Source: http://docplayer.net/17911792-Solicitation-for-applications-for-medicare-prescription-drug-plan-2017-contracts.html
Timestamp: 2018-12-19 08:18:18
Document Index: 96652367

Matched Legal Cases: ['art 423', 'art 423', 'art 376', 'art 423', 'art 423', 'art 423', 'art 423', 'arts 160', 'art 423']

Solicitation for Applications for Medicare Prescription Drug Plan 2017 Contracts - PDF
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1 MEDICARE PRESCRIPTION DRUG BENEFIT Solicitation for Applications for Medicare Prescription Drug Plan 2017 Contracts New Medicare Prescription Drug Plan (PDP), Medicare Advantage-Prescription Drug (MA-PD) (with and without EGWP), and Expansion of Existing Contracts with CMS for PDP and MA-PD (including CCP, PFFS, RPPO, Cost Plan, SNPs and EGWPs) Contract Year PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is TBD. The time required to complete this information collection is estimated to average 11.0 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C , Baltimore, Maryland Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact MEDICARE. Expiration: TBD
2 1 GENERAL INFORMATION Purpose of Solicitation Background Schedule Summary of Application Approval, Part D Bid Review, and Contracting Processes INSTRUCTIONS Overview Technical Assistance Health Plan Management System (HPMS) Data Entry Instructions and Format of Qualifications Instructions Completion of Attestations Application Review Standard Application Review Process and Cure Periods Applicant Seeking to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) PDP EGWP Service Area Applicants Seeking to Offer New Individual and 800 Series Plans Pharmacy Access Applicants Seeking to Offer Only New 800 Series Plans Pharmacy Access Applicant Seeking to Offer New Employer/Union Direct Contract PDPs and PFFS Applicant Entity Same as Contracting Entity Joint Enterprise as Applicant and Contracting Entity Essential Operations Tests Automatic Enrollment of Full-benefit Dual Eligible Individuals Withdrawal of a Part D Application Technical Support Bid and Formulary Submission Software Training Pharmacy Access Retail Pharmacy Access Home Infusion Pharmacy Access Long-Term Care Pharmacy Access
3 2.6.4 Indian Tribe and Tribal Organization, and Urban Indian Organization (I/T/U) Waivers Related to Pharmacy Access Waivers for Plans in the Territories (excluding Puerto Rico) Waivers for MAPD Plans Waivers for Cost Plans Waivers Related to Attestations for MAPD and PDP EGWP and MAPD and PDP Direct Contract Applicants ( 800 Series Plans ) Waivers for MA-PD and Cost Plan Applicants Standard Contract with MAPD and PDP Sponsors Protection of Confidential Information APPLICATION Applicant Experience, Contracts, Licensure and Financial Stability Management and Operations 42 CFR Part 423 Subpart K; CMS issued guidance 08/15/06 and 08/26/08; 2014 Call Letter Licensure and Solvency 42 CFR Part 423, Subpart I; 2008 Call Letter; CMS issued guidance 03/17/ Program Integrity 2 CFR part 376 and Compliance Program 42 CFR (b)(4)(vi); Prescription Drug Benefit Manual, Chapter 9; CMS guidance issued 1/11/ HPMS Part D Contacts CMS Guidance issued 08/16/06, 08/22/07, 11/30/07, 08/06/07, 03/17/09, 07/09/09, 08/04/09, and 01/25/ Benefit Design Formulary/Pharmacy and Therapeutics (P&T) Committee Social Security Act 186-D-4(b)(3)(G), 42 CFR (b), 42 CFR (b)(2); Prescription Drug Benefit Manual, Chapter 6; 2014 Call Letter; CMS issued guidance 03/25/ Utilization Management Standards 42 CFR (b); Prescription Drug Benefit Manual, Chapter 6 and Chapter 7; 2013 Call Letter; 2014 Call Letter; 2015 Call Letter Quality Assurance and Patient Safety Social Security Act 1860D-4(c)(3); 42 CFR (c); Prescription Drug Benefit Manual, Chapter 7; 2013 Call Letter; 2014 Call Letter; 2015 Call Letter Medication Therapy Management 42 CFR (d); Social Security Act 1860D-4(c)(2); Prescription Drug Benefit Manual, Chapter 7; 2013 Call Letter; 2014 Call Letter; 2015 Call Letter; 2016 Call Letter Electronic Prescription Program and Health Information Technology Standards 42 CFR ; Prescription Drug Benefit Manual, Chapter 7; P.L (2009); 2010 Call Letter
4 3.2.6 Bids 42 CFR , and Service Area/Regions 42 CFR ; Prescription Drug Benefit Manual, Chapter Private Fee-For-Service Pharmacy Access 42 CFR (a)(7); Prescription Drug Benefit Manual, Chapter General Pharmacy Access 42 CFR (a); Prescription Drug Benefit Manual, Chapter Retail Pharmacy 42 CFR (a); 42 CFR (c); Prescription Drug Benefit Manual, Chapter 5; 2016 Call Letter Out of Network Access 42 CFR ; Prescription Drug Benefit Manual, Chapter Mail Order Pharmacy 42 CFR (a)(10); Prescription Drug Benefit Manual, Chapter 5; 2014 Call Letter; 2016 Call Letter Home Infusion Pharmacy 42 CFR (a)(4); Prescription Drug Benefit Manual, Chapter Long -Term Care (LTC) Pharmacy 42 CFR (a)(5); Prescription Drug Benefit Manual, Chapter 5; CMS issued guidance 04/28/ Indian Health Service, Indian Tribe and Tribal Organization, and Urban Indian Organization (I/T/U) Pharmacy 42 CFR (a)(6); Prescription Drug Benefit Manual, Chapter Specialty Pharmacy Prescription Drug Benefit Manual, Chapter Enrollment and Eligibility 42 CFR ; Prescription Drug Benefit Manual, Chapters 3, 4, and 13; Plan Communications User Guide; CMS issued guidance 07/21/ Complaints Tracking Prescription Drug Benefit Manual, Chapter 7; CMS issued guidance 11/16/06, 07/28/2008, 12/09/08, and 6/8/ Medicare Plan Finder Prescription Drug Benefit Manual, Chapter 7; CMS issued guidance 07/17/06, 11/20/07, 08/21/08, 05/20/ Grievances 42 CFR Part 423 Subpart M; Prescription Drug Benefit Manual, Chapter Coverage Determinations (including Exceptions) and Appeals 42 CFR Part 423 Subpart M; Prescription Drug Benefit Manual, Chapter 18; Part D QIC Reconsideration Procedures Manual Coordination of Benefits 42 CFR Part 423 Subpart J; Prescription Drug Benefit Manual, Chapter 14; 2015 Call Letter; 2016 Call Letter Tracking True Out-of Pocket Costs (TrOOP) Social Security Act 1860D- 2(b)(4); 42 CFR Part 423 Subpart J; Prescription Drug Benefit Manual, Chapters 13 and Chapter
