evekhm/cms_iom_500 huggingface dataset:
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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) * * *
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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
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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
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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 of materials. * * * * * (a) * * * (2) Materials must be submitted to the HPMS Marketing Module by the Part D sponsor or, where materials have been developed by a Third Party Marketing Organization for multiple Part D sponsors or plans, by a Third Party Marketing Organization with prior review of each Part D sponsor on whose behalf the materials were created or will be used. * * * * * 47. Section 423.2262 is amended by revising paragraph (a)(1)(ii) and adding paragraph (a)(1)(xviii) to read as follows:  423.2262 General communications materials and activity requirements. * * * * * (ii) Use of superlatives, unless sources of documentation or data supportive of the superlative is also referenced in the material. Such supportive documentation or data must reflect data, reports, studies, or other documentation that applies to the current contract year or prior contract year. (A) Including data older than the prior contract year is permitted provided the current and prior contract year data are specifically identified. (B) [Reserved] * * * * * (xviii) Use of the Medicare name, CMS logo, and products or information issued by the Federal Government, including the Medicare card in a misleading way. Use of the Medicare card image is permitted only with authorization from CMS. * * * * * 48. Section 423.2263 is amended by adding paragraphs (b)(8) through (10) to read as follows:  423.2263 General marketing requirements. * * * * *
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* * * * * 48. Section 423.2263 is amended by adding paragraphs (b)(8) through (10) to read as follows:  423.2263 General marketing requirements. * * * * * (b) * * * (8) Advertise benefits that are not available to beneficiaries in the service area(s) where the marketing appears, unless the advertisement is in local media that serves the service area(s) where the benefits are available and reaching beneficiaries who reside in other service areas is unavoidable. (9) Market any products or plans, benefits, or costs, unless the Part D sponsor or marketing name(s) as listed in HPMS of the entities offering the referenced products or plans, benefits, or costs are identified in the marketing material. (i) Part D sponsor or marketing names must be in 12-point font in print and may not be in the form of a disclaimer or in fine print. (ii) For television, online, or social media, the Part D sponsor or marketing name(s) must be either read at the same pace as the phone number or must be displayed throughout the entire advertisement in a font size equivalent to the advertised phone number, contact information or benefits. (iii) For radio or other voice-based advertisements, Part D sponsor or marketing names must be read at the same pace as phone numbers or contact information. (10) Part D sponsors may not include information about savings available to potential enrollees that are based on a comparison of typical expenses borne by uninsured individuals, unpaid costs of dually eligible beneficiaries, or other unrealized costs of a Medicare beneficiary. * * * * * 49. Section 423.2264 is amended by: a. Adding paragraphs (a)(2)(i)(A) and (B); b. Revising paragraphs (b)(2); c. Removing paragraph (c)(1)(ii)(C); d. Redesignating paragraphs (c)(1)(ii)(D) and E as paragraphs (c)(1)(ii)(C) and (D); e. Revising newly redesignated paragraph (c)(1)(ii)(D); and f. Revising paragraphs
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E as paragraphs (c)(1)(ii)(C) and (D); e. Revising newly redesignated paragraph (c)(1)(ii)(D); and f. Revising paragraphs (c)(2)(i), (c)(3)(i), and (c)(3)(iii)(A) and (B). The addition additions and revisions read as follows: VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00222 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222341 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations  423.2264 Beneficiary contact. * * * * * (a) * * * (2) * * * (i) * * * (A) Contact is unsolicited door-to- door contact unless an appointment, at the beneficiarys home at the applicable time and date, was previously scheduled. (B) [Reserved] * * * * * (b) * * * (2) If the Part D sponsor reaches out to beneficiaries regarding plan business, as outlined in this section, the Part D sponsor must provide notice to all beneficiaries whom the plan contacts as least once annually, in writing, of the individuals ability to opt out of future calls regarding plan business. (c) * * * (1) * * * (ii) * * * (D) Make available and receive beneficiary contact information, including Business Reply Cards, but not including Scope of Appointment forms (c) * * * (2) * * * (i) Marketing events are prohibited from taking place within 12 hours of an educational event, in the same location. The same location is defined as the entire building or adjacent buildings. * * * * * (3) * * * (i) At least 48 hours prior to the scheduled personal marketing appointment, the Part D plan (or agent or broker, as applicable) must agree upon and record the Scope of Appointment with the beneficiary(ies),
