Every October, the Centers for Medicare & Medicaid Services (CMS) distributes a Readiness Checklist to Medicare Advantage and Prescription Drug Plan (MAPD) Sponsors as a reminder to prepare for the upcoming plan year. Although CMS no longer requires Sponsors to submit assessment attestations, CMS still expects Sponsors to review the comprehensive checklist and self-assess their ability to meet the requirements. The Readiness Checklist includes many of the same critical requirements every year; however, it also includes new items based on concerns identified by CMS audits and new or revised regulations.
The CMS Readiness Checklist is not an exhaustive list of all requirements under the Medicare regulations, but is a reminder of potential risk items, expected to be implemented by January 1, 2023.
Why is this ‘readiness’ exercise important?
CMS requirements are in place to protect Medicare members. Sponsors have an opportunity to use this ‘readiness’ exercise to create visibility and transparency, identify risk, and craft remediation plans well in advance of the new contract year. Sponsors must notify their account manager(s) of any requirements that are at risk or where technical assistance is needed to remain compliant. Sponsors can increase profitability and STAR ratings by implementing efficient and effective processes geared toward a positive member experience.
For CY 2023, there are new requirements for MAPD. The 2023 Readiness Checklist highlights some of these new requirements:
- Inflation Reduction Act of 2022 – This law is inclusive of numerous updates; however, pay attention to the vaccine and insulin coverage and requirements in the following sections:
- Section 11401 – Coverage of Adult Vaccines Recommended by the Advisory Committee on Immunization Practices Under Medicare Part D
- Section 11406 – Appropriate Cost-Sharing for Covered Insulin Products Under Medicare Part D
- Note: Sponsors should carefully review the memos mentioned in the October 17, 2022, HPMS memo for assistance in the implementation of IRA provisions effective January 1, 2023
- Beginning January 1, 2023, through March 31, 2023: Part D incorrect cost-sharing based on previously approved CY 2023 PBP, sponsors must reimburse the enrollee within 30 calendar days for an amount over $35 for a one-month supply of a covered insulin product. (Refer to memo dated September 26, 2022).
- Sponsors participating in the Part D Senior Savings (PDSS) model in CY 23 should refer to the additional clarifying guidance and PDE reporting instructions.
- State Medicaid Agency Contracts – Sponsors offering D-SNPs must establish one or more enrollee advisory committees (EAC) for each state the D-SNP operates in, beginning January 1, 2023.
- Beneficiary Real-Time Benefit Tool – Part D sponsors must implement and provide enrollees with an easy-to-understand, accurate, timely, clinically appropriate, beneficiary-specific portal.
It is the Sponsors sole responsibility to ensure the accuracy of the readiness assessment, not their subcontractors or related entities. CMS will continue to monitor Part C and Part D programs and Sponsors to ensure they abide by the rules and regulations of CMS.
Going through this activity has major benefits:
- Sponsors should establish a process to complete the Readiness Checklist that includes business owner attestation with supporting documentation. The next step is an independent validation of the responses by the Compliance department or a trusted partner to validate the completeness of the supporting documentation.
- The independent validation can also feed into your annual Compliance Risk Assessment by examining the risk impact associated with the people, process, and technology that supports the requirement. Additional best practice includes summary reporting to create a roadmap for process improvement opportunities.
We’re here to help provide support with:
- Development of the Readiness Checklist process
- Tools to track compliance, supporting documentation, and risk assessment scores
- Validation of business owners’ responses, and
- Assist with the resolution of identified risks
CODY® has the team, expertise, and state-of-the-art technology to support health plan operations, improve performance, and ensure compliance with industry and regulatory standards. To learn more, contact us today for a consultation or a software demo.
About us: CODY® has worked with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Membership Suite™™, our proprietary suites of software, are designed specifically for health plans. www.codyconsulting.com