5 3.20 Medicare Secondary Payer 42 CFR ; Prescription Drug Benefit Manual, Chapter 14; CMS issued guidance 4/23/ Marketing/Beneficiary Communications 42 CFR ; 42 CFR ; Prescription Drug Benefit Manual, Chapter Provider Communications Prescription Drug Benefit Manual, Chapter Reporting Requirements Social Security Act 1150A; 42 CFR ; 2012 Reporting Requirements Data Exchange between Part D Sponsor and CMS 42 CFR (c) and (k) Health Insurance Portability and Accountability Act of 1996 (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH Act), and Related CMS Requirements 45 CFR Parts 160, 162, and 164; CMS issued guidance 08/15/2006 and 08/26/ Prohibition on Use of SSN or Medicare ID number on Enrollee ID Cards Prescription Drug Benefit Manual, Chapter Record Retention 42 CFR (d) Prescription Drug Event (PDE) Records; 42 CFR Part 423 Subpart G; CMS issued guidance 04/27/2006, 06/23/2006, 12/17/20101, 03/01/2011, 03/04/2011, 04/28/2011, 05/16/2011, 2/4/ Claims Processing; 42 CFR (c)(4); 42 CFR ; CMS issued guidance 04/26/2006, 01/13/2010, and 03/29/ Premium Billing 42 CFR ; CMS issued guidance 03/08/ Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Administration 42 CFR CERTIFICATION APPENDICES APPENDIX I Summary of Medicare Part D Regulatory Requirements Fulfilled under Part C for Medicare Advantage Prescription Drug (MA-PD) Applicants APPENDIX II Summary of PDP Application Requirements Fulfilled under Part C for Cost Plan Prescription Drug Applicants APPENDIX III Attestation for Employer/Union-Only Group Waiver Plans (800- Series) APPENDIX IV Employer Direct Contract MA-PD Attestations APPENDIX V Employer Direct Contract PDP Attestation APPENDIX VI Part D Financial Solvency & Capital Adequacy Documentation APPENDIX VII Federal Waiver of State Licensure APPENDIX VIII Financial Solvency Documentation for Applicant Not Licensed as a Risk-bearing Entity in Any State APPENDIX IX Organization Background and Structure
6 APPENDIX X Crosswalks of Section 3.1.1E Requirements in Subcontracts submitted as Attachments to Section APPENDIX XI Crosswalk for Retail Pharmacy Access Contracts APPENDIX XII Crosswalk for Mail Order Pharmacy Access Contracts APPENDIX XIII Crosswalk for Home Infusion Pharmacy Access Contracts. 117 APPENDIX XIV Crosswalk for Long-Term Care Pharmacy Access Contracts APPENDIX XV Crosswalk for Indian Tribe and Tribal Organization, and Urban Indian Organization (I/T/U) Pharmacy Access Contracts APPENDIX XVI Applicant Submission of P&T Committee Member List and Certification Statement APPENDIX XVII I/T/U Contract Addendum APPENDIX XVIII Compliance Program Crosswalk
7 1 GENERAL INFORMATION 1.1 Purpose of Solicitation The Centers for Medicare & Medicaid Services is seeking applications from qualified entities to enter into contracts to offer prescription drug coverage and to expand the service areas of existing contracts offering prescription drug coverage as described in the Medicare Prescription Drug Benefit Final Rule published in the Federal Register on January 28, 2005 (70 Fed. Reg. 4194). This application must be used for all organizations seeking new Prescription Drug Plan (PDP) and Medicare Advantage- Prescription Drug Plan (MA-PD) contracts, seeking to expand the service area of existing contracts, and seeking to add prescription drug coverage. Please submit your applications according to the process described in Section Background The Medicare Prescription Drug Benefit program was established by section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), as amended, and is codified in sections 1860D-1 through 1860D-43 of the Social Security Act (the Act). Applicants who offer either a PDP or MA-PD plan may offer national plans (with coverage in every region) or regional plans. MA-PD plan applicants may also offer local plans. CMS has identified 26 MA Regions and 34 PDP Regions; in addition, each territory is its own PDP region. Additional information about the regions can be found on the website. It is important to note that Medicare Advantage (MA) organizations offering coordinated care plans must qualify to offer at least one plan that includes both Part C and Part D drug benefits throughout the organization s approved Part C service area. Similarly, MA organizations offering a preferred provider organization (PPO) plan must offer Part D coverage throughout the PPO regions in which they are approved to offer a Part C plan. However, MA organizations offering private fee-for-service plans may, but are not required to, offer a Part D drug benefit. Medicare Cost Plans offered under section 1876(h) of the Act may, at their election, offer prescription drug coverage as a supplemental benefit. Part D sponsors and MA organizations have flexibility in terms of benefit design. This flexibility includes, but is not limited to, authority to establish a formulary that designates specific drugs that will be available within each therapeutic class of drugs, and the ability to have a cost-sharing structure other than the statutorily defined structure (subject to certain actuarial tests). The plans also may include supplemental benefits coverage such that the total value of the coverage exceeds the value of basic prescription drug coverage. 7
8 1.3 Schedule 2017 Milestones Date November 13, 2015 December 4, 2015 January 12, 2016 January 31, 2016 February 17, 2016 February 2016 March 2016 April 2016 April 2016 May 2016 Milestone Recommended date by which applicants should submit their Notice of Intent to Apply Form to CMS to ensure access to Health Plan Management System (HPMS) by the date applications are released CMS User ID form due to CMS Release of the 2017 MAO/MA-PD/PDP/Service Area Expansion Applications Deadline for NOIA form submission to CMS 2017 Applications due CMS releases guidance concerning updates to Parent Organization designations in HPMS Parent Organization Update requests from sponsors due to CMS (instructional memo to be released in February 2016) Plan Creation module, Plan Benefit Package (PBP), and Bid Pricing Tool (BPT) available on HPMS Release of the 2017 Medication Therapy Management (MTM) Program Submission Module in HPMS Medication Therapy Management (MTM) Program submissions due May 2016 Health Plan Management System (HPMS) formulary submission window Transition Policy Attestations and Policy due to CMS May 2016 June 6, 2016 Early August 2016 Late August 2016 CMS sends Part D contract eligibility determination to Applicants, based on review of application. Applicant s bids must still be negotiated. (see below) All bids due CMS publishes national average Part D premium CMS completes review and approval of bid data. 8