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* * (i) At least 48 hours prior to the scheduled personal marketing appointment, the Part D plan (or agent or broker, as applicable) must agree upon and record the Scope of Appointment with the beneficiary(ies), except for: (A) SOAs that are completed during the last four days prior of a valid election period for the beneficiary. (B) Unscheduled in person visits (walk-ins) initiated by the beneficiary. * * * * * (iii) * * * (A) Market any health care related product during a marketing appointment beyond the scope agreed upon by the beneficiary, and documented by the plan in a Scope of Appointment, business reply card, or request to receive additional information, which is valid for 12 months following the date of beneficiarys signature date or the date of the beneficiarys initial request for information. (B) Market additional health related lines of plan business not identified prior to an individual appointment without a separate Scope of Appointment, identifying the additional lines of business to be discussed; such Scope of Appointment is valid for 12 months following the beneficiarys signature date. * * * * * 50. Section 423.2267 is amended by a. Redesignating paragraph (a)(3) as paragraph (a)(5); b. Adding new paragraphs (a)(3) and (4); c. Revising paragraph (e)(4) introductory text; d. Adding paragraph (e)(4)(viii); e. Revising paragraphs (e)(13) introductory text, (e)(32)(vi), and (e)(41); and f. Adding new paragraphs (e)(42) through (e)(44). The revisions and additions read as follows:  423.2267 Required materials and content. * * * * * (a) * * * (3) Be provided to enrollees on a standing basis in any non-English language identified in paragraphs (a)(2) and (4) of this section and/or accessible format using auxiliary aids and services upon receiving a request for the materials in a non-English language or accessible format or when otherwise learning of the enrollees primary language and/or need for
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and (4) of this section and/or accessible format using auxiliary aids and services upon receiving a request for the materials in a non-English language or accessible format or when otherwise learning of the enrollees primary language and/or need for an accessible format. This requirement also applies to the individualized plans of care described in  422.101(f)(1)(ii) of this chapter for special needs plan enrollees. (4) For any fully integrated dual eligible special needs plan or highly integrated dual eligible special needs plan as defined at  422.2 of this chapter, or applicable integrated plan as defined at  422.561 of this chapter, be translated into the language(s) required by the Medicaid translation standard as specified through their capitated Medicaid managed care contract in addition to the language(s) required by the Medicare translation standard in paragraph (a)(2) of this section. * * * * * (e) * * * (4) Pre-enrollment checklist (PECL). The PECL is a standardized communications material that plans must provide to prospective enrollees with the enrollment form, so that the enrollees understand important plan benefits and rules. For telephonic enrollments the contents of the PECL must be reviewed with the prospective enrollee prior to the completion of the enrollment. It references information on the following: * * * * * (viii) Effect on current coverage. * * * * * (13) Non-renewal notice. This is a standardized communications material through which plans must provide the information required under  423.507. * * * * * (32) * * * (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 Part D sponsors 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 options. If the TPMO sells for all Part D sponsors in the service area the
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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 Part D sponsors 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. (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. (42) [Reserved] (43) Comprehensive medication reviewwritten summary. This is the standardized communications material Part D sponsors must provide to all MTM program enrollees who receive a comprehensive medication review, as required under  423.153(d)(1)(vii)(B). (44) Safe disposal information. This is model communications material Part D sponsors must provide to all enrollees targeted for its MTM program, as required under  423.153(d)(1)(vii)(E). 51. Section 423.2272 is amended by adding paragraph (e) to read as follows: VerDate Sep<11>2014 21:20 Apr 11, 2023 Jkt 259001 PO 00000 Frm 00223 Fmt 4701 Sfmt 4700 E:\FR\FM\12APR2.SGM 12APR2ddrumheller on DSK120RN23PROD with RULES222342 Federal Register / Vol. 88, No. 70 / Wednesday, April 12, 2023 / Rules and Regulations  423.2272 Licensing of marketing representatives and confirmation of marketing resources. * * * * * (e) Establish and implement an oversight plan that monitors agent and broker
