Annual plan out-of-pocket maximum $6,000 $4,000 $4,000 While the requirement to send a written denial notice is subject to the PRA, the requirement and burden are currently approved by OMB under control number 0938-0976 (CMS-10146). We did not receive any PRA-related public comments and are finalizing the proposed provisions without modification. Since this rule will not impose any new or revised requirements/burden, we are not making any changes under the 0938-0976 control number. As discussed in section II.A.9 of this rule, we are finalizing the proposed changes to § 423.578(a) and (c) without modification. The changes establish a revised framework for treatment of tiering exception requests based on whether the requested drug is a brand name or generic drug or biological product, and where the same type of drug alternatives are located on the plan’s formulary. The changes also clarify the appropriate cost-sharing assigned to approved tiering exception requests when preferred alternative drugs are on multiple lower-cost tiers. At the coverage determination level, if a plan issues a decision that is partially or fully adverse to the enrollee, it is already required to send written notice of that decision. The current requirement to send written notice of an adverse coverage determination is not changed by this rule. We do not expect that any of the changes will significantly impact the overall volume or the approval rate of tiering exceptions requests, which represent a consistently low percentage of total request volume.
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Comment: A commenter recommended that each updated preclusion list file be effective at least five (5) business days after Part D sponsors receive it to allow them time to configure their claims adjudication systems with the most current version.
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WebMD does not provide medical advice, diagnosis or treatment. See additional information. I have loads of unanswered questions about these new Medicare policies. Below are some questions that I hope I can actually answer!
Existing quality assurance regulations at § 423.153(c)(1) require that Part D plan sponsors have representation that Start Printed Page 16595network providers are required to comply with minimum standards for pharmacy practice as established by the states. Every state, and the District of Columbia (state) requires pharmacies to be licensed in the state in which they are located. However, CMS recognizes that there are differential licensure requirements for prescriptions mailed across state lines. Some states require out-of-state pharmacies to be licensed in their state, by nature of mailing prescriptions to Part D enrollees located in their state, but others do not. Additionally, to the extent a state does not require a pharmacy mailing prescriptions into it to be licensed in such state, it would be unreasonable for a Part D plan sponsor to require that a pharmacy be licensed in such state, particularly if licensure in such state requires an address, physical or otherwise, in such state. Therefore, CMS does not believe that the commenters’ additional licensure language is necessary for the definition of mail-order pharmacy and additionally has concerns about the imposition of such a standard term or condition for pharmacies, retail or otherwise, which perform a mail function.
Notice of Privacy Practices Response: We believe that by utilizing Medicare’s current revocation authorities as criteria to evaluate a prescriber’s inclusion on the preclusion list, we are, in fact, safeguarding beneficiaries against overprescribing of opioids. The current revocation reasons at § 424.535 allow CMS to exclude or remove from the program those prescribers who may prove to be a detriment to Medicare. The preclusion list expands CMS’ authority by allowing the application of these revocation authorities to not only Medicare-enrolled prescribers and providers but also to any prescriber or provider that could potentially provide care to our beneficiaries, thus further broadening our ability to keep out problematic providers. We also reiterate that Medicare has two revocation authorities at § 424.535(a)(13) and (14) that specifically focus on a prescriber’s prescribing practices. The authority at (a)(14), for instance, gives Medicare the ability to revoke if a prescriber shows a pattern or practice of abusive prescribing that CMS determines is a threat to the health and safety of Medicare beneficiaries. Given this clarification, we respectfully decline to adopt the commenter’s recommendation.
Hubbert AO, Hays BJ. “Seniors’ Need for and Use of Medicare Home Health Services.” Home Health Care Services Quarterly. 2002;21(2):19–34. [PubMed]
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Comment: Most commenters expressed support for our proposal to permit simplified elections for seamless continuation of commercial coverage into a MA plan offered by the same organization. A commenter expressed opposition to the offering of a simplified (opt-in) enrollment mechanism to anyone enrolled in a Medicaid managed care plan. Another commenter asked that we consider making the simplified (opt-in) enrollment mechanism available to all beneficiaries, including those who are not in their ICEP and those who are not enrolled in a non-Medicare plan offered by the same organization.
We received the following comments on our proposals and our responses follow: Benchmark Price Response: We appreciate the comment; however, we disagree with allowing individuals identified as potentially at risk or at risk to use the duals’ SEP. Even if an at-risk individual joined another plan that had a drug management program in place, there would be challenges in terms of preventing a gap managing their potential or actual overutilization of frequently abused drugs due to the timing of information sharing between the plans and possible difference in provider networks.