9 Date September 1, 2016 October 15, 2016 Milestone CMS executes Part D contracts with those organizations who submit an acceptable bid 2017 Annual Coordinated Election Period begins NOTE: CMS reserves the right to revise the Medicare Prescription Drug Benefit program implementation schedule, including the solicitation and bidding process timelines. This timeline does not represent an all-inclusive list of key dates related to the Medicare Prescription Drug Benefit program. CMS reserves the right to amend or cancel this solicitation at any time. 1.4 Summary of Application Approval, Part D Bid Review, and Contracting Processes There are three distinct phases to the overall review to determine whether CMS will enter into a contract with an applicant. The first phase is the application review process. CMS will review all applications submitted on or by February 18, 2016 to determine whether the applicant meets the qualifications we have established to enter into a Part D contract. The second phase has two steps the formulary upload which begins May 2016 and the bid upload which begins in May The formulary review entails determining that the proposed formulary (if one is used): Has at least two drugs in every therapeutic category and class (unless special circumstances exist that would allow only one drug); Does not substantially discourage enrollment by certain types of Part D eligible individuals; Includes adequate coverage of the types of drugs most commonly needed by Part D enrollees; Includes all drugs in certain classes and categories as established by the Secretary; and Includes an appropriate transition policy. CMS will contact applicants if any issues are identified during the formulary review to provide an opportunity for applicants to make any necessary corrections prior to the Part D bid submission date. The second step involves the bid review and negotiations with applicants to ensure that valuations of the proposed benefits are reasonable and actuarially equivalent. The third phase is contracting. Applicants judged qualified to enter into a Part D contract or addendum as a result of successfully completing phase one and two will be offered a Part D contract, or addendum to their Medicare managed care contract, by CMS. 9
10 2 INSTRUCTIONS 2.1 Overview There are six types of entities with which CMS contracts to offer the Medicare prescription drug benefit: PDP sponsors, Medicare Advantage organizations that offer MA-PDs (including local HMO plans, local PPOs, regional PPOs, and Private Fee-for- Service plans); organizations with Cost Plans under section 1876(h) of the Act, Employer Groups (both Employer Group Waiver Plans (EGWPs), and Employer Direct), and PACE organizations. This application is for any organization seeking to offer a new PDP or MAPD, and for any organization seeking to expand or add coverage to an existing MAPD, PDP, or Cost Plan contract, including EGWP and Employer Direct contracts. There is a separate application and separate application process for PACE organizations. 2.2 Technical Assistance For technical assistance in the completion of this Application, contact: Arianne Spaccarelli by at or by phone at As stated in section 2.4.1, Applicants must contact the HPMS Help Desk if they are experiencing technical difficulties uploading or completing any part of this solicitation within HPMS prior to the submission deadline. Applicants requesting technical assistance with uploading or completing any part of the online HPMS application after the published CMS application deadline will not be granted technical assistance, nor the opportunity to complete their application submission. 2.3 Health Plan Management System (HPMS) Data Entry Organizations that submit a Notice of Intent to Apply form for an initial application are assigned a pending contract identifier (contract ID) with a prefix of either E-, H-, R-, or S-, followed by four digits. The contract ID is used throughout the application and subsequent operational processes. Applicants seeking to add or expand coverage under an existing contract use the associated contract ID. Once CMS assigns a contract ID, and applicants apply for, and receive, their CMS User ID(s) and password(s) for HPMS access, applicants must input contact and other related information into HPMS (see section 3.1.4). Applicants must ensure prompt entry and ongoing maintenance of data in HPMS. By keeping the information in HPMS current, applicants facilitate the tracking of their applications throughout the review process and ensure that CMS has the most current information for providing application status updates, guidance, and other correspondence. If an applicant is awarded a contract, CMS uses this information for frequent communications during implementation and throughout the contract year. It is important that the information in HPMS remain accurate at all times. 10
