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pdf05/20/2011
Comments on Draft 2012 Part D Reporting Requirements
Section number and
Page number
Issue
Section I Enrollment &
Disenrollment
Paragraphs 4 & 5
Page 5
These paragraphs mention transactions that will be going away
with the April 2011 software release.
1.B
Page 5
It's unclear whether "complete" means complete when received
or complete following a request for information. In other words,
are 1B and 1C exclusive of each other, or could some of the
enrollments in 1C also be in 1B?
1.J
Page 6
It's unclear exactly what is meant by "employed" agents and
brokers.
2.A
Page 6
Should plans include only voluntary disenrollments for this
element? Meaning we would exclude out-of-area or
incarcerated disenrollments.
2.B
Page 6
It's unclear whether "complete" means complete when received
or complete following a request for information.
2.C
Page 6
Should the the number of disenrollment requests denied include
both denials for ineligibility and denials for not responding to a
request for information?
2.D
Page 6
Disenrollments due to failure to pay premium would not be
voluntary and based on the answer to 2.A above would probably
not be included in "total reported in A."
05/20/2011
Comments
Please remove the applicable transactions that will be going
away with the April 2011 software release (e.g. 60,62,)
Please clarify.
Please provide a definition for employed agents/brokers.
Please add clarifying language.
Please clarify.
Please add clarifying language.
Please clarify.
Medco Health Solutions, Inc.
Comments on CY 2012 Draft Reporting Requirements
Medco Health Solutions, Inc. respectfully submits the following comments on the CY
2012 Draft Reporting Requirements:
Section I. Enrollment and Disenrollment
Effective 4/18/2011 CMS is introducing changes to the enrollment processing
rules (MARx System Re-design – April Software release). The change result in
elimination of certain type codes such as code 60, 62. Therefore section below
should be modified accordingly to include proper codes:
Data elements 1.A-1.P must include all enrollments (60, 61, 62 and 71 transactions)
Section VI- Pharmacy support Electronic prescribing
Recommend that CMS eliminate the need for plan sponsors to report this information. It
would be more efficient if CMS received this information from a central source such as
NCPDP since pharmacies that support electronic prescribing would do so for all Plan
Sponsors for which the pharmacy is a network participant. This capability is not a Plan
Sponsor specific capability.
Section IX. Coverage Determinations and Exceptions
It is recommended for Report element A- The total number of pharmacy transactions in
the reporting time period be further refined to specify the types of pharmacy transactions
should be included (example specifying only paid claims, rejected claims and reversed
claims and eliminating any other types of transactions such as adjustments which are
purely done for financial reasons and do not impact drug utilization management).
Can CMS please clarify the rationale for reporting multiple transactions for the same
beneficiary, same drug, same pharmacy, same rejection reason on the same date of
service?
Section IX. Coverage Determinations and Exceptions
1) All the following elements use the word “processed” in the reporting period. Can
CMS clarify what they mean by “processed?” Is it CMS’ expectation that cases
be reported when they are decided and not when they are requested?
Elements:
C. Total number of PAs processed in the reporting period
F. Total number of UM exceptions processed in the reporting period
I. Total number of tier exceptions processed in the reporting period
L. Total number of formulary exceptions processed in the reporting period
Section X Redeterminations
Report Element A- Total number of redeterminations made in the reporting periodplease clarify how these should be reported –should it be based on the date of the
redetermination decision?
Section XI. Long-Term Care (LTC) Utilization and Waste
For Element D:
D. For each network LTC pharmacy in the service area:
1. LTC pharmacy name;
2. LTC pharmacy NPI;
3. Contract entity name of LTC pharmacy;
4. Chain code of LTC pharmacy;
5. The total number of returned brand solid oral units (tablets, capsules, etc)
6. The total cost of these returned brand drugs, where total cost should be
calculated as gross drug cost (Ingredient cost + Dispensing Fee + Sales Tax)
7. The total number of returned generic solid oral units (tablets, capsules, etc)
8. The total cost of these returned generic drugs, where total cost should be
calculated as gross drug cost (Ingredient cost + Dispensing Fee + Sales Tax)
1. We are concerned that plans currently do not have a way to track returns on
elements 5-8. Plans do not directly contract with LTC facilities, thus will not
have the authority to “require” LTC facilities to return unused medications to
LTC pharmacies. Additionally, neither plans nor PBMs have a way to receive this
type of information from LTC pharmacies or any other type of pharmacy.
