The Bridge – Volume 11

Jennifer Young
Jennifer Young, Executive Vice President

CMS Important News Releases

With a general election, massive increases in COVID-19 cases across the country, and many organizations focusing on the Annual Election Period, you may have missed these important CMS news releases.

Advance Notice of Methodological Change for 2022

CMS will calculate 100% of the risk score using the 2020 CMSHCC model (vs. the current 2017 model) and propose to calculate risk scores for payment to MA organizations and certain demonstrations using only risk adjustment eligible diagnoses identified from encounter data submitted by MA organizations and FFS claims. Health plans need to be prepared to shift to the new model for CY 2022, including using 2021 to identify and remediate gaps in encounter reporting and error resolution.

Changes in Part B Drug Pricing

HHS has enacted the Most Favored National (MFN) Model, a drug payment model that will lower Medicare Part B payments for certain drugs to the lowest price among similar countries. This will save American taxpayers and beneficiaries more than $85 billion over seven years. Health plans paying at Medicare FFS rates will need to update pricing and configuration to pay claims according to the new pricing model, as well as notify their providers who commonly prescribe the drugs impacted by the new payment model.

Changes in Stark Law

As part of the Patients Over Paperwork initiative, this final rule allows for changes that will help modernize the healthcare system by recognizing the administrative burden and restrictions of an antiquated healthcare model. The changes will allow for much needed exceptions that will be important for health plans to update in their provider policies and communications.

Need help planning for these changes? Call 720.428.2650 or email

January Readiness

Sue Dahlkamp, Interim Compliance Officer & Director, Operations, Nicole Izzolena, Program Manager

AEP members must receive their new ID cards by January first. Are you ready with all member materials and eligibility files? Here are some of our best practice reconciliation tips to ensure that you have provided the critical materials your members need to access their benefits and services.

Compare your fulfillment reports to your membership files to check for gaps. For MAPD and PDP plans, double check your 4Rx data. For MAPD and MA plans, make sure the PCP is correctly identified. Remind members to securely destroy their old cards and start using the new card on January first.

New members will be anxious to receive their membership materials/Welcome Kits. Again, compare your fulfillment report to membership for gaps. These materials must be sent prior to January first, so expedite any items not already on the way.

It is also important to make sure you are timely in your submission to CMS. You will want to compare application signature dates for all plan applications including the OEC Submit Time, rolling back 11 hours, to your MARx submission date to determine timeliness. As a reminder, CMS uses 95% timeliness factor for compliance.

Your PBM eligibility files need to contain accurate 4Rx information and eligibility spans for all active members as of January first. Your IT department should be running queries comparing membership system information to the eligibility files for accuracy and gaps. Make sure your IT team produces a “fallout” report for any missing members or incorrect information.

Reach out to Madena’s experts for assistance determining if your files are accurate and complete.

What’s Next?

Now that we are through AEP, it is time to prepare for the Medicare Advantage Open Enrollment Period (MA OEP), which runs between January 1 – March 31.

During the MA OEP, MA plan enrollees may enroll in another MA plan or disenroll from their MA plan and return to Original Medicare. Individuals may make only one election during the MA OEP.

It is important to utilize the election type code usage section in the eligibility side of Marx to determine if the individual has already used their one-time election for this enrollment period. If they used the election to enroll, you will see “E.” If they used the election to disenroll, you will see “D” in this section. Please refer to CMS guidance for a comprehensive understanding of this enrollment period.

HPMS Memo Summary

Sara King, Senior QA Tester & Account Manager

A helpful round-up of the final memos from CMS this year.

Announcement of the November 2020 Encounter Data Software Release Updates

The Centers for Medicare and Medicaid Services (CMS) continues to implement software improvements to the systems that accept and process encounter data to support the Medicare Advantage (MA) program. These changes were implemented in the Encounter Data Processing System (EDPS) on Nov. 13, 2020.

2021 Medicare-Medicaid Plan (MMP) Program Audit Update

CMS announced that it will use the audit protocols for the 2020 program audits to conduct the 2021 program audits. CMS will also use the 2020 MMP program audit protocols to conduct the 2021 MMP program audits.

2021 Part D Income-Related Monthly Premium Adjustment

CMS released information on the income-related monthly adjustment amounts for enrollees in Part D prescription drug plans who have incomes above specified threshold amounts.

Contract Year (CY) 2021 Notices for Applicable Integrated Plans: “Coverage Decision Letter”, “Letter about Your Right to Make a Fast Complaint” and “Appeal Decision Letter”

Announced the release of the Coverage Decision Letter and form instructions for applicable integrated plans to use starting on January 1, 2021.

Updated CY 2020 Part D Reporting Requirements Technical Specifications: Employer/Union-Sponsored Group Health Plan Sponsor Section

Effective for 2020 reporting, all “800 series” PDPs offered to employers are required to report data for this reporting section.

Medicare Advantage/Prescription Drug System (MARx) December 2020 Payment INFORMATION

Provides information about the December payment, which is scheduled for receipt on December 1, 2020, and other payment related items that may require plan action.

  • Coverage Gap Discount (CGD) Invoice Offsets
  • Payment Adjustments to PACE Organizations for Calendar Years 2010 – 2020
  • PACE ESRD Payment Error in November 2020 Payment
  • Sequestration
  • Changes to MARx Plan Transaction Processing
  • End-of-Year 2020 Part C Premium Processing (Transaction Code 78)
  • End-of-Year 2020 Premium Payment Option (PPO) Processing (Transaction Code 75)
  • End-of-Year 2020 Automatic Assignment of Segment IDs in the MARx System

Final Addendum to the Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

CMS released a final Addendum to the Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (“Part C & D Guidance”). This becomes effective on January 1, 2021.

Madena: A Year in Review

Denyse Wise, CEO

As 2020 draws to a close, I am inclined to avoid reflecting on the past few months in anticipation of putting the year behind us. But I know considering the past is necessary to build a better future.

Madena started 2020 strong and motivated to take on new clients and roll out a number of improvements to our Membership Suite™ suite. Our priorities shifted slightly in March as we needed to address the safety and health of our workers and families. As we evolved and adapted to a virtual workforce and executed business continuity drills, we invested more in security and technology to better protect our client’s data and maintain productivity for all our workers within their unique living situations.

By late Spring we were able to shift our focus back to our expansion and growth goals for 2020. We kicked-off a series of software enhancement projects to improve our Membership Suite™ Letter Module and incorporate the new CMS BIC-BEQ Real-Time API within our Membership Suite™ Enrollment system.

We believe we have made best-in-class improvements with our Letter Module, enabling organizations with complex plan profiles and letter requirements to have extensive configurability options to cover all letter types. With our new Letter Admin Console, we are able to handle countless scenarios for systematically generating member-related correspondence, all maintained through a user-interface.

We’re also thrilled to be working with CMS as one of their early partners to test and roll-out the new CMS BIC-BEQ API. We are currently working to integrate the API within our BEQ Module. We are also redesigning our system to accommodate the changes related to the real-time BEQ Responses. Our first Go-Live date should be in early January 2021.

Madena had a hard year as a business. However, to reflect on all we sustained and accomplished for both clients and staff, despite the challenges, we cannot help but feel grateful and motivated to transition into 2021 with even greater goals and offerings for our clients.

Be sure to follow us on LinkedIn. We will be sharing exciting news in January on what we are up to in 2021! Happy holidays and wishing all a peaceful, healthy New Year.

View/Download a PDF of the December newsletter.

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