11 2.4 Instructions and Format of Qualifications Applications must be submitted by February 18, Applicants must use the 2017 solicitation. CMS will not accept or review any submissions using a prior version of the solicitation, including the use of CMS provided templates from prior years (e.g and earlier) Instructions Applicants must complete the entire solicitation via HPMS. CMS will not accept any information in hard copy. If an applicant submits the information via hard copy, the application will not be considered received. CMS will communicate with all applicants via . The notifications will be generated through HPMS, so organizations must ensure that the applicant s Part D contact information provided through the Notice of Intent to Apply process is current and correct, and that there are no firewalls in place that would prevent an from the web address from being delivered. Upon completion of the HPMS online application, organizations are required to click Final Submit, which time and date stamps the completion of the application. No additional work on the application may be done after the applicant clicks Final Submit. Organizations will receive a confirmation number from HPMS upon clicking Final Submit. Failure to obtain a confirmation number indicates that the applicant failed to properly submit its Part D application by the CMS-established deadline. Any entity that experiences technical difficulties during the submission process must contact the HPMS Help Desk prior to the submission deadline, and CMS will make case by case determinations where appropriate regarding the timeliness of the application submission Completion of Attestations In preparing your application in response to the attestations in Section 3 of this solicitation, please mark Yes or No or Not Applicable in HPMS. In many instances, applicants are directed to affirm within HPMS that they meet particular requirements by indicating Yes next to a statement of a particular Part D program requirement. By providing such attestation, an applicant confirms that its organization complies with the relevant requirements as of the date its application is submitted to CMS, unless a different date is stated by CMS Application Review Standard CMS will check the application for completeness shortly after its receipt. Consistent with the 2010 Call Letter, CMS will make determinations concerning the validity of each organization s submission. Some examples of invalid submissions include but are not limited to the following: Applicants that fail to upload executed agreements or contract templates; Applicants that upload contract crosswalks only instead of contracts; or 11
12 Applicants that fail to upload any pharmacy network lists. CMS will notify any applicants that are determined to have provided invalid submissions. In accordance with 42 CFR and 503, applicants must demonstrate that they meet all (not substantially all ) Part D program requirements to qualify as a Part D sponsor in their proposed service area Application Review Process and Cure Periods For those applicants with valid submissions, CMS will notify your organization via of any deficiencies and afford a courtesy opportunity to amend the application(s). The application status s are accessible in HPMS at the Communications History link in Contract Management>Basic Contract Management> Submit Application Data. CMS will only review the last submission provided during this courtesy cure period. As with all aspects of a Part D sponsor s operations under its contract with CMS, we may verify a sponsor s compliance with qualifications it attests it meets through on-site visits at the Part D sponsor s facilities and through other program monitoring techniques. Failure to meet the requirements attested to in this solicitation and failure to operate its Part D plan(s) consistent with the requirements of the applicable statutes, regulations, call letter, guidance, and the Part D contract may delay a Part D sponsor s marketing and enrollment activities or, if corrections cannot be made in a timely manner, the Part D sponsor will be disqualified from participation in the Part D program. An individual with legal authority to bind the applicant must execute the certification found in Section 4. CMS reserves the right to request clarifications or corrections to a submitted application. Failure to provide requested clarifications within the time period specified by CMS for responding could result in the applicant receiving a notice of intent to deny the application. Applicants failing to cure deficiencies following the courtesy cure period will be issued a Notice of Intent to Deny the application. Applicants receiving notices of intent to deny have 10 days to remedy their applications. The end of the 10-day period is the last opportunity an applicant has to provide CMS with clarifications or corrections. CMS will only review the last submission provided during this cure period. Application materials will not be accepted after this 10-day time period. This solicitation does not commit CMS to pay any cost for the preparation and submission of an application. If a subsidiary, parent, or otherwise related organization is also applying to offer Part D benefits, these entities MUST submit separate applications. Entities intending to have both local MA-PD and Regional PPO contracts must submit separate MA-PD applications Applicant Seeking to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) All new Part D applicants seeking to offer new 800 series EGWPs with or without corresponding individual plans, including applicants that have not previously applied to 12