Specifically, currently there is no data or system that is able to support and
capture the “return information” between LTC facilities and pharmacies and then
trace a returned medication back to an individual processor (PBM) at the
individual plan, beneficiary, and claim level. NCPDP returns standards will not
be available until 2014.
2. What will CMS do with the “chain code” value (e.g., are the ‘rolling up’ the data
to ownership level to examine the patterns of returns by each owner of the chain?
Additionally, which “chain code” value is to be used (NCPDP or Medco’s) in the
reporting? Is “affiliation code” appropriate/needed for independents as CMS
might be looking a network contract (versus ownership) patterns?
3. Do the “cost” values include patient cost share (OOP cost of the ingredient) or
only the plan’s share?
4. Do LTC facilities include all but ALFs and then reporting on returns would only
be for those claims paid as LTC (not retail as with an ALF)?
PUBLIC SUBMISSION
As of: February 22, 2011
Received: February 15, 2011
Status: Draft
Category: Health Plan or Association
Tracking No. 80bef405
Comments Due: February 15, 2011
Submission Type: Web
Docket: CMS-2010-0282
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Comment On: CMS-2010-0282-0001
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Document: CMS-2010-0282-DRAFT-0003
CA
Submitter Information
Name: Cindy Lynch
Address:
Cerritos, CA, 90703
Organization: CareMore Health Plan
General Comment
The encounter data submission requirement should be for Medicare covered services only given the
formats/forms of data CMS is requesting the data provided. Non Medicare covered services generally
do NOT come in these formats and vary substantially between health plans. Our plan would incur an
unfair level of administrative costs if required to provide this data in the requested formats.
The CMS submission error process needs to be revised for this (eg penalties for duplicate claim
submission).
In order to optimize use of the data submitted, plans will need to send in information about their
model of care, payment rules, adjudication procedures, etc. in addition to the data. These rules will
obviously need to be regularly updated. We are concerned about the extra resources and costs
associate with such a requirement.
Are lab results required to be included with the submission of lab claims? If so, this will result in
more administrative costs and a different data format than requested.
Is the data submission on an incurred or paid basis?
How are interim bills handled? Are plans required to bundle first or will CMS do?
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PUBLIC SUBMISSION
As of: February 22, 2011
Received: February 15, 2011
Status: Draft
Category: Health Plan or Association
Tracking No. 80bef4a2
Comments Due: February 15, 2011
Submission Type: Web
Docket: CMS-2010-0282
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Comment On: CMS-2010-0282-0001
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Document: CMS-2010-0282-DRAFT-0004
CA
Submitter Information
Name: Cindy Lynch
Address:
Cerritos, CA, 90703
Organization: CareMore Health Plan
General Comment
With regard to the submission of all encounters, plans may possibly lose site of what’s approved, etc.
CareMore requests that Plans be provided with a matrix of what’s being accepted and paid.
file:///T|/...0199/10185/2010(CY2012)/60%20Day%20Package/60%20day%20comments/CMS-2010-0282-DRAFT-0004.html[05/20/2011 2:55:33 PM]
PUBLIC SUBMISSION
As of: February 22, 2011
Received: February 15, 2011
Status: Draft
Category: Health Plan or Association
Tracking No. 80bef4a7
Comments Due: February 15, 2011
Submission Type: Web
Docket: CMS-2010-0282
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Comment On: CMS-2010-0282-0001
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Document: CMS-2010-0282-DRAFT-0005
none
Submitter Information
Name: Stephanie Bayer
Address:
Solon, OH, 44139
Organization: Universal American
General Comment
Reporting Requirements, Section XI, Subsection D.5-D.8 (page 19) are not currently feasible to
report as these are not submitted/collected in any way as part of a submitted and/or reversed claim.
Additionally, this methodology would still not account for drugs that are not returned, rather
destroyed. Suggestion to remove this requirment until such time that NCPDP can include appropriate
fields with the claim segment to capture this information.
file:///T|/...0199/10185/2010(CY2012)/60%20Day%20Package/60%20day%20comments/CMS-2010-0282-DRAFT-0005.html[05/20/2011 2:55:33 PM]
PUBLIC SUBMISSION
As of: February 22, 2011
Received: February 15, 2011
Status: Draft
Category: Health Plan or Association
Tracking No. 80befdc6
Comments Due: February 15, 2011
Submission Type: Web
Docket: CMS-2010-0282
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Comment On: CMS-2010-0282-0001
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Document: CMS-2010-0282-DRAFT-0006
NY
Submitter Information
Name: Jeremy Laubacker
Address:
Buffalo, NY, 14216
Organization: Independent Health
General Comment
Section IV. Medication Therapy Management Programs – data element Q. Number of changes to
drug therapy made as a result of MTM interventions. Changes include dosage changes, therapeutic or
generic substitutions, and discontinuation of therapy.
