice on a payment request. We believe the proposed change will enhance efficiency in the adjudication of these types of cases, reduce adverse payment decisions, and reduce the number of late cases that have to be auto-forwarded to the IRE. As previously noted, the proposed change to a 14-calendar day adjudication timeframe will also apply to payment requests processed by the Part D IRE. Because the enrollee has received the prescription drug that is subject to the payment request, we disagree with commenters who believe the additional time will needlessly delay access to treatment. We believe that allowing plan sponsors and the IRE additional time to obtain necessary documentation and thoroughly review the case will be beneficial overall and that the advantages offset the additional 7 calendar days an enrollee may have to wait for a decision on a payment request.
Comment: A commenter recommended that we only include MTM programs in QIA if the sponsor utilizes pharmacists at qualified long-term care pharmacies. Overview
Domain Don’t Miss Out on Preventive Care We proposed to delete § 460.71(b)(7). We are finalizing the methodology to determine cut points for CAHPS measures in §§ 422.166(a)(3) and 423.186(a)(3) substantively as proposed. We are finalizing the regulation text with minor technical revisions to improve readability.
Author Affiliations Comment: Many commenters provided valuable feedback related to our request for suggestions on how to educate the affected population and other stakeholders of changes to the dual SEP. Suggestions included the following:
CMS-1612-F2 In the proposed rule, CMS explained that it would want to change the MOOP limits if a consistent pattern of increasing or decreasing costs emerges over time. CMS also summarized how stakeholders have suggested changes to how CMS establishes MOOP limits, including suggestions to use the most appropriate data to inform its decision-making, increase the MOOP limits and the number of service categories that have higher cost sharing in return for a plan offering a lower MOOP limit, and implement different levels of MOOP and service category cost sharing standards to encourage plan offerings with lower MOOP limits.
Your Nearest Store Key Staff After consideration of the public comments received, we are finalizing our proposal on expedited substitutions of certain generics and other midyear formulary changes with the following modification as discussed and as follows:
All of the comments we received were generally supportive, and therefore we are finalizing the proposal to redesignate paragraphs (b)(1)(iii) as (b)(1)(iv); redesignate paragraphs (b)(2)(iii) as (b)(1)(iii); remove paragraphs (b)(2)(i) and (ii); and redesignate paragraphs (b)(3) as paragraphs (b)(2) in §§ 422.2274 and 423.2274, without modification. In addition, we are finalizing the technical correction to newly redesignated paragraph § 423.2274(b)(2)(iii) to replace the reference to an MA plan with a reference to a Part D sponsor.
MEDIGAP Open Enrollment Period Medicare-Medicaid Coordination
Insurance Elder Options of Texas This means that beneficiaries meeting these criteria will be reported to sponsors by OMS and sponsors with drug management programs must review each case and report their findings back to OMS as they do today consistent with how they have operated under the current policy. In addition, sponsors may not vary these minimum criteria. However, as we previously stated, sponsors will be permitted to apply the minimum criteria more frequently using their own prescription claims data than CMS will apply them through OMS quarterly. According to our analysis of 2017 PDE data, these minimum criteria would identify 44,332 potential at-risk beneficiaries and is the option based on 90 MME in the RIA that has a revised program size estimate which is closest to our original estimate of 33,053 but that would not identify fewer at-risk beneficiaries. Given the scope of the opioid crisis, and current data showing significant reduction in the number of beneficiaries meeting the OMS criteria, finalizing criteria that would have resulted in a smaller program size could undermine the increasing momentum in addressing opioid overutilization in the Medicare Part D program.
Response: CMS thanks the commenter for this suggestion. However, this suggestion is outside the scope of the proposed rule. This comment will be shared with others in CMS who will be interested in the suggestion.
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Patients With COPD Prioritize Symptom Control Information Online, Survey Finds Statutes, Rules and Regulations
Traditional rounding rules mean that the last digit in a value will be rounded. If rounding to a whole number, look at the digit in the first decimal place. If the digit in the first decimal place is 0, 1, 2, 3, or 4, then the value should be rounded down by deleting the digit in the first decimal place. If the digit in the first decimal place is 5 or greater, then the value should be rounded up by 1 and the digit in the first decimal place deleted.
Comment: Commenters submitted a number of questions about prepackaging, for example, a commenter suggested that CMS clarify that a month’s supply would be considered 30 days unless packaging dictated. In another example, a commenter recommended that CMS confirm that a drug package in an unbreakable 28 day supply would meet the one month supply requirement for transition fill. Other commenters requested that CMS provide specific examples of how the transition policy would apply or confirm their understanding of the policy as set forth in the examples the commenters provided with different quantities (such as 17 or 21 day supplies) and types of drugs (such as insulin or creams).
A Place For Mom is the largest assisted living referral service. We are paid by our participating communities, therefore our service is offered at no charge to families.
Dental & Vision Coverage The American Association of Retired Persons (AARP) offers AARP Medicare Supplemental Insurance plans via UnitedHealthcare. UnitedHealthcare is a subsidiary of UnitedHealth Group and is America’s biggest health insurer, boasting over 130 million members.
1997: 38 (ii) The Star Ratings posted on Medicare Plan Finder for contracts that consolidate are as follows: If you want coverage designed to supplement Medicare, you can find out more about Medigap policies.
Is Medicare Your Only Health Coverage? Where can I find Ascensia diabetes self-monitoring testing supplies? Genetics
Certified Reinsurers Medicare Part B also covers health screenings for alcohol abuse, obesity, nutrition therapy and depression.
If you have significant LTC needs, you may want to explore other kinds of insurance that may provide you with more comprehensive coverage: Organization Contract No. Adjusted MLR (%) Remittance amount ($)
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Find a Community: Evidence of Coverage (EOC) File financial information for my insurance company
19. The Bipartisan Budget Act specifically identifies the chronically ill as individuals with (1) one or more morbidities that is life threatening and limits overall function (2) has a high risk of hospitalization and adverse outcomes, and (3) requires intensive care coordination.
Who We Regulate Response: We plan to use OMS to identify all potential at-risk beneficiaries who meet the minimum criteria of the clinical guidelines, discussed earlier, to report to Part D plan sponsors. We will modify the OMS as appropriate to implement the Part drug management program requirements. We will issue guidance and updated OMS technical user guides to plan sponsors at a later time, including data sources used in OMS reporting.
Monday to Friday 8:30 a.m. to 5 p.m. Benefits overview (PDF) Sources: Additional benefits 42 CFR 405 Count of 2018 Formularies Covering the Top Medicare Drugs Program-wide
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