13 offer plans to individual beneficiaries or 800 series EGWPs must complete the appropriate EGWP attestation. PDP applicants should complete the attestation in Appendix III. MA-PD applications should complete the attestation found in the 2017 Application Instructions for MA Organizations to Offer New Employer/Union-Only Group Waiver Plans (for MAPD applicants). The Appendix provides the Applicant with the ability to choose between only offering 800 series plans and participating in both the individual and group markets. The attestation provided in Appendix III specifies those individual market requirements that are not applicable in the employer market PDP EGWP Service Area New PDP applicants and existing PDP Sponsors will be able to enter their EGWP service areas directly into HPMS during the application process (refer to HPMS User Guide). PDP applicants may provide coverage to employer group members wherever they reside (i.e., nationwide). However, in order to provide coverage to retirees wherever they reside, PDP applicants must set their EGWP service area to include all areas where retirees reside during the plan year (i.e., set national service areas). SAE of Employer-only service area Applicants with existing contracts seeking to add EGWP for the first time, or expand only the EGWP service area, will complete an abbreviated application consisting of attestations, and application certifications Applicants Seeking to Offer New Individual and 800 Series Plans Pharmacy Access Applicants seeking to offer both individual and 800 series plans are not required to submit separate pharmacy access lists (retail, mail order, home infusion, long-term care, I/T/U) for their 800 series service areas in addition to those required to be submitted for their individual plan service areas. Sponsors will not initially be required to have retail and other pharmacy networks in place for those designated EGWP service areas outside of their individual plan service areas. However, in accordance with employer group waiver pharmacy access policy, pharmacy access sufficient to meet the needs of enrollees must be in place once the sponsor enrolls members of an employer or union group residing in particular geographic locations outside of its individual plan service area Applicants Seeking to Offer Only New 800 Series Plans Pharmacy Access Applicants applying to only offer 800 series plans (i.e., no plans will be offered to individual Medicare beneficiaries under this contract number) must submit retail and other pharmacy access lists (mail order, home infusion, long-term care, I/T/U) for the entire defined EGWP service area during the application process and demonstrate sufficient access in these areas in accordance with employer group waiver pharmacy access policy. 13
14 2.4.3 Applicant Seeking to Offer New Employer/Union Direct Contract PDPs and PFFS New Employer/Union Direct Contract applicants must enter their service area directly into HPMS during the application process. In general, Part D sponsors can only cover beneficiaries in the service areas in which they are licensed and approved by CMS to offer benefits. CMS has waived these requirements for Direct Contract sponsors. Direct Contract sponsors can extend coverage to all of their retirees, regardless of where in the nation they reside. In order to provide coverage to retirees wherever they reside, Direct Contract applicants must set their service areas to include all areas where retirees may reside during the plan year. Direct Contract applicants are required to submit retail and other pharmacy access information for the entire defined service area during the application process and demonstrate sufficient access in these areas in accordance with employer group waiver pharmacy access policy. Those employers or unions seeking to directly contract with CMS to become sponsors for their Medicare-eligible retirees must complete the following materials: The 2017 Medicare Advantage Application (for Direct Contract PFFS applicants ONLY) The 2017 Solicitation for Applications for Prescription Drug Plan Sponsors Appendix IV Direct Contract MA-PD Attestations Appendix V Direct Contract PDP Attestation Appendix VI -- Part D Financial Solvency & Capital Adequacy Documentation for Direct Contract PDP Sponsor Applicants Applicant Entity Same as Contracting Entity The legal entity that submits this application must be the same entity with which CMS enters into a Part D contract, or in the case of an MA-PD and Cost Plan sponsor, the same legal entity seeking an addendum to an MA or Cost Plan contract Joint Enterprise as Applicant and Contracting Entity CMS will recognize as applicants those joint enterprises formed by agreement among multiple state-licensed organizations (or organizations that have applied to CMS for a licensure waiver) for the purpose of administering a stand-alone PDP or an MA Regional PPO (RPPO) in at least one entire PDP region. Each member of the joint enterprise will be contractually liable to CMS for the administration of the Part D benefit in the State(s) in which it is licensed or for which it has received a CMS licensure waiver. The joint enterprise need submit only one application on behalf of the enterprise s member organizations and such application shall represent the joint enterprise s commitment to offering a uniform benefit in each PDP region in which it will offer Part D 14
15 benefits. However, the information requested in Section 3.1 of this solicitation must be provided for each member of the joint enterprise with separate accompanying Appendices as necessary. For example, each joint enterprise member must provide identifying information about its organization, copies of its executed contracts with entities performing critical tasks related to the delivery of the Part D benefit, and information related to its business integrity. The responses provided in the remainder of the application may be made once by the joint enterprise applicant and will be considered binding on each member of the joint enterprise. Also, a separate certification statement, shown in Section 4.0, must be provided for each joint enterprise member organization. Each certification statement must be signed by an individual specifically granted the authority to bind the member organization. Joint enterprise applicants are required to submit to CMS for approval a copy of the executed agreement among the joint enterprise member organizations. Please see Section G, for instructions concerning this requirement. Upon CMS determination that the members of the joint enterprise are qualified to enter into a contract and approval of the bid(s) submitted by the joint enterprise, CMS will enter into a multiple-party contract signed by authorized representatives of CMS and each member of the joint enterprise Essential Operations Tests Applicants new to the Part D