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As part of an initiative to streamline the Medicare Advantage and Prescription Drug appeals and grievance processes, CMS has consolidated Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. They are doing this to better align and provider a more defined, straightforward and non-repetitive understanding of current Part C and Part D appeals policy. The hope is that this document will allow health plans to better manage their processes and align their reporting efforts, ultimately resulting in better compliance and smoother audit preparation.

With that being said, CMS is currently seeking industry guidance on the changes so at this time nothing is set in stone. We see this as a positive initiative to help streamline and simplify compliance and can only hope that the new structure target date of January 1, 2019 becomes a reality. Here are some of the general and structural changes:

  • Simple, universal terminology used where guidance is applicable
  • Guidance applicable to only Part C or Par D, is clearly separated and easily identifiable
  • Sections reorganized to align with the order of the appeals process
  • Changes to align Part C and Part D policies:
    • Withdrawals and dismissals
    • When to use the reopening process
    • Verbal requests made by an individual on behalf of the enrollee

Rules and regulations are always changing, and it is difficult to stay ahead of the curve to ensure your own compliance is maintained. It is promising to see this initiative by CMS to help plans better manage their business. For now we will monitor feedback and advise of any new updates and changes.

To submit comments, you can send to Part_C_Appeals@cms.hhs.gov with “Part C and Part D Appeals Guidance” in the subject line. Comments must be submitted by close of business Monday, October 22, 2019 to be considered. For a copy of the guidance document please click here.

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New CMS Guidance

  As part of an initiative to streamline the Medicare Advantage and Prescription Drug appeals and grievance processes, CMS has consolidated Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. They are doing this to better align and provider a more defined, straightforward and non-repetitive understanding of […]

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