The 2/28 reporting deadline does not allow for the most accurate picture of the data.
For example, there can be many recommendations made to providers each month (including
December) and it is not uncommon that responses to these recommendations indicate that the
prescriber will discuss with the patient at their next visit. It is not uncommon for the next visit to be
3-6 months later, so complete change data would not be available until June of the following year for
December recommendations.
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Reporting timeline:
Argus Comment: The timeline requirements for the new data elements specific to waste reporting are
overly aggressive given the industry has not defined a transaction to report waste. The industry has
provided feedback to CMS through the review of CMS‐4144‐P. The feedback stated that return tracking
should not be implemented until 2015 at the earliest.
For each network LTC pharmacy in the service area:
5. The total number of returned brand solid oral units (tablets, capsules, etc)
Argus comment: Please clarify where you would expect us to report brand drugs that are exempt from
the 7 day dispensing requirement. For example if inhalers are exempt because they are in a package size
that cannot be broken, should these still be reported under Brand?
6. The total cost of these returned brand drugs, where total cost should be calculated as gross drug cost
(Ingredient cost + Dispensing Fee + Sales Tax)
Argus Comment: By including dispense fee and sales tax in the returned drug amount, the potential
savings would be overstated. Return for destruction is not a refund. No crediting to plan will be done,
therefore dispense fees and sales tax will not be credited. It is strictly the return of the drug and
therefore the maximum potential savings would be the cost of the drug and a prorated amount of the
sales tax at best (assuming it was never dispensed which is the ideal situation). It is unlikely that the
dispense fee will be less therefore including the dispense fee in the estimated amount of savings would
be overstating the potential dollars saved.
8. The total cost of these returned generic drugs, where total cost should be calculated as gross drug
cost (Ingredient cost + Dispensing Fee + Sales Tax)
Argus Comment: By including dispense fee and sales tax in the returned drug amount, the potential
savings would be overstated. Return for destruction is not a refund. No crediting to plan will be done,
therefore dispense fees and sales tax will not be credited. It is strictly the return of the drug and
therefore the maximum potential savings would be the cost of the drug and a prorated amount of the
sales tax at best (assuming it was never dispensed which is the ideal situation). It is unlikely that the
dispense fee will be less therefore including the dispense fee in the estimated amount of savings would
be overstating the potential dollars saved.
9. By each NCPDP submission clarification code.
Argus Comment: Need to identify which submission clarification codes referenced. If referring to
dispensing frequency, please state that you would like these reported by SCC (submission clarification
code) that indicates the frequency of dispensing (i.e. 7 day)
Reporting timeline:
Argus Comment: The timeline requirements for the new data elements specific to waste reporting are
overly aggressive given the industry has not defined a transaction to report waste. The industry has
provided feedback to CMS through the review of CMS‐4144‐P. The feedback stated that return tracking
should not be implemented until 2015 at the earliest.
For each network LTC pharmacy in the service area:
5. The total number of returned brand solid oral units (tablets, capsules, etc)
Argus comment: Please clarify where you would expect us to report brand drugs that are exempt from
the 7 day dispensing requirement. For example if inhalers are exempt because they are in a package size
that cannot be broken, should these still be reported under Brand?
6. The total cost of these returned brand drugs, where total cost should be calculated as gross drug cost
(Ingredient cost + Dispensing Fee + Sales Tax)
Argus Comment: By including dispense fee and sales tax in the returned drug amount, the potential
savings would be overstated. Return for destruction is not a refund. No crediting to plan will be done,
therefore dispense fees and sales tax will not be credited. It is strictly the return of the drug and
therefore the maximum potential savings would be the cost of the drug and a prorated amount of the
sales tax at best (assuming it was never dispensed which is the ideal situation). It is unlikely that the
dispense fee will be less therefore including the dispense fee in the estimated amount of savings would
be overstating the potential dollars saved.