program may be subject to an essential operations test prior to the start of the plan year, as provided in 42 CFR (b)(10). The test is designed to evaluate whether a sponsor is prepared to administer the Part D benefit, including claims processing, formulary administration, appeals and grievances, and other key functions. CMS may decline to enter into a contract with a sponsor that fails to pass the essential operations test Automatic Enrollment of Full-benefit Dual Eligible Individuals When there is more than one PDP in a region with a premium that makes it eligible for automatic enrollment of full-benefit dual eligible individuals (as provided in 42 CFR (d)), CMS enrolls beneficiaries into the eligible PDPs on a random basis. For this purpose, CMS counts the Applicant and its parent and affiliates as a single PDP, regardless of how many of those entities have bids that are at or below the low income subsidy threshold Withdrawal of a Part D Application In those instances where an organization seeks to withdraw its application or reduce the service area of a pending application prior to the execution of a Part D contract, then the organization must send an official notice to CMS. The notice should be on organization letterhead, clearly identify the pending application number and service area (as appropriate), and be signed by the Chief Executive Officer (CEO) of the organization. The notice should be delivered via to and, for MAPD applicants, The subject line of the should 15
16 read Pending application withdrawal or reduction to pending service area. The withdrawal will be considered effective as of the date of the Technical Support CMS conducts technical support calls, also known as user group calls, for applicants and existing Part D sponsors. CMS operational experts (e.g., from areas such as enrollment, information systems, marketing, bidding, formulary design, and coordination of benefits) are available to discuss and answer questions regarding the agenda items for each meeting. Registration for the technical support calls and to join the list serve to get updates on CMS guidance can be found at CMS also conducts special training sessions, including a user group call dedicated to addressing issues unique to sponsors that are new to the Part D program. CMS provides two user manuals to assist applicants with the technical requirements of submitting the Part D application through the Health Plan Management System (HPMS). The Basic Contract Management User s Manual provides information on completing and maintaining basic information required in Contract Management. These data must be completed prior to the final submission of any application. The Online Application User s Manual provides detailed instructions on completing the various online applications. Both manuals can be found in HPMS by clicking on Contract Management>Basic Contract Management>Documentation. 2.5 Bid and Formulary Submission Software Training CMS will provide technical instructions and guidance upon release of the HPMS formulary and bid functionality as well as the Plan Benefit Package (PBP) and Bid Pricing Tool (BPT) software. In addition, systems training will be available at the Bid Training in April Pharmacy Access An integral component of this Solicitation concerns the pharmacy access standards established under section 1860D-4(b)(1)(C) of the Act. The standards require in part that each sponsor secure the participation in their pharmacy networks of a sufficient number of pharmacies to dispense drugs directly to patients (other than by mail order) to ensure convenient access to covered Part D drugs by Part D plan enrollees. Furthermore, Part D sponsors must provide adequate access to home infusion and convenient access to long-term care, and Indian Health Service, Indian Tribe and Tribal Organization, and Urban Indian Organization (I/T/U) pharmacies in accordance with 42 CFR and related CMS instructions and guidance Retail Pharmacy Access Applicants must ensure that their retail pharmacy network meets the criteria established under 42 CFR CMS rules require that applicants establish retail pharmacy networks in which: 16
17 In urban areas, at least 90 percent of Medicare beneficiaries in the applicant s service area, on average, live within 2 miles of a retail pharmacy participating in the applicant s network; In suburban areas, at least 90 percent of Medicare beneficiaries in the applicant s service area, on average, live within 5 miles of a retail pharmacy participating in the applicant s network; and In rural areas, at least 70 percent of Medicare beneficiaries in the applicant s service area, on average, live within 15 miles of a retail pharmacy participating in the applicant s network. Applicants may count I/T/U pharmacies and pharmacies operated by Federally Qualified Health Centers and Rural Health Centers towards the standards of convenient access to retail pharmacy networks. Applicants may use their contracted pharmacy benefit manager s (PBM) existing 2016 Part D network to demonstrate compliance with retail pharmacy access standards. If an applicant is creating a new Part D network, the submission must be based on executed contracts for year If the applicant retail pharmacy network is segmented (i.e., the applicant has developed multiple networks for use in the same service area), the applicant must submit the most restrictive (or, least accessible) network based on its executed contracts for CMS conducts the review of retail pharmacy access based on the service area that the applicant has provided in HPMS by February 18, The access review is automated. Applicants must input their pending service area into HPMS per the instructions at section 3.3. As explained in section 3.6.B, applicants must upload the retail pharmacy list in HPMS. Based on the information provided by the applicant and the Medicare Beneficiary Count file available on the CMS application guidance website, CMS will generate access percentages for all applicants. With limited exceptions, this