evekhm/cms_iom_500 huggingface dataset:
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* * * * * (12) Provider Termination Notice. This is a model communications material through which plans must provide the information required under  422.111(e). (i) The written Provider Termination Notice must be provided in hard copy via U.S. mail (first class postage is recommended, but not required). (ii) The written Provider Termination Notice must do all of the following: (A) Inform the enrollee that the provider will no longer be in the network and the date the provider will leave the network. (B) Include names and phone numbers of in-network providers that the enrollee may access for continued care (this information may be supplemented with information for accessing a current provider directory, including both online and direct mail options). (C) Explain how the enrollee may request a continuation of ongoing medical treatment or therapies with their current provider. (D) Provide information about the annual coordinated election period and the MA open enrollment period, as well as explain that an enrollee who is impacted by the provider termination may contact 1800MEDICARE to request assistance in identifying and switching to other coverage, or to request consideration for a special election period, as specified in  422.62(b)(26), based on the individuals unique circumstances and consistent with existing parameters for this SEP. (E) Include the MA organizations call center telephone number, TTY number, and hours and days of operation. (iii) The telephonic Provider Termination Notice specified in  422.111(e)(1)(i) must relay the same information as the written Provider Termination Notice as described in paragraph (e)(12)(ii) of this section. * * * * * (30) * * * (vi) Is excluded from the translation requirement under paragraphs (a)(2) through (4) of this section; and * * * * * (41) Third-party marketing organization disclaimer. This is standardized content. If a TPMO does not sell for all MA organizations in the service area the disclaimer consists of the statement: We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov, 1800MEDICARE, or your local State Health Insurance Program to get information on all of your
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Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov, 1800MEDICARE, or your local State Health Insurance Program to get information on all of your options. If the TPMO sells for all MA organizations in the service area the disclaimer consists of the statement: Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. You can always contact Medicare.gov, 1800MEDICARE, or your local State Health Insurance Program for help with plan choices. The MA organization must ensure that the disclaimer is as follows: (i) Used by any TPMO, as defined under  422.2260, that sells plans on behalf of more than one MA organization. VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00218 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222337 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations (ii) Verbally conveyed within the first minute of a sales call. (iii) Electronically conveyed when communicating with a beneficiary through email, online chat, or other electronic means of communication. (iv) Prominently displayed on TPMO websites. (v) Included in any marketing materials, including print materials and television advertisements, developed, used or distributed by the TPMO. 32. Section 422.2272 is amended by adding paragraph (e) to read as follows:  422.2272 Licensing of marketing representatives and confirmation of marketing resources. * * * * * (e) Establish and implement an oversight plan that monitors agent and broker activities, identifies non- compliance with CMS requirements, and reports non-compliance to CMS. 33. Section 422.2274 is amended by adding paragraph (c)(12) and revising paragraph (g)(2)(ii) to read as follows:  422.2274 Agent, broker, and other third- party requirements. * * * * * (c) * * * (12) Ensure that, prior to an enrollment,
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to read as follows:  422.2274 Agent, broker, and other third- party requirements. * * * * * (c) * * * (12) Ensure that, prior to an enrollment, CMS required questions and topics regarding beneficiary needs in a health plan choice are fully discussed. Topics include information regarding primary care providers and specialists (that is, whether or not the beneficiarys current providers are in the plans network), regarding pharmacies (that is, whether or not the beneficiarys current pharmacy is in the plans network), prescription drug coverage and costs (including whether or not the beneficiarys current prescriptions are covered), costs of health care services, premiums, benefits, and specific health care needs. * * * * * (g) * * * (2) * * * (ii) Record all marketing, sales, and enrollment calls, including the audio portion of calls via web-based technology, in their entirety. * * * * * PART 423VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT 34. The authority citation for part 423 continues to read as follows: Authority: 42 U.S.C. 1302, 1306, 1395w- 101 through 1395w-152, and 1395hh. 35. Section 423.4 is amended by adding in alphabetical order definitions for Immediate need individual, and Limited Income Newly Eligible Transition (LI NET) sponsor to read as follows:  423.4 Definitions. * * * * * Immediate need individual means a beneficiary whose enrollment into LI NET is on the basis of presumed low income subsidy eligibility and immediate need of a Part D drug. * * * * * Limited Income Newly Eligible Transition (LI NET) sponsor means a Part D sponsor selected by CMS to administer the LI NET program. * * * * * 36. Section 423.38 is amended by a. Revising paragraph (c)(16). b. Redesignating paragraph (c)(34) as paragraph (c)(35); and c. Adding new paragraph (c)(34). The revision and addition read as follows:  423.38 Enrollment periods. (c) * * * * * * * * (16) The individual who is not entitled
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and c. Adding new paragraph (c)(34). The revision and addition read as follows:  423.38 Enrollment periods. (c) * * * * * * * * (16) The individual who is not entitled to premium free Part A and enrolls in Part B during the General Enrollment Period for Part B that starts January 1, 2023, is eligible to request enrollment in a Part D plan. The special enrollment period begins when the individual submits their Part B application and continues for the first 2 months of Part B enrollment. The Part D plan enrollment is effective the first of the month following the month the Part D sponsor receives the enrollment request. * * * * * (34) The individual enrolls in Medicare premium-Part A or Part B using an exceptional condition SEP, as described in 42 CFR parts 406.27 and 407.23. The SEP begins when the individual submits their premium-Part A or Part B application and continues for the first 2 months of enrollment in premium Part A or Part B. The Part D plan enrollment is effective the first of the month following the month the Part D plan receives the enrollment request. * * * * * 37. Section 423.154 is amended by revising paragraph (c) to read as follows:  423.154 Appropriate dispensing of prescription drugs in long-term care facilities under PDPs and MAPD plans. * * * * * (c) Waivers. CMS waives the requirements under paragraph (a) of this section, except paragraphs (a)(2) and (3) o this section, for pharmacies when they service intermediate care facilities for individuals with intellectual disabilities (ICFs/IID) and institutes for mental disease (IMDs) as defined in  435.1010 and for I/T/U pharmacies (as defined in  423.100). * * * * * 38. Section 423.182 is amended by a. In paragraph (a) adding in alphabetical order a definition for health equity index and revising the definition of highly-rated contract; and b. Revising paragraphs (b)(1) and (b)(3)(ii)(A)(1). The addition and revisions read as follows:  423.182 Part D Prescription Drug Plan Quality
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and b. Revising paragraphs (b)(1) and (b)(3)(ii)(A)(1). The addition and revisions read as follows:  423.182 Part D Prescription Drug Plan Quality Rating System. (a) * * * Health equity index means an index that summarizes contract performance among those with specified social risk factors (SRFs) across multiple measures into a single score. * * * * * Highly-rated contract means a contract that has 4 or more stars for its highest rating when calculated without the improvement measures and with all applicable adjustments in  423.186(f). * * * * * (b) * * * (1) General. CMS calculates an overall Star Rating, Part C summary rating, and Part D summary rating for each MAPD contract and a Part D summary rating for each PDP contract using the 5-star rating system described in this subpart. For PDP contracts, the Part D summary rating is the highest rating. Measures are assigned stars at the contract level and weighted in accordance with  423.186(a). Domain ratings are the unweighted mean of the individual measure ratings under the topic area in accordance with  423.186(b). Summary ratings are the weighted mean of the individual measure ratings for Part C or Part D in accordance with  423.186(c), with the applicable adjustments provided in paragraph (f) of this section. Overall Star Ratings are calculated by using the weighted mean of the individual measure ratings in accordance with  423.186(d), with the applicable adjustments provided in paragraph (f) of this section. CMS includes the Star Ratings measures in the overall and summary ratings that are associated with the contract type for the Star Ratings year. * * * * * (3) * * * (ii) * * * (A)(1) For the first year after consolidation, CMS uses enrollment- weighted measure scores using the July enrollment of the measurement period VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00219 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222338 Federal Register / Vol.