8. The total cost of these returned generic drugs, where total cost should be calculated as gross drug
cost (Ingredient cost + Dispensing Fee + Sales Tax)
Argus Comment: By including dispense fee and sales tax in the returned drug amount, the potential
savings would be overstated. Return for destruction is not a refund. No crediting to plan will be done,
therefore dispense fees and sales tax will not be credited. It is strictly the return of the drug and
therefore the maximum potential savings would be the cost of the drug and a prorated amount of the
sales tax at best (assuming it was never dispensed which is the ideal situation). It is unlikely that the
dispense fee will be less therefore including the dispense fee in the estimated amount of savings would
be overstating the potential dollars saved.
9. By each NCPDP submission clarification code.
Argus Comment: Need to identify which submission clarification codes referenced. If referring to
dispensing frequency, please state that you would like these reported by SCC (submission clarification
code) that indicates the frequency of dispensing (i.e. 7 day)
PUBLIC SUBMISSION
As of: February 22, 2011
Received: February 15, 2011
Status: Draft
Category: Health Plan or Association
Tracking No. 80befddb
Comments Due: February 15, 2011
Submission Type: Web
Docket: CMS-2010-0282
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Comment On: CMS-2010-0282-0001
Medicare Part D Reporting Requirements and Supporting Regulations under 42 CFR section 423.505
(CMS-10185)
Document: CMS-2010-0282-DRAFT-0008
NY
Submitter Information
Name: Jeremy Laubacker
Address:
Buffalo, NY, 14221
Organization: Independent Health
General Comment
Revised Measure: Part C Grievances
CMS should consider excluding the timely notification reporting requirement for fraud grievances. This
type of grievance does not have a timeframe for notification like other grievances do, and therefore
does not make sense to report on this. Reporting total number of fraud grievances should be
sufficient.
New Measure: Part C Enrollment/Disenrollment
These changes are significant. If an existing report from our enrollment vendor cannot accommodate
these changes, then this would be a very manual report, and very cumbersome to report on.
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February 15, 2011
CMS Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development
Attention: CMS–10185 (OMB#: 0938–0992)
Room C4–26–05
7500 Security Boulevard
Baltimore, MD 21244–1850
Re:
CMS–10185 (OMB#: 0938–0992)
Dear Sir or Madam:
I am writing on behalf of America’s Health Insurance Plans (AHIP) in response to the
Federal Register notice (75 FR 79000) published under the Paperwork Reduction Act on
December 17, 2010, by the Centers for Medicare & Medicaid Services (CMS) providing an
opportunity to comment on the Draft Medicare Part D Reporting Requirements for CY 2012.
AHIP is the national association representing nearly 1,300 member companies providing
health care coverage to more than 200 million Americans. The draft Part D reporting
requirements are of significant interest to AHIP’s member organizations, many of which
participate in the Medicare Part D Prescription Drug Benefit (Part D) program. Our
comments appear below.
SPECIFIC COMMENTS
Section I. Enrollment and Disenrollment
1. Enrollment
+
Data Element M. Data Element M proposes to require sponsors to report, of the
total number reported in Element A, “the number of enrollment transactions
submitted using the SEP Election Period code “S” related to change in residence.”
-The introductory language for this section of the reporting requirements
indicates that CMS intends to collect data that are not otherwise available
to the agency. However, sponsors are currently reporting to CMS through
the enrollment process transactions associated with SEPs for changes in
residence. Therefore, we recommend that CMS remove this data element
from the proposed Part D Reporting Requirements.
February 15, 2011
Page 2
--
+
In addition, it appears that the reference to SEP Election Period code “S”
is erroneous; it is our understanding that the SEP associated with changes
in residence has been assigned its own Election Period code “V.” (See
Plan Communications User Guide (PCUG) Appendices, page 140.)
Data Elements Q., R., and S. With the exception of Elements Q., R., and S., the
descriptions of the data elements explicitly specify that they should be reported as
a subset of either Element A. or C. It appears that a reference to Element A may
be appropriate in Elements Q., R., and S. If this is correct, we recommend that
the reference be added.
2. Disenrollment
+
Data Element A. Data element A proposes to require sponsors to report the total
number of disenrollment requests received in the specified time period.
(Emphasis added.) Use of the word, “requests,” appears to be in error because the
instructions for this reporting section indicate that sponsors must report all
disenrollments, which we interpret to mean both voluntary and involuntary
disenrollments. However, involuntary disenrollments do not typically involve
“requests.” For clarity, we recommend element A be revised to explicitly state
that voluntary and involuntary disenrollment requests be reported.
