Response to 60-day Comments

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Comment Number

Entity Submitting Comments

Subject Matter

Summary of Comment

Accept/Deny Change

General Instructions

1

Ovations (UnitedHealth)

Application upload to HPMS

Request the ability to test a Part D HPMS application upload prior to the time the Final Applications are released in order to determine time and staffing needs.

Deny. Applications will be posted on January 23, 2008 with submissions due six weeks later on March 10, 2008. During that six weeks, applicants have access to technical assistance for both HPMS uploads and application content, and have multiple opportunities to submit during this period. Most fundamentally the timelines for the release of the HPMS module is too tight to accomodate this.

2

Argus Health Systems

Application upload to HPMS

Since all items for 2009 application need to be submitted via HPMS, the timing and coordination of creating GEO Access reports will need to be streamlined. In previous years Argus was able to complete accommodate late submissions via CSs hardcopies submissions. Requests that CMS remind plans in a timely manner to submit GEO access information with their application.

Accept. CMS will issue specific deadlines. Further, we will issue one or more reminders of the application deadline as that date approaches. We will also provide training on the requirements of the HPMS uploads.

Benefit Design

3

Argus Health Systems

MA-PD Bundling of home infusion drugs with home infusion supplies/services

If a MAPD decides to bundle coverage of home infusion drugs with home infusion supplies/services as part of a supplemental benefit under Part C: (1) drugs are not part of the standard formulary submission, (2) claims are not processed through Argus, (3) medical claims submitted by provider to the plan. Plans would need to ensure that these drugs are not listed on the plan formulary and not allowed to process through the Part D benefit so that coverage is directed to Part C for the bundled supplemental benefit.

No action requested.

4

Argus Health Systems

Vaccine Administration

Challenges related to implementing vaccine administration are: linking split claims from different providers, processing physician claims in non-5.1 formats, getting reimbursement to physicians and handling orphan administration-only billing claims. There do not appear to be any pharmacy network access requirements. Out of Network Access contains the following: Applicant agrees to ensure that enrollees have adequate access to covered Part D drugs dispensed at physician offices for covered Part D drugs that are appropriately dispensed and administered in physician offices (e.g. part D-covered vaccines). CMS should consider hosting discussion forums to address challenges in implementing vaccine administration requirements. Argus can not address the out of network access; customer issue.

This comment is a policy implementation issue and not related to the 2009 Part D application itself. This comment will be shared with the appropriate people within CMS.

5

AHIP

CAHPS

Follow-up to CAHPS Survey. Draft Part D applications contain a new attestation that states: "Applicant agrees to comply with the appropriate follow-up related to the Consumer Assessment of Health Providers and Systems Survey (CAHPS)." The "High-Level Summary of All Part D Application Revisions from 2008 Solicitation for the 2009 Solicitation" that CMS issued with the proposed applications notes in item six that the new attestation is "Based on 2008 Call Letter and Chapter 7 of the Prescription Drug Benefit Manual." However, neither document contains guidance about the nature and scope of the required CAHPS survey follow-up activities. Section 40.2 of Chapter 7 of the Prescription Drug Benefit Manual states only that, "Specific responsibilities for plan follow-up based upon survey results from CAHPS, once developed, will be described here." To permit sponsors to clearly understand the obligation referenced in the attestation, recomment that its inclusion be deferred until the guidance in the Manual is issued.

Accept. The attestation has been deleted from the Draft 2009 applications.

Pharmacy Access

6

Quest Analytics

Pharmacy Network Access reports

Quest Analytics offers a competing software that is capable of producing pharmacy network access reports. The organization's comments provide details of how their software is equal to that of GeoNetworks and should be accepted by CMS.

Accept. Applications will be modified to provide detailed instructions for both Geonetworks and Quest Analytics software.

7

Express Scripts, Inc

General Pharmacy Requirements

We request that CMS clarify this section of the application to indicate if CMS is referring to the plan finder files. To protect the integrity of our pharmacy network and to ensure that convenient access is provided for all the plans we serve, ESI prefers not to provide beneficiaries with access to confidential provider agreement reimbursement rates as this requirement appears to infer. Since pharmacy reimbursement is negotiated confidentially between the provider and the payer(s) and is part of a proprietary and confidential Provider Agreement, providing this information to another entity, in this case a beneficiary, could impede future negotiations between the pharmacy and the payer and may, in fact, negatively impact beneficiary cost share in subsequent benefit years.

The regulatory language referenced by Express Scripts, Inc. requires that beneficiaries "access" the negotiated prices when paying a pharmacy for dispensed medication and does not state that they have access to confidential provider agreements.

TrOOP

8

Argus Health Systems

Processing TrOOP-related Data

The challenges with the FIR will be applying preceding plan dollars when coverage overlap occurred, adjusting existing TrOOP and GCDC dollars when frequent previous plan adjustments are received, identifying the correct member to report on (F1, F3) and/or to update (F2, F3) along with the interaction of FIR transfers and our existing internal dollar transfer logic. We are awaiting CMS guidance on the rework of TrOOP and GCDC dollars, the adjustment frequency, duration and processing rules, the beneficiary reimbursement for overpayment and other key details. With this many unknowns, adequately meeting the 01.01.08 deadline is very challenging.

