2023-07115.pdf

are conceptually similar to the SRFs of interest. (B) The HEI is calculated by combining measure-level scores for the subset of enrollees with SRFs of interest included in the HEI across the two most recent measurement years using a modeling approach that includes year as an adjustor to account for potential differences in performance across years and to adjust the data to reflect performance in the second of the 2 years of data used. Measure-level scores are used for contracts that have data for only the most recent of the 2 years, but measure-level scores are not used for contracts that have data for only the first of the 2 years. (ii) In determining the HEI scores, a measure will be excluded from the calculation of the index if the measure meets any of the following: (A) The focus of the measurement is not the enrollee but rather the plan or provider. (B) The measure is retired, moved to display, or has a substantive specification change in either year of data used to construct the HEI. (C) The measure is applicable only to SNPs. (D) At least 25 percent of contracts are unable to meet the criteria specified in paragraph (f)(3)(iv) of this section. For Part D measures, this criterion is assessed separately for MAPDs and cost contracts, and for PDPs. (iii) The Star Ratings measures that remain after the exclusion criteria in paragraph (f)(3)(ii) of this section have been applied will be included in the calculation of the HEI. CMS will announce the measures being evaluated for inclusion in the calculation of the HEI under this paragraph (f)(3) of this section through the process described for changes in and adoption of payment VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00220 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222339 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations and risk adjustment policies in section 1853(b) of the Act. (iv) For a measure to be included in the calculation of a contracts HEI score, the measure must meet both of the following criteria: (A) The measure must have a reliability of at least 0.7 for the contract when calculated for the combined subset of enrollees with the SRF(s) specified in paragraph (f)(3)(i)(A) of this section across 2 years of data. (B) The measure-specific denominator criteria must be met for the contract using only the combined subset of enrollees with the SRF(s) specified in paragraph (f)(3)(i)(A) of this section across 2 years of data. (v) To calculate the rating-specific HEI score, the distribution of contract performance on each eligible measure for the subset of enrollees that have one or more of the specified SRFs will be assessed and separated into thirds, with the top third of contracts receiving 1 point, the middle third of contracts receiving 0 points, and the bottom third of contracts receiving 1 point. The rating-specific HEI will then be calculated as the weighted sum of points across all measures included in the index using the Star Ratings measure weight for each measure divided by the weighted sum of the number of eligible measures for the given contract. The measure weight for each measure is the weight used for the measure in the current Star Ratings year as specified in paragraph (e) of this section. (vi) To have the HEI calculated, contracts must have at least 500 enrollees in the most recent measurement year used in the HEI and have at least half of the measures included in the HEI meet the criteria specified under paragraph (f)(3)(iv) of this section. (vii) In order to qualify for the full HEI reward, contracts must have percentages of enrollees with the specified SRFs combined greater than or equal to the contract-level median in the most recent year of data used to calculate the HEI and a rating-specific minimum index score of greater than zero. In order to qualify for one-half of the HEI reward, contracts must have percentages of enrollees with SRFs greater than or equal to one-half of the contract-level median up to, but not including, the contract-level median percentage of enrollees with SRFs in the most recent year of data used to calculate the HEI and a rating-specific minimum index score of greater than zero. One-half of the contract-level median and the contract-level median enrollment percentages are assessed separately for contracts that offer Part C and stand- alone Part D contracts. (A) For contracts with service areas wholly located in Puerto Rico, the percentage of enrollees that are LIS/DE or disabled is calculated by adding the number of DE/disabled enrollees to the estimated LIS percentage calculated by taking the percentage LIS/DE as calculated at  422.166(f)(2)(vi) and (vii) and 423.186(f)(2)(vi) and (vii) and subtracting the percentage of DE enrollees. (B) Contracts with service areas wholly located in Puerto Rico are excluded from the calculation of one- half of the contract-level median and the contract-level median. (viii) For contracts that have percentages of enrollees with SRFs greater than or equal to the contract- level median enrollment percentage, the HEI reward added to the contracts summary and overall ratings will vary from 0 to 0.4 on a linear scale with a contract receiving 0 if the contract receives a score of 0 or less on the HEI and 0.4 if the contract receives a score of 1 on the HEI. For contracts that have percentages of enrollees with SRFs greater than or equal to one-half the median percentage of enrollees with SRFs up to, but not including, the contract-level median percentage of enrollees with SRFs, the HEI reward added to the contracts summary and overall ratings will vary from 0 to 0.2 on a linear scale, with a contract receiving 0 if the contract receives a score of 0 or less on the HEI and 0.2 if the contract receives a score of 1 on the HEI. The HEI reward is rounded and displayed with 6 decimal places. Contracts that cannot have a HEI score calculated (that is, contracts that are not scored on at least half of the