+
Data Element D. Data Element D proposes to require sponsors to report, of the
total number reported in Element A, the total number of disenrollments that were
due to failure to pay premium. The instructions for this reporting section indicate
that CMS will collect data on the elements that are “otherwise not available to
CMS.” However, sponsors are currently reporting to CMS the disenrollment
transactions associated with failure to pay premiums. (See PCUG Appendices,
page H-106.) Therefore, we recommend that CMS remove this proposed data
element from the Part D Reporting Requirements.
Section XI. Long-Term Care (LTC) Utilization and Waste
Data Element D. Data Element D proposes several new items (specifically items 5-8)
related to the reporting of the total number of returned prescription drugs and the total
cost of the returned drugs for each network LTC pharmacy in the Part D sponsor’s
service area. It is our understanding that there is currently no standard transaction for use
by LTC pharmacies in reporting to the plan sponsor the drugs that have been returned
from a LTC facility back to the pharmacy. Accordingly, we recommend that CMS delay
implementation of the proposed new items 5-8 of Element D. under this section of the
reporting requirements until a suitable standard has been developed by NCPDP.
February 15, 2011
Page 3
We have appreciated the opportunity to comment. Please contact me if additional
information would be helpful or if you have questions about the issues we have raised. I can
be reached at (202) 778-3209 or [email protected].
Sincerely,
Candace Schaller
Senior Vice President, Federal Programs
SNP Alliance
Comments on Proposed CMS Plans
2/15/11
Comments on Proposed Plans for Collection of Encounter Data
From Medicare Advantage Organizations
Form Number: CMS–10340 (OMB #:0938–New);
Name of Commenting Organization: SNP Alliance
Contact Person: Richard Bringewatt
Email: [email protected]
Phone: 202‐62‐1516
The following comments are made in response to proposed Part C Medicare Advantage
(MA) Reporting Requirements and Supporting Regulations as communicated in the Federal
Register/Vo. 75, No. 242/Friday, December 17, 2010. These comments are made with the
assumption that beginning January 2012, CMS intends to collect encounter data for
Medicare Advantage (MA) organizations to be used for “determining the risk adjustment
factors for payment, calibrating the risk adjustment model, calculating Medicare DSH
percentages, Medicare coverage purposes, and quality review and improvement activities.”
We also understand that CMS is asking for comments on the following issues:
1. The need for the information collection and its usefulness in carrying out the proper
functions of the agency.
2. The accuracy of CMS’ estimate of the information collection burden.
3. The quality, utility, and clarity of the information to be collected.
4. Recommendations to minimize the information collection burden on the affected
public, including automation collection techniques.
General Comments
While the SNP Alliance understands CMS’s interest in capturing more information about
ongoing practice, and the potential for using encounter data to improve risk adjustment and
to help address a variety of other proposed uses, we are concerned about:
1. The pace of implementation without commensurate timely guidance from CMS.
2. The significant additional costs that will be incurred by health plans, particularly for
smaller plans and those with a higher level of care complexity, without evidence of
added value.
3. The absence of clarity about the methodology that CMS will use to calibrate risk
adjustment and the absence of information about plans for other cited uses.
4. The potential for further delay in CMS efforts to “evaluate and revise the HCC risk
adjustment system in order to, as accurately as possible, account for higher medical
and care coordination costs associated with frailty, individuals with multiple,
comorbid chronic conditions, and individuals with a diagnosis of mental illness, and
also to account for costs that may be associated with higher concentrations of
beneficiaries with those conditions,” as required by Congress.
We are particularly concerned about the growing, disproportionate regulatory and
reporting complexities and costs accruing for plans seeking to specialize in care of poor,
frail, disabled, and/or seriously ill beneficiaries—Medicare’s most vulnerable, fast‐growing,
and high‐cost service groups.
1
SNP Alliance
Comments on Proposed CMS Plans
2/15/11
The timeframe for implementation is extremely aggressive.
Plans are awaiting final encounter data requirements and training for this project. More
detailed requirements are needed by plans to initiate development of their encounter data
systems. Further delays in accessing the detailed requirements will make it very difficult to
meet the current timeframe. We understand that plans need at least 12‐18 months to
implement the system after full information and technical resources become available. This
not only creates significant time pressures for plans but many plans did not have sufficient
information to include additional needed costs in their 2011 bids. A number of plans are
also concerned about the added complexity and costs associated with implementing this
new system under the ICD‐9 coding system when the ICD‐10 system will be implemented
shortly.