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Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222338 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations of the consumed and surviving contracts for all measures, except survey-based measures, call center measures, and improvement measures. The survey- based measures will use enrollment of the surviving and consumed contracts at the time the sample is pulled for the rating year. The call center measures will use average enrollment during the study period. The Part C and D improvement measures are not calculated for first year consolidations. * * * * * 39. Section 423.184 is amended by adding paragraph (e)(1)(iii) to read as follows:  423.184 Adding, updating, and removing measures. * * * * * (e) * * * (1) * * * (iii) The measure steward other than CMS retires a measure. * * * * * 40. Section 423.186 is amended by a. Revising paragraphs (a)(2)(i), (c)(1), (d)(1), (e)(1)(iii) and (iv), (f)(1) introductory text, and (f)(2)(i) introductory text; b. Adding paragraph (f)(3); and c. Revising paragraphs (g)(1), (i)(7)(i), and (i)(8)(i). The revisions and addition read as follows:  423.186 Calculation of Star Ratings. (a) * * * (2) * * * (i) The method maximizes differences across the star categories and minimizes the differences within star categories using mean resampling with the hierarchal clustering of the current years data. Effective for the Star Ratings issued in October 2023 and subsequent years, prior to applying mean resampling with hierarchal clustering, Tukey outer fence outliers are removed. Effective for the Star Ratings issued in October 2022 and subsequent years, CMS will add a guardrail so that the measure-threshold-specific cut points for
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with hierarchal clustering, Tukey outer fence outliers are removed. Effective for the Star Ratings issued in October 2022 and subsequent years, CMS will add a guardrail so that the measure-threshold-specific cut points for non-CAHPS measures do not increase or decrease more than the value of the cap from 1 year to the next. The cap is equal to 5 percentage points for measures having a 0 to 100 scale (absolute percentage cap) or 5 percent of the restricted range for measures not having a 0 to 100 scale (restricted range cap). New measures that have been in the Part C and D Star Rating program for 3 years or less use the hierarchal clustering methodology with mean resampling with no guardrail for the first 3 years in the program. * * * * * (c) * * * (1) CMS will calculate the Part D summary ratings using the weighted mean of the measure-level Star Ratings for Part D, weighted in accordance with paragraph (e) of this section and with the applicable adjustments provided in paragraph (f) of this section. * * * * * (d) * * * (1) The overall rating for a MAPD contract will be calculated using a weighted mean of the Part C and Part D measure-level Star Ratings, weighted in accordance with paragraph (e) of this section and with the applicable adjustments provided in paragraph (f) of this section. * * * * * (e) * * * (1) * * * (iii) Through the 2025 Star Ratings, patient experience and complaint measures receive a weight of 4. Starting with the 2026 Star Ratings and subsequent Star Ratings years, patient experience and complaint measures receive a weight of 2. (iv) Through the 2025 Star Ratings, access measures receive a weight of 4. Starting with the 2026 Star Ratings and subsequent Star Ratings years, access measures receive a weight of 2. * * * * * (f) * * * (1) Reward factor. Through the 2026 Star Ratings, this rating-specific reward factor is added to both the summary and overall ratings of contracts that qualify for this reward factor based on both high and stable relative performance for the rating level. * * * * * (2) * * * (i) The CAI is added to or subtracted from the contracts overall and summary ratings and is applied after the reward factor adjustment described in paragraph
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stable relative performance for the rating level. * * * * * (2) * * * (i) The CAI is added to or subtracted from the contracts overall and summary ratings and is applied after the reward factor adjustment described in paragraph (f)(1) of this section (if applicable). * * * * * (3) Health equity index. Starting with the 2027 Star Ratings year and subsequent Star Ratings years, CMS applies a health equity index rating- specific factor to both the summary and overall ratings of contracts that qualify based on an assessment of contract performance on quality measures among enrollees with certain social risk factors (SRFs). (i) The health equity index (HEI) is calculated separately for the overall rating for MAPDs and cost contracts including the applicable Part C and D measures; Part C summary rating for MA-only, MAPD, and cost contracts including the applicable Part C measures; Part D summary rating for MAPDs and cost contracts including the applicable Part D measures; and Part D summary rating for PDPs including the applicable Part D measures. (A) The SRFs included in the HEI are receipt of the low-income subsidy or being dually eligible for Medicare and Medicaid (LIS/DE), or having a disability. Enrollees will be identified as LIS/DE or as having a disability as specified in paragraph (f)(2)(i)(B) of this section. If a person meets the LIS/DE criteria for only one of the two measurement years included in the HEI, the data for that person for just that year are used. Measures that are case-mix adjusted in the Star Ratings are adjusted using all standard case-mix adjustors for the measure except for those adjusters that are the SRFs of interest in the index, are strongly correlated with the SRFs of interest, or 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
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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.
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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
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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