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No. 70 / Wednesday, April 12, 2023 / Rules and Regulations  423.2272 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. 52. Section 423.2274 is amended by adding paragraph (c)(12) and revising paragraph (g)(2)(ii):  423.2274 Required materials and content. * * * * * (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 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), premiums, and other services or incentives. * * * * * (g) * * * (2) * * * (ii) Record all marketing, sales, and enrollment calls, including the audio portion of calls occurring via web-based technology, in their entirety. * * * * * 53. Subpart Y is added to read as follows: Subpart YTransitional Coverage and Retroactive Medicare Part D Coverage for Certain Low-Income Beneficiaries Through the Limited Income Newly Eligible Transition (LI NET) Program Sec. 423.2500 Basis and scope. 423.2504 LI NET eligibility and enrollment. 423.2508 LI NET benefits and beneficiary protections. 423.2512 LI NET sponsor requirements. 423.2516 Selection of LI NET sponsor and contracting provisions. 423.2518 Intermediate sanctions for the LI NET sponsor. 423.2520 Non-renewal or termination of appointment. 423.2524 Bidding and payments to LI NET sponsor. 423.2536 Waiver of Part D program requirements. Subpart YTransitional Coverage and Retroactive Medicare Part D Coverage for Certain Low-Income Beneficiaries Through the Limited Income Newly Eligible Transition (LI NET) Program  423.2500 Basis and scope. (a) Basis. This subpart is based on section 1860D14 of the Social
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for Certain Low-Income Beneficiaries Through the Limited Income Newly Eligible Transition (LI NET) Program  423.2500 Basis and scope. (a) Basis. This subpart is based on section 1860D14 of the Social Security Act. (b) Scope. This subpart sets forth the requirements for the Limited Income Newly Eligible Transition (LI NET) program that begins no later than January 1, 2024. Under this program, eligible individuals are provided transitional coverage for Part D drugs.  423.2504 LI NET eligibility and enrollment. (a) Eligibility. An individual is eligible for LI NET coverage if they satisfy the criteria at paragraph (a)(1) or (2) of this section. (1) LIS-eligible. The individual is a low-income subsidy eligible individual as defined at  423.773 and (i) Has not yet enrolled in a prescription drug plan or an MAPD plan; or (ii) Has enrolled in a prescription drug plan or MAPD plan but their coverage has not yet taken effect. (2) Immediate need individuals. An individual who states their eligibility for LIS and immediate need for their prescription, but whose eligibility as defined at  423.773 cannot be confirmed at the point-of-sale, will be granted immediate need LI NET coverage. (3) Documentation of LIS eligibility. Individuals may provide documentation to the LI NET sponsor to demonstrate LIS eligibility. Documentation may include, but is not limited to: (i) A copy of the beneficiarys Medicaid card that includes their name and the eligibility date; (ii) A copy of a letter from the State or SSA showing LIS or Extra Help status; (iii) The date that a verification call was made to the State Medicaid Agency, the name and telephone number of the State staff person who verified the Medicaid period, and the Medicaid eligibility dates confirmed on the call; (iv) A copy of a State document that confirms active Medicaid status; (v) A screen-print from the States Medicaid systems showing Medicaid status; or (vi) Evidence at point-of-sale of recent Medicaid billing and payment in the pharmacys patient profile. (4) Confirmation of LIS eligibility. CMS uses documentation submitted under paragraph
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systems showing Medicaid status; or (vi) Evidence at point-of-sale of recent Medicaid billing and payment in the pharmacys patient profile. (4) Confirmation of LIS eligibility. CMS uses documentation submitted under paragraph (a)(3) of this section to confirm LIS eligibility. (5) Inability to confirmation of eligibility. If CMS cannot confirm an immediate need individuals eligibility during the period of LI NET coverage, the individual will not be auto-enrolled into a standalone Part D plan in accordance with  423.34(d) following their LI NET coverage. (b) Enrollment. Individuals who are eligible for LI NET as defined in  423.2504 are enrolled into the LI NET program as follows: (1) Automatic enrollment. Beneficiaries who are LIS-eligible and whose auto-enrollment into a Part D plan (as outlined in  423.34(d)(1)) has not taken effect will be automatically enrolled by CMS into the LI NET program unless the beneficiary has affirmatively declined enrollment in Part D per  423.34(e); (2) Point-of-sale enrollment. An individual who is not automatically enrolled in accordance with paragraph (b)(1) of this section and whose claim is submitted at the point-of-sale and accepted by the LI NET sponsor will be enrolled into the LI NET program by the LI NET sponsor; or (3) Direct reimbursement request. An individual described in paragraph (a)(1) of this section who is not automatically enrolled in accordance with paragraph (b)(1) or at the point-of-sale as provided in paragraph (b)(2) of this section and who submits a direct reimbursement request form, receipts for reimbursement for eligible claims paid out of pocket (with and optional documentation of LIS eligibility listed in paragraph (a)(3) of this section), will be retroactively enrolled into the LI NET program by the LI NET sponsor. The LI NET sponsor has 14 calendar days to reply with a coverage decision; or (4) LI NET application form. An individual who is not enrolled through one of the methods in paragraphs (b)(1) though (3) of this section may submit an LI NET application form to the LI NET sponsor (with optional documentation of LIS eligibility listed