This comment is a policy issue and not related to the 2009 Part D application. This comment will be shared with the appropriate people within CMS.

9

National PACE Association

TrOOP

On Page 27 under the Tracking Out-of-Pocket Costs (TrOOP), the note for more information regarding the TrOOP facilitator contains a website link (http://Medeifacd.ndchealth.com/home/medifacd_home.htm) that does not work.

Accept.: The website link has been corrected to http://Medifacd.ndchealth.com/home/medifacd_home.htm

Marketing/Beneficiary Communications

10

Argus Health Systems

Call center average wait time

For the plans that contract with Argus for Call Center Services, no serious impacts are expected, if the definition of a call begins once the beneficiary passes through the Integrated Voice Response (IVR) system. CMS needs to clarify when the wait time begins.

Accept. CMS will add a clarifying statement of when calls are considered initiated.

Provider Communications

11

Argus Health Systems

Pharmacy call center

For the plans that contract with Argus for Call Center Services, no serious impacts are expected, if the definition of a call begins once the beneficiary passes through the Integrated Voice Response (IVR) system. CMS needs to clarify when the wait time begins.

Accept. CMS will add a clarifying statement of when calls are considered initiated.

Claims Processing

12

Express Scripts, Inc

Applicant develops and oeprates a paper claims processing system designed to pay claims submitted by non-network pharmacies on behalf of Part D plan enrollees. Applicant processes claims according to the following standards: 100% of claims requiring no intervention handled within 15 calendar days; 100% of claims requiring intervention handled within 30 calendar days; and 99% of all manually keyed claims paid with no errors. [Express Scripts, Inc.] requests that CMS clarify this requirement to note that out-of-network claims are not paid to the out-of-network pharmacy, rather to the beneficiary using the out-of-network pharmacy.

Deny: The request would limit how out-of-network pharmacies are paid and prevent sponsors from paying them directly and requiring beneficiaries always pay upfront and then be reimbursed by the sponsor. This is not the intent and CMS will continue to allow flexibility in the mechanisms used to make payment to the out-of-network pharmacies.

Premium Billing

13

Ovations (UnitedHealth)

Premium withhold status

The PDP sponsor has no visibility to SSA to know when the premium withhold status has changed. The PDP sponsor can only rely on CMS for premium withhold status. Revise.

This is a policy and operations issue and not related to the 2009 application. This comment will be shared with the appropriate people at CMS.

Part C

14

Coventry Health Care

Attestations

Coventry is concerned that the addition of numerous attestations, may be perceived as a shift in the oversight relationship between CMS and sponsors. Sponsors may view such additions as creating additional regulatory burden while signaling a move away from the longstanding partnership relationship to one that is more onerous. Sponsors already implement these requirements as outlined in regulations, manuals, statute, contracts and other guidance. Adding these attestations to the application may only serve to create hesitation as these organizations determine whether to contract with CMS.

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

15

Coventry Health Care

Application upload to HPMS

We [Coventry] applaud[s] CMS' decision to move to electronic submission o fthe MA application for 2009. We believe this is a great step forward in simplifying the application process while creating a more, efficient approach for Medicare Advantage organizations

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

16

Coventry Health Care

Enrollment Disenrollment

Element 19 typo - delete "disembroils" and replace with "disenrolls"

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

17

Coventry Health Care

Access to Services

Include more information on what CMS is looking for in this element. A verb appears to be missing after "will" and prior to "CMS". Insert "implement" after "will".

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

18

Coventry Health Care

Payment Provisions

Coventry would appreciate the addition of clarifying language around what CMS expects in this element.

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

19

Coventry Health Care

Health Services Delivery

Delete "that is" after "Policies".

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

20

Coventry Health Care

General Guidance for Special Needs Plans

March 10, 2007 date is confusing; perhaps this was meant to be March X, 2008. Please clarify.

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

21

Coventry Health Care

General Guidance for Special Needs Plans

Coventry encourages CMS to consider moving to a more fully automated process for the SNP application process in the future.

Comments were addressed to both Part C and Part D; however all Coventry comments were only related to the 2009 Draft Part C applications. Comments were forwarded to the appropriate division within CMS to address.

22

AHIP

Application process for Cost Plans to MA-PD Sponsor

Application Process for a Cost Plan with a Part D Contract to Become an MA-PD Plan Sponsor. Recommend that CMS provide a streamlined application process to address the circumstance in which a Cost Plan that also has a contract as a Part D plan sponsor decides to non-renew its Cost Plan contract and apply to become an MA-PD plan sponsor. Under such a process, where the information provided in the Cost Plan's previously approved Part D application continues to be correct, we recommend that the organization be permitted to complete only the Medicare Advantage portion of the application and provide through an attestation confirmation that the information in the previous Part D application remains accurate. We also recommend that the organization be permitted to request continuation of some or all waivers approved for the existing Part D contract based upon an attestation that the circumstances supporting the waiver(s) still apply.

For 2009 this would require development of a new "conversion" application which would be under the purview of the Medicare Advantage Group. This comment has been forwarded to the appropriate division within CMS and we will take this under advisement for 2010.