1. HFMA Regulatory Overview
Medicare Advantage
An Overview of the Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program

2. Major Provisions
Implementation of the Comprehensive Addiction & Recovery Act of 2016 (CARA)
Revisions to Timing & Method of Disclosure Requirements
Preclusion List Requirements for Prescribers in Part D & Individuals & Entities in Medicare Advantage (MA)

3. Implementation of the Comprehensive Addiction & Recover Act of 2016 (CARA)
CMS finalized with modifications to implement the provisions of CARA into the current Part D drug management programs: Overutilization Monitoring System (OMS) & Opioid Drug Utilization Review (DUR).
Part D plan sponsors may establish a program for beneficiaries at-risk for prescription drug abuse including case management and ability to limit access.
Implement a claim edit to prevent further coverage and abuse
Lock-in requirement applied to beneficiary’s coverage that limits access to frequently abused drugs
Exempted beneficiaries
Individuals being treated for active cancer-related pain
Enrollee who has elected to receive hospice care or is receiving palliative or end-of-life care
Resident of a long-term care facility, intermediate care facility for mentally disabled, or another facility for which frequently abused drugs are dispensed through a contract with a single pharmacy

4. Revisions to Timing & Method Disclosure Requirements
CMS finalized the proposal for a change to the timeline that must be met in disclosing certain types of information to enrollees and allows more flexibility in method of delivery.
Evidence of Coverage (EOC), provider or pharmacy directory, and formulary will now be required to be provided by the first day of the annual enrollment period instead of 15 days prior. Plans are required to provide hardcopy mailings of the Annual Notice of Change (ANOC) 15 days prior to the open enrollment period.
Plans may post certain documents electronically, including the EOC, and provide a hardcopy only upon request.

5. Preclusion List Requirements for Prescribers in Part D & Individuals & Entities in MA
CMS finalized the proposal to eliminate the requirement that providers and suppliers be enrolled in the Medicare program in order to provide services to enrollees. CMS will use a “Preclusion List” policy in lieu of current enrollment requirements for providers and suppliers.
CMS will compile a Preclusion List of individuals or entities who are currently revoked from Medicare, are under a reenrollment bar, and CMS determines the underlying conduct that led to the revocations is detrimental; or have engaged in behavior for which CMS could have revoked the prescriber to the extent applicable if they had been enrolled in Medicare, and CMS determines the underlying conduct that would have led to revocations is detrimental to the Medicare program.
MAOs and prescribers are required to deny claims by individuals or entities on the preclusion list. There is no exception for emergency or urgently needed services.

6. STAR Ratings Modifications
CMS finalized the proposal to codify key aspects of the Star Ratings methodology for MA and Part D programs beginning with measurement periods in contract year This includes the addition of new measures. CMS acknowledges the rulemaking process may prolong the process of adding new measures but sates that this provision balances some needs including greater transparency.
CMS adopted the proposal to modify the assignment of Star Ratings when there is a contract consolidation. Effective on or after January 1, 2019, CMS will assign Star Ratings based on the enrollment-weighted mean of the measure scores of the remaining and consumed contracts.

7. Helpful Links Full summary of the final rule.
Final rule, published in the April 16, 2018, Federal Register.
CMS Fact Sheet, CMS Finalizes Policy Changes and Updates for Medicare Advantage and the Prescription Drug Benefit Program for Contract Year 2019 (CMS-4182-F).
April 2, 2018, Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter.
Read HFMA Business News article, Medicare Advantage Rates, Policies Draw Insurer Praise, for additional insight.