Recommendation: CMS should reevaluate its current timeframe for implementation in
light of these concerns and make appropriate changes in schedule to ensure for a smooth
transition that reduces the potential for system‐induced error and unnecessary additional
costs.
There has been some inconsistency in verbal and written communication from CMS
that needs clarification. For example—
1. Encounter Data Submission Frequency. Page 6 & 7 of the Notice indicate that
encounter data must be submitted at least weekly while the National Encounter meeting
and subsequent workgroup handouts indicate submission will occur at least monthly.
Recommendation: We request that data be submitted on a monthly basis.
2. Collection Frequency (Page 7, section 6). The Notice indicates that the final
submission deadlines would be similar to those for the risk adjustment data. The
National Encounter meeting and subsequent workgroup meetings have discussed
shortening the final submission deadline.
Recommendation: We recommend maintaining the existing risk adjustment timeline
to allow providers to submit claims to health plans within their allowed timelines, and
for the plans to process these claims.
3. Pricing Information: The Notice does not specify what type of payment information
will be required.
Recommendation: FIDESNPs suggested submitting total Medicare and Medicaid
payments on claims on a workgroup call and CMS concurred. We request confirmation
of this approach. We also request clarification of whether total payment should also be
submitted by DSNPs that provide some but not all Medicaid benefits; i.e., should all
Medicare and Medicaid payments be included in the claim submission?
4. Scope of Encounter Data Submission: CMS initially suggested that plans submit all
adjudicated claims/encounters. In subsequent discussion, CMS indicated that CMS
would edit the encounter data against the NPPES files for a valid NPI. If CMS uses a
front‐end edit to the encounter data system, instead of when the data are extracted to
feed the risk adjustment system, we understand atypical provider data will be excluded
2
SNP Alliance
Comments on Proposed CMS Plans
2/15/11
from CMS’s system. While this would not affect risk adjustment, since atypical
providers are not allowable provider types, the exclusion would under represent the
true costs of serving duals. Plans have also noted that providers do not always update
their information on the NPPES files. Thus, the information plans are receiving on a
claim may coincide with what is on the NPPES files. This may affect the collection of
illness burden data, as well as further suppress the cost of serving the population.
Recommendation: If CMS is interested in obtaining a comprehensive picture of total
dual costs, all data should be captured in some manner. We think this information
would be of significant interest to policymakers and would be important information for
CMMI and FCHCO as they develop methods for benchmarking dual demonstrations.
The potential burden of implementation appears to be more severe for plans
that specialize in care of complex care beneficiaries.
1. Unlike feeforservice providers, staff model plans and plans with capitated
provider networks do not always generate claims.
There is considerable evidence that care of persons with multiple, complex, ongoing
care needs require a closer and ongoing working relationship with beneficiaries and
their families, as well as with multiple care providers. As a result, a number of specialty
care programs have chosen to become more actively involved in primary care and
related care management functions for high‐risk beneficiaries. With an encounter
system rooted in claims data, this creates new complexity for plans that either provide
services directly or contract with providers in ways that do not generate claims as they
do for providers paid under fee‐for‐service.
Recommendation: We request that CMS consider establish a simplified policy for staff
model plan or plans functioning as a plan/provider hybrid in order to provide CMS with
needed data without unnecessarily burdening these plans or requiring them to change
practices that have proven to be more effective is serving high‐risk populations.
2. Small plans. While some would suggest that the additional burden experienced by
small plans in seeking to respond to new encounter data requirements provides further
evidence that small plans should either merge or become program components of other
larger plans, there is increased evidence that under certain circumstances, smaller plans
are more able to maintain ongoing relationships important in care of high‐risk
populations. PACE, Institutional SNPs, and Dual SNPs that exclusively serve persons
who are nursing home certifiable are examples of plans that have proven themselves to
be not only high quality programs but financially viable at enrollment levels deemed too
small for general MA plan populations. A plan’s ability to respond to increased
administrative burdens should not be the determining factor for defining optimum plan
size. Rather, a plan’s over all effectiveness in serving a defined population should be the
primary factor.
Some small plans are particularly concerned about the backend processes that will
require significant additional resources and systems to manage. The proposed
encounter data requirements will most likely result in smaller plans having to create an
3
SNP Alliance
Comments on Proposed CMS Plans
2/15/11
entirely new operational business unit to manage; and in some cases they will need to
design an entirely new business function.
