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Summary of Key Takeaways from the Recent CMS Released Medicare Advantage and Prescription Drug Plan Appeals Guidance

By Dorothy DeAngelis, Diane R. Ramey

March 6, 2019

On February 22, 2019, Centers for Medicare and Medicaid Services (CMS) released the final Parts C and D Enrollee Grievance, Organization/Coverage Determinations, and Appeals Guidance, an update to the draft guidance released on October 1, 2018.[1]

Based upon recent regulatory changes and updates Ankura has identified key areas plans need to consider implementing in operational processes, policies and procedures, and job aides to meet the requirements as early as possible. These key areas include:

Part D:

  • If an enrollee disagrees with a plan’s Part D at-risk determination, as part of a plan drug management program, enrollees may request a redetermination and potentially a higher level of appeal.
  • Regarding Tiering Exceptions, CMS clarified the following limitations to be applied by the plan:
    • Brand name drugs are eligible to the lowest applicable cost-sharing associated with brand name alternatives.
    • Biological products are eligible to the lowest applicable cost-sharing associated with biological alternatives.
    • Non-preferred generic drugs are eligible to the lowest applicable cost sharing associated with alternatives which are either brand or generic drugs.
    • No requirement to offer exceptions for brand name drugs or biological products at the cost-sharing of alternative generic drugs.
    • Plans may design specialty tiers to be exempt from exceptions.
  • Level 1 Appeals processing timeframes for Part D redetermination exception requests cannot be tolled for receipt of the prescribing physician’s supporting statement. CMS recommends for Part D coverage determination requests, tolling for additional information should not exceed 14 days.

Part C & Part D:

  • Revised regulatory guidance on “good faith effort to provide verbal notification.” If a plan is successful in verbal notification, and written notification is required, the plan must send written notification within three calendar days of the verbal notice. However, if a good faith effort was made but not successful, written notice must be made in the applicable timeframes.
  • Provided clarification for when outreach is necessary to make a coverage or appeal decision, stating a minimum of one attempt is sufficient. However, plans may adopt best practices for additional outreach. Plans are not required to conduct outreach prior to denial if they believe they have all necessary information.
  • Revised guidance on appointment of representative. Enrollee cannot verbally appoint a representative. Appointment must be submitted on a valid Appointment of Representative (AOR) form. CMS also clarified the lack of receipt of an AOR form pending time frame, to be the conclusion of the applicable timeframe for request, plus extension, if applicable.
  • Plans received three important clarifications to help calculate and monitor timeliness.
    • CMS bifurcated when a plan’s request is considered received. For standard requests, the timeframe begins when any unit or delegated entity receives the request. Expedited requests are considered received when they reach the appropriate department.
    • Written notification is considered delivered on the date the plan drops the notice in the courier drop box (US Postal or FedEx) or the date funds are distributed via Electronic Funds Transfer (EFTs) for payment.
    • For purposes of timeliness calculation, the day after a grievance, initial determination, or level 1 appeal is received clarifies when a request is considered received by the plan.
  • Plans must determine whether an issue is a grievance, coverage request, appeal, or combination.  If the issue is a grievance or an appeal, the plan will need to inform enrollees, either verbally or in writing. Further clarification language was provided on the differences between inquiries, grievance, coverage request, and appeals for training purposes.
  • Updates to reopening guidelines:
    • A reopening can be either oral or verbal.
    • CMS recommends that reopenings, at the plan level, be completed within 60 days of receipt.
    • Part D may process clerical errors as reopenings, however, Part C must reopen request.
    • Reopenings resulting in a change to denial rationale must result in delivery of a written notification.
  • If a plan makes a favorable decision for Part C or Part D within 24 hours after the end of the adjudication timeframe, they should notify the enrollee of the decision in lieu of forwarding to the Independent Review Entity (IRE).

Although the update to Part C and Part D guidance is not expected to be audited until January 2020, plans should  prepare and proceed with implementation of changes and updates. Ankura has served many roles in the operational and process improvements of these areas and can help your organization in end-to-end process reviews, data analytics, revising policies and procedures, and implementing key metrics dashboards. Contact us for more information on how we can help your organization.


[1] Centers for Medicare and Medicaid Services Memo: February 22, 2019, Release of Medicare Advantage and Prescription Drug Plan Appeal Guidance