information gathered from the pharmacy lists will be used by CMS to geo-code the specific street-level locations of the pharmacies to precisely determine retail pharmacy access. Exceptions to this process may include, but not be limited to, those instances where a street-level address cannot be precisely geo-coded. In those situations, CMS will utilize the ZIP code-level address information to geo-code the approximate pharmacy location. The retail pharmacy lists may contain contracted pharmacies that are outside of the applicant s pending service area (to account for applicants who contract for a national pharmacy network); however, CMS will only evaluate retail pharmacy access for the pending service area. While applicants are required to demonstrate that they meet the Part D pharmacy access requirements at the time this application is submitted to CMS, CMS expects that pharmacy network contracting will be ongoing in order to maintain compliance with our retail pharmacy access requirements. 17
18 2.6.2 Home Infusion Pharmacy Access Applicants must demonstrate that their contracted pharmacy network provides adequate access to home infusion pharmacies. In order to demonstrate adequate access to home infusion pharmacies, Applicants must provide a list of all contracted home infusion pharmacies (see section 3.9). CMS uses this pharmacy listing to compare applicants home infusion pharmacy network against existing Part D sponsors in the same service areas to ensure that applicants have contracted with an adequate number of home infusion pharmacies. The adequate number of home infusion pharmacies is developed based on data provided by all Part D sponsors through the annual Part D Reporting Requirements. A reference file entitled Adequate Access to Home Infusion Pharmacies is provided on the CMS website, Coverage/PrescriptionDrugCovContra/RxContracting_ApplicationGuidance.html Long-Term Care Pharmacy Access Applicants must demonstrate that their contracted pharmacy network provides convenient access to long-term care (LTC) pharmacies. In order to demonstrate convenient access to long-term care pharmacies, applicants must provide a list of all contracted long-term care pharmacies (see section 3.10). CMS uses this pharmacy listing, as well as information reported as part of applicants reporting requirements and complaints data, to evaluate initial and ongoing compliance with the convenient access standard. To assist applicants with preparing their LTC pharmacy network, CMS provides the LTC Facilities List on the CMS website, Coverage/PrescriptionDrugCovContra/RxContracting_ApplicationGuidance.html Indian Tribe and Tribal Organization, and Urban Indian Organization (I/T/U) Applicants must demonstrate that they have offered standard contracts to all I/T/U pharmacies residing within the applicants service areas. In order to demonstrate convenient access to I/T/U pharmacies, applicants must provide a list of all I/T/U pharmacies to which they have offered contracts (see section 3.11). CMS provides the current national list of all I/T/U pharmacies to assist applicants in identifying the states in which I/T/U pharmacies reside. The in the ITU Pharmacies Reference File is located on the CMS website, Coverage/PrescriptionDrugCovContra/RxContracting_ApplicationGuidance.html Waivers Related to Pharmacy Access Waivers for Plans in the Territories (excluding Puerto Rico) To ensure access to coverage in the territories, section 1860D-42(a) of the Act grants CMS the authority to waive the necessary requirements to secure access to qualified prescription drug coverage for Part D eligible individuals residing in the territories. The regulations at 42 CFR (c) allow CMS to waive or modify the requirement for access to coverage in the territories either at an applicant s request or at CMS own 18
19 determination. Under that authority, CMS will consider waiving the convenient access requirements for a plan s Part D contracted retail pharmacy network, found in 42 CFR (a)(1) for the Territories, if an applicant requests such a waiver, and demonstrates that it has made a good faith effort to meet the requirements described in Section 3.6 D of this solicitation Waivers for MAPD Plans CMS guidance regarding waivers of the pharmacy access and any willing pharmacy requirements for certain MA-PD sponsors is contained at sections 50.7 and of Chapter 5 of the Prescription Drug Benefit Manual. These waivers are described below. Waiver of Retail Convenient Access Standards for MA-PDs As described in section of Chapter 5 of the Prescription Drug Benefit Manual, the requirement that MA-PD sponsors must offer their Part D plan benefit through a contracted retail pharmacy network that meets CMS convenient access standards is waived for MA-PD sponsors that operate their own pharmacies. MA-PD sponsors must demonstrate at the plan level that a majority (50%) of the prescriptions are filled at retail pharmacies owned and operated by the organization in order to be granted the waiver. (See section 3.6F) Waiver of Convenient Access Standards for MA-PFFS As described in section of Chapter 5 of the Prescription Drug Benefit Manual, the requirement that MA-PD sponsors must offer Part D plan benefits through a contracted pharmacy network that meets CMS convenient access standards is waived for MA- PFFS plans that meet the criteria in table 3.4. (See section 3.6.F) Waiver of Any Willing Pharmacy Requirements for MA-PD As described in section of Chapter 5 of the Prescription Drug Benefit Manual, the requirement that MA-PD sponsors must offer a network pharmacy contract to any willing pharmacy that agrees to accept MA-PD sponsor s standard terms and conditions is waived for MA-PD sponsors that own and operate the pharmacies in their network. MA- PD sponsors must demonstrate at the plan level that at least 98% of prescriptions are filled through pharmacies that are owned and operated by plan sponsor in order to be granted the waiver. (See section 3.6G) Waivers for Cost Plans CMS guidance regarding waivers of the pharmacy access and any willing pharmacy requirements for certain Cost Plan sponsors is contained at sections 50.7 and of Chapter 5 of the Prescription Drug Benefit Manual. These waivers are described below. Waiver of Retail Convenient Access Standards As described in section of Chapter 5 of the Prescription Drug Benefit Manual, the requirement that Applicants must offer their Part D plan benefit through a contracted retail pharmacy network that meets CMS convenient access standards is waived for Applicants that operate their own pharmacies. Applicants must demonstrate at the plan 19