Recommendation: We request that consideration be given to providing additional
support to small plans, extending the timeframe for their compliance, or reducing the
complexity of the requirements for small plans.
3. Plans responsible for Medicare AND Medicaid services for dual beneficiaries. A
key concern for plans with contracts for Medicaid services is that CMS is implementing a
new encounter data reporting system without coordinating this effort with state
requirements for encounter data reporting. This is not only going to result in
significantly higher costs and unnecessary administrative complexities for dual plans
focused on advancing integration, in any form; but it will further bifurcate the
administration of Medicare and Medicaid programs for duals at the very time that CMS
is advocating for full integration through the Center for Medicare and Medicaid
Innovation. This is not only true for programs that may evolve under new
demonstration authority but for plans that have long‐standing practices established
through prior demonstration authority.
Recommendation: Work with FCHCO, fully integrated plans, and States advancing fully
integrated care programs to establish an integrated policy and approach for addressing
the interface between Medicare and Medicaid for SNPs that have Medicaid contracts.
This needs to occur for ALL SNPs with Medicaid contracts and not just for those that
may evolve under new demonstration authority.
4. Plans with a high percentage of persons with multiple, complex and ongoing care
needs.
Since data reporting will be based on a much larger set of variables and new data
validation requirements will be imposed based on physician taxonomies, it will be much
more challenging for plans to validate data from multiple providers serving persons
with multiple chronic conditions who frequently see 15 or more unique physicians per
year, with multiple encounters throughout the year. The sheer volume of encounters to
manage will not only increase their average PMPM cost for compliance and curing
deficiencies, but exposes them to potential fraud and abuse challenges that are related
more to unintentional administrative error than to any intent to deceive or do harm.
SNPs already have a significantly greater data burden than standard MA plans as a
result of existing additional reporting requirements for HEDIS and for structure and
process measurement. They also have higher clinical and administrative costs related
to Model of Care requirements, including the expectation that SNPs provide add‐on
services and benefits to address special needs. Additional administrative requirements
were added this year by the SNP approval process mandated by the ACA. The
accumulation of additional data burden above and beyond that required for standard
MA plans is beginning to threaten the financial viability of specialized managed care.
This is particularly true for small plans with limited IT and resources.
Recommendation: Work with the SNP Alliance to evaluate and revise encounter data
requirements to account for the added complexities of compliance for plans with higher
concentrations of beneficiaries with higher medical and care coordination costs and
4
SNP Alliance
Comments on Proposed CMS Plans
2/15/11
more complicated encounter management problems related to care of frail elders;
adults with disabilities; persons with complex medical conditions; and individuals with
a diagnosis of mental illness.
There is a great deal of uncertainty about the relative value of using encounter data for
determining the risk adjustment factors for payment and calibrating the risk
adjustment model for plans that have higher concentrations of frail elders, adults with
disabilities, and other persons with complex medical conditions.
The SNP Alliance continues to have concerns about the adequacy of HCC risk adjustment
methodology for plans specializing in care of persons who are dually eligible for Medicare
and Medicaid and for those who are frail, disabled, and with complex medical conditions.
Without greater knowledge about the encounter data methodology to be used in
determining the risk adjustment factors for payment and calibrating the risk adjustment
model for plans that specialize in care of persons with unique and complex care needs, it is
difficult to provide meaningful comment on CMS’s stated primary purpose of implementing
a new encounter data system.
Recommendation: We strongly encourage CMS to proceed as quickly as possible with
evaluating whether the current risk adjustment methodology “fully accounts for the medical
and care management costs of persons associated with frailty, individuals with multiple,
comorbid chronic conditions, and individuals with a diagnosis of mental illness, and also
accounts for costs that may be associated with higher concentrations of beneficiaries with
those conditions,” as required by the Affordable Care Act. We also request that CMS
consider allowing plans to maintain a chronic diagnosis from year to year, once verified and
accepted by CMS, to reduce the risk of diagnostic codes being inadvertently dropped,
resulting in an inappropriate reduction in risk score and payment. In addition, we request
that CMS provide Special Needs Plans with information, as soon as possible, about its plans
for using encounter data to calibrate the risk adjustment model so that plans can
appropriately evaluate and prepare for its potential effects on specialized managed care
programs.
5
| File Type | application/pdf |
| Author | A0J591 |
| File Modified | 2011-05-20 |
| File Created | 2011-05-20 |