measures included in the index) will not receive an HEI reward. (ix) The HEI reward is calculated separately for, and then added to, the overall rating, Part C rating for MAPDs and MA-only contracts (and cost contracts), Part D rating for MAPDs (and cost contracts), and Part D rating for PDPs after the addition of the CAI as specified in paragraph (f)(2) of this section and application of the improvement measures as specified in paragraph (g) of this section and before the final overall and Part C and D summary ratings are calculated by rounding to the nearest half star. (g) * * * (1) CMS runs the calculations twice for the highest level rating for each contract-type (overall rating for MAPD contracts and Part D summary rating for PDPs), with the reward factor adjustment if applicable and the CAI adjustment, once including the improvement measure(s) and once without including the improvement measure(s). In deciding whether to include the improvement measures in a contracts final highest rating, CMS applies the following rules: * * * * * (i) * * * (7) * * * (i) Through the 2025 Star Ratings, CMS excludes the numeric values for affected contracts with 60 percent or more of their enrollees in the FEMA- designated Individual Assistance area at the time of the extreme and uncontrollable circumstance from the clustering algorithms described in paragraph (a)(2) of this section. * * * * * (8) * * * (i) Through the 2025 Star Ratings, CMS excludes the numeric values for affected contracts with 60 percent or more of their enrollees in the FEMA- designated Individual Assistance area at the time of the extreme and uncontrollable circumstance from the determination of the performance summary and variance thresholds for the reward factor described in paragraph (f)(1) of this section. * * * * * 41. Section 423.265 is amended by a. Redesignating paragraphs (b)(2) and (3) as paragraphs (b)(3) and (4), respectively; b. Adding new paragraph (b)(2). c. Adding a paragraph heading to the newly redesignated paragraph (b)(4); and The additions read as follows:  423.265 Submission of bids and related information. * * * * * (b) * * * (2) Substantial differences between bids(i) General rule. Except as provided in paragraph (b)(2)(ii) of this section, potential Part D sponsors bid submissions must reflect differences in benefit packages or plan costs that CMS determines to represent substantial differences relative to a sponsors other bid submissions. In order to be considered substantially different, each bid must be significantly different from the sponsors other bids with respect to beneficiary out-of-pocket costs or formulary structures. (ii) Exception. A potential Part D sponsors enhanced bid submission does not have to reflect the substantial differences as required in paragraph (b)(2)(i) of this section relative to any of its other enhanced bid submissions. * * * * * (4) Bid acceptance. ***  * * * * * VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00221 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222340 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations 42. In  423.308 amend the definition of Gross covered prescription drug costs by revising the introductory text and paragraph (1) to read as follows:  423.308 Definitions and terminology. * * * * * Gross covered prescription drug costs means those costs incurred under a Part D plan, excluding administrative costs, but including dispensing fees, during the coverage year. They equal the sum of the following: (1) The share of actual costs (as defined by  423.100 of this part) paid by the Part D plan that is received as reimbursement by the pharmacy, or other dispensing entity, reimbursement paid to indemnify an enrollee when the reimbursement is associated with an enrollee obtaining covered Part D drugs under the Part D plan, or payments made by the Part D sponsor to other parties listed in  423.464(f)(1) of this part with which the Part D sponsor must coordinate benefits, including other Part D plans, or as the result of any reconciliation process developed by CMS under  423.464 of this part. * * * * * 43. Section 423.505 is amended by revising paragraph (b)(22) to read as follows:  423.505 Contract provisions. * * * * * (b) * * * (22) Through the CMS complaint tracking system, address and resolve complaints received by CMS against the Part D sponsor. * * * * * 44. Section 423.773 is amended by: a. Revising paragraph (b)(1); b. In paragraph (b)(2)(ii) removing the phrase For subsequent years, and adding in its place the phrase For years 2007 through 2023,; c. Adding paragraph (b)(2)(iii); and d. Revising paragraph (d) introductory text. The revisions and addition read as follows:  423.773 Requirements for eligibility. * * * * * (b) ***  (1) Has income below 135 percent of the FPL applicable to the individuals family size or, with respect to a plan year beginning on or after January 1, 2024, has income below 150 percent of the FPL applicable to the individuals family size; and (2) * * * (iii) For plan years beginning on or after January 1, 2024, the amount of resources specified at paragraph (d)(2) of this section. * * * * * (d) Other low-income subsidy individuals. Other low-income subsidy individuals are subsidy eligible individuals who, for plan years beginning before January 1, 2024 * * * * * 45. Section 423.780 is amended by revising paragraph (d) introductory text to read as follows:  423.780 Premium subsidy. * * * * * (d) Other low-income subsidy eligible individualssliding scale premium. Other low-income subsidy eligible individuals are entitled to a premium subsidy for plan years beginning before January 1, 2024, based on a linear sliding scale ranging from 100 percent of the premium subsidy amount described in paragraph (b) of this section as follows: * * * * * 46. Section 423.2261 is amended by revising paragraph (a)(2) and removing paragraph (a)(3). The revision reads as follows:  423.2261 Submission, review, and distribution