20 level that a majority (50%) of the prescriptions are filled at retail pharmacies owned and operated by the organization in order to be granted the waiver. Waiver of Any Willing Pharmacy Requirements As described in section of Chapter 5 of the Prescription Drug Benefit Manual, the requirement that Applicants must offer a network pharmacy contract to any willing pharmacy that agrees to accept Applicant s standard terms and conditions is waived for Applicants that own and operate the pharmacies in their network. Applicants must demonstrate at the plan level that at least 98% of prescriptions are filled through pharmacies that are owned and operated by plan sponsor in order to be granted the waiver. (See Sections 3.6 F & G) 2.7 Waivers Related to Attestations for MAPD and PDP EGWP and MAPD and PDP Direct Contract Applicants ( 800 Series Plans ) As a part of the application process, those organizations seeking to offer 800 series plans may submit individual waiver/modification requests to CMS. Applicants should submit an attachment via an upload in the HPMS Part D Attestations section that addresses the following: Specific provisions of existing statutory, regulatory, and/or CMS policy requirement(s) the applicant is requesting to be waived or modified (e.g., 42 CFR , Section 30.4 of the Part D Enrollment Manual); How the particular requirement(s) hinder the design of, the offering of, or the enrollment in, the employer-sponsored group plan; Detailed description of the waiver/modification requested including how the waiver/modification will remedy the impediment to the design of, the offering of, or the enrollment in, the employer-sponsored group prescription drug plan; Other details specific to the particular waiver/modification that would assist CMS in the evaluation of the request; and Contact information (contract number, name, position, phone, fax and address) of the person who is available to answer inquiries about the waiver/modification request. Note: Applicants should review the waivers currently approved by CMS in Chapter 12 of the Medicare Prescription Drug Benefit Manual to assess whether the sponsoring organization is similarly situated to qualify for an existing waiver prior to submitting a request to CMS. 2.8 Waivers for MA-PD and Cost Plan Applicants CMS is authorized to grant waivers of Part D program requirements where requirements conflict with or duplicate a Part C or Cost Plan requirement, or where granting a waiver would improve the MA-PD or Cost Plan sponsor s coordination of Part C and Part D benefits. Accordingly, CMS has identified the waivers it is granting to all MA-PD sponsors in the chart shown in Appendix I Summary of Medicare Part D Regulatory Requirements Fulfilled under Part C for Medicare Advantage Prescription Drug (MA-PD) 20
21 Applicants. As a result of these CMS-granted waivers, the MA-PD sponsor application is less comprehensive than the PDP sponsor application. These waivers will be reflected in each MA-PD sponsor s Part D addendum. Applicant Requests for Additional Waivers: CMS may grant additional waivers upon an MA-PD or Cost Plan sponsor s request. Any waiver granted by CMS will apply to all similarly situated MA-PD sponsors. For each waiver request, the applicant must provide, as an upload in HPMS, a statement that includes: 1. The Part D regulation reference. 2. The appropriate waiver criteria (e.g., duplicative, conflicts, improves benefit coordination). 3. A discussion of how the requested waiver meets at least one of the three waiver criteria. CMS will notify applicants whether their requests were approved via a CMS web posting of all approved waivers. Where this application directs the applicant to attest that it will meet a particular Part D requirement for which the applicant has requested a waiver, the applicant should check both the Yes box and the Waiver Requested box within HPMS. In the event that CMS does not approve a particular waiver, the applicant will still have attested that it will meet all the applicable Part D program requirements and remain eligible to enter into a Part D addendum upon approval of its bids. This process will prevent applicants from having to submit additional application responses after the original February 18, 2016 deadline. If, as a result of CMS denial of its waiver request, the applicant no longer intends to offer a Part D benefit plan, the applicant must notify CMS in writing on or before June 30, CMS will not execute a Part D addendum with applicants that submit such a notice. This notice of withdrawal should be sent following instructions in section Withdrawal of Part D Applications. No hard copies will be accepted. 2.9 Standard Contract with MAPD and PDP Sponsors Successful applicants will be deemed qualified to enter into a Part D contract with CMS to operate one or more Medicare prescription drug plans after CMS has reviewed the Applicant s entire submission. Only after the qualified applicant and CMS have reached agreement on the applicant s bid submissions will the applicant be asked to execute its Part D contract. Approved Part D applications are valid for the forthcoming contract year. Should an applicant decide to not execute a contract after receiving application approval, the applicant will be required to reapply in a subsequent year if it desires to enter a Part D contract in the future. 21
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