The Centers for Medicare and Medicaid Services (CMS) released final program changes for Medicare Advantage (MA) Part C and Part D. Key provisions with impact to long-term care providers include the following:
Efficient Dispensing of Medications in Long Term Care Facilities
CMS clarified and tightened the language in the provision to further support the use of efficient medication dispensing techniques in long-term care settings.
This was accomplished through:
- The prohibition of payment arrangements that penalize more efficient medication dispensing techniques by prorated dispensing fees.
- Adding a requirement that any differences in payment methodology result in incentives to adopt more efficient dispensing methodologies.
Clarification on Medicare Advantage Organization Timeframes for Organizational Determinations and Reconsiderations
In general, Medicare Advantage plans have very specific timeframes that must be adhered to when a provider or enrollee requests an organizational determination (ex. authorization/approval) or reconsideration (ex. appeal of a denial of coverage).
In cases where an enrollee’s life, health or functioning is at serious risk, a physician can request an expedited decision.
Typically, the health plan has 72 hours to respond to expedited requests. In limited circumstances, the health plan has the ability to extend the review timeframe.
However, this extension must be in the enrollees’ best interest and not simply for the convenience of the plan.
Based on results from Medicare Advantage plan audits, CMS found that some Medicare Advantage organizations routinely and inappropriately exercising the 14-day extension.
This occurred mostly when the Medicare Advantage plan had insufficient resources to handle the volume of requests within the 72-hour timeframe, and when documentation from a provider was outstanding.
In the proposed and final rules, CMS revised the provision by tightening the language around when an extension is acceptable. First and foremost, an extension must be in the best interest of the enrollee.
If additional medical information is required from a non-contracted provider that could result in a reversal of a coverage denial an extension may be warranted.
CMS clarified that extensions are for extraordinary and non-routine circumstances and must not be invoked for the convenience of the plan.
As a result of these changes, long-term care providers may see improvements in timeliness of organizational determinations and reconsiderations from Medicare Advantage plans.
It is imperative that providers understand the processes and timeframes associated with MA organizational determinations and reconsiderations. Tracking of submitted requests and follow up as deadlines approach is necessary.
Delays should be reported to CMS.
Be sure to check out more information on Medicare Advantage requirements related to organizational determinations.
Medication Dispensing
Additionally, efficient medication dispensing techniques should be enhanced or, at the least, not hindered by the payment arrangements between Part D plans and long-term care pharmacies.
As long-term care pharmacies and Medicare Advantage plans implement the changes required by the final rule, providers should monitor changes in dispensing patterns and alert pharmacies to the revisions in support of more efficient dispensing techniques.
This provision of the rule goes into effect Jan. 1, 2016.