2018 Platinum Blue with Rx Physicians will need to choose between one of two payment categories: 1) Merit-Based Incentive Payment System (MIPS) and 2) Alternative Payment Model (APM).
That’s forcing Medicare to review how it comes up with money to pay for that. Seema Verma, head of the Centers for Medicare and Medicaid Services, says a comprehensive review of the payment protocol is set to begin.
Be an E-Advocate Genome Additional opportunities to improve measures so that they further reflect the quality of health outcomes under the rated plans.
(C) A contract with low variance and a relatively high mean will have a reward factor equal to 0.2.
Juliette Cubanski Follow @jcubanski on Twitter, Tricia Neuman Follow @tricia_neuman on Twitter, and Anthony Damico
Receiving MA plans must not have any prohibition on new enrollment imposed by CMS. Figure 5: Counting the manufacturer discount towards beneficiary out-of-pocket costs has contributed to a rise in the number of non-LIS Part D enrollees who qualify for catastrophic coverage
With localized medical news and in-language editions 1. Private Sector Wages R. Schoenthaler (B) The maximum deductibles for each category of services (institutional and professional claims) are identified by using the net benefit premium (NBP) determined in Table PIP-11 as the starting point in Table PIP-12. Any combination of institutional and professional attachment points for which the NBP in Table PIP-12 is greater than the NBP determined in Table PIP-11 is permissible. Interpolation may be used to find the NBP values in Table PIP-12 that are closest to the NBP identified in Table PIP-11.
In the November 28, 2017 (82 FR 56336) proposed rule, we solicited public comment on each of these issues for the following sections of the rule containing information collection requirements (ICRs). We received comments and we provide a summary of the comments and our responses under the respective ICR section.
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A Cost plan is somewhat of a hybrid – a cross between a Medicare supplement and a Medicare Advantage plan. For some people, the benefits are the best of both worlds. Similar to an Advantage plan, a Cost plan has a network of doctors and hospitals that the insured must use. There may be some cost sharing (a copay for example) when visiting a doctor, for a hospital stay, labs, or diagnostic tests, but this cost sharing all adds up to an out-of-pocket maximum to limit the annual risk for the insured.
July 2017 (1) Related Resources REFERENCES Early Intervention/Infant Learning Program
Compare Medicare Advantage Plans Enrollment processing and notification requirements are codified at Start Printed Page 16693§ 423.32(c) and (d) and are not being revised as part of this rulemaking. Therefore, no new or additional information collection requirements are being imposed. Moreover, the enrollment processing and notification requirements and burden are currently approved by OMB under control number 0938-0964 (CMS-10141). Since this rule will not impose any new or revised requirements/burden, we are not making any changes under the 0938-0964 control number. We did not receive any comments pertaining to the burden discussion within our proposed rule.
Response: We thank those commenters for their support of both our proposed policies.
National Retired Teachers Association (B) A contract with medium variance and a high mean will have a reward factor equal to 0.3. Learn about your options if you’re retired but don’t have Medicare coverage.
The transition fill policy is being finalized with modifications. To summarize, the final transition fill supply policy effective for plan year 2019 is to require Part D sponsors to provide as a minimum (unless prescriptions are written for fewer days) an approved month’s supply for enrollees in both the outpatient and LTC settings. Please note that we also are finalizing a revision to § 423.120(b)(3)(i)(B) to state that the transition process is not applicable in cases in which a Part D sponsor substitutes a generic drug for a brand name drug as specified under paragraph § 423.120(b)(3)(iv). See II.A.14 Expedited Substitutions of Certain Generics and Other Midyear Formulary Changes.
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Call the Hub Medicare and Medicaid: Senior Living and Care Coverage Comment: A commenter recommended that CMS develop prescriber preclusion list criteria that focuses on beneficiary safety and mitigates the risks of opioid prescribing.
Vision Plans Comment: A commenter noted that the MACRA legislation, which included the valid NPI requirement, was signed into law on April 16, 2015 and became effective January 1, 2016. Accordingly, the commenter stated that it, alongside other major PBMs, has been enforcing the active NPI requirement at the point of sale since January 1, 2016. The commenter thus expressed confusion about the modifications to (c)(5) and the request for comments, and sought clarification from CMS regarding the intent of this modified guidance.
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