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ARTICULOS Y TEMAS DE INTERES PARA LOS FACTURADORES Y COMUNIDAD

"The secret of joy in work is contained in one word - EXCELLENCE. To know how to do something well is to enjoy it"

Raúl Alicea, MBA/HCM, CHA

Health Insurance Specialist

Provider Outreach & Education

Centers for Medicare & Medicaid Services

P 787-771-3660

F 787-771-3689

C 787-300-0389

 

"The secret of joy in work is contained in one word - EXCELLENCE. To know how to do something well is to enjoy it"

 

Medicare tools to compare 2009 options are online now…

 

Beneficiaries can now visit www.Medicare.gov to access the Medicare Prescription Drug Plan finder and Medicare Options Compare to review their options for 2009.  The Plan Finder allows beneficiaries to compare prescription drug coverage from both PDPs and MA-PDs and to view premiums, formularies, and availability of coverage in the gap.  The Medicare Options Compare tool allows beneficiaries to compare Medicare health plan options, such as HMOs and PPOs

 

The general version of the “Medicare & You 2009” handbook is also available online.  This general version contains information about 2009 costs, covered services, beneficiary choices, help for those with limited income and resources, and beneficiary rights and protections.  Additionally, there are 59 geographic-specific versions of the handbook which include drug and health plan comparison charts for particular states or regions.  These handbooks are currently being mailed to people with Medicare and partners through out the country.

 

Important information about Part D Fraud, Waste, and Abuse Training Requirements…

 

Please see this important notice from the CMS Office of Financial Management.  I’ve pasted the full text of this notice immediately below.

 

 

CLARIFICATION OF CMS’ REQUIREMENT FOR PART D FRAUD, WASTE, AND ABUSE TRAINING LISTSERVE ALERT

 

 

The Centers for Medicare and Medicaid Services (CMS) has received hundreds of phone calls and emails from Part D Sponsors and their first tier, downstream, and related entities about the fraud, waste, and abuse training requirement that becomes effective as of January 1, 2009. 

 

Quick facts about the requirement:

1)   It is the Part D Sponsor’s responsibility to provide their first tier, downstream, and related entities with the appropriate training;

2)   This training requirement becomes effective January 1, 2009.  Since this is a yearly requirement, each Sponsor has from January 1, 2009 to December 31, 2009 to meet this requirement; and

3)   This requirement could be cumbersome for first tier, downstream, and related entities because these entities often contract with multiple Part D Sponsors.  To alleviate the necessity for first tier, downstream, and related entities to take training multiple times, there are a few associations that are working to create a training that will meet CMS’ requirements.  The goal would be to offer training that employees from the Part D Sponsor and the first tier, downstream, and related entities could take once a year to meet their annual  obligation with all the Part D Sponsors with which they contract. 

 

If you would like more specific details, please read below:

 

The final rule entitled, "Revisions to the Medicare Advantage and Part D Prescription Drug Contract Determinations, Appeals, and Intermediate Sanctions Processes,” FR Doc. 07-5946 (72 FR 68700 through 68741), published December 5, 2007, updated the compliance plan requirements for Medicare Advantage (MA) organizations and Part D Sponsors.  Specifically, the compliance regulation states that a compliance plan, which must include measures to detect, correct, and prevent fraud, waste and abuse, must consist of training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, and directors, as well as first tier, downstream, and related entities.  This change clarifies that MA organizations and Part D Sponsors need to apply these training and communication requirements to all entities they are partnering with in the MA and Part D programs, not just the direct employees within their organizations.

 

MA organizations and Part D Sponsors are responsible for ensuring that all employees (including managers and directors) and the first tier, downstream, and related entities are provided appropriate training.  MA organizations and Part D Sponsors must either provide the training directly to all of its employees (including managers and directors) and first tier, downstream, and related entities or provide the appropriate training materials to its employees (including managers and directors) and first tier, downstream, and related entities and ensure that the training has been taken.  First tier, downstream, and related entities, including pharmacies, should not develop  their own training.  The first tier, downstream, and related entities can administer the training if the materials are provided by the Sponsor.

 

This change in the training requirement becomes effective January 1, 2009.  Therefore,  the mandatory training of the MA organization and the Part D Sponsor’s employees (including managers and  directors) and the first tier, downstream, and related entities must begin  January 1, 2009, and  must be completed within one year (by December 31, 2009).  The training does not need to be completed by January 1, 2009.  Thereafter, the training on the Part D program must be provided on an annual basis.   

 

CMS recognizes that because first tier, downstream and related entities, including pharmacies, often contract with many different MA and Part D plans, this requirement would impose a burden on the first tier, downstream and related entities that contract with multiple Sponsors.  As a result, CMS is currently working with a few associations to assist the industry in developing a training program that meets CMS’ requirements.  The training program would reduce the burden on first tier, downstream, and related entities since they would only have to take this training once a year, and the one time training would satisfy the CMS requirement for all MA Organizations and Part D Sponsors with which they are affiliated.

 

It is CMS’ hope that training that meets CMS’ requirements will be available soon.  Until such time as this training program is available, MA Organizations and Part D Sponsors are responsible for either providing the training directly to all of their employees (including managers and directors) and first tier, downstream, and related entities or providing the appropriate materials to their employees (including managers and directors) and first tier, downstream, and related entities and ensuring that the training has been taken.  If you have any questions about this policy, please contact either Stephanie Blaydes Kaisler at 410-786-0957 or Lynn Merritt-Nixon at 410-786-4652.         

 

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