Library Guide: Medicare Part D

Transcription

1 Library Guide: Medicare Part D

2 Overview: With the advent of the Medicare Part D prescription drug benefit, health plans must develop a thorough and detailed understanding of regulatory requirements in order to meet the challenges and opportunities presented. UL EduNeering s internal regulatory compliance attorneys and our nationally-recognized Medicare Part D Subject Matter Experts have developed a curriculum that not only fulfills training requirements, but also is regularly updated to reflect changes in the regulations and subregulatory guidance. The Centers for Medicare and Medicaid Services (CMS) specifically recommends general and specialized compliance training for everyone involved in your Medicare Advantage program. The breadth of our Medicare Part D curriculum not only facilitates compliance with the regulations, but also provides in-depth training ensuring that your employees perform their department-specific functions successfully. Our curriculum consists of nine courses with topics such as fraud and abuse, administration and management, appeals and grievances, bid submission, claim and payment processes, enrollment, disenrollment, marketing, pharmacy access and quality management. Our Medicare Part D Curriculum expressly created for the Managed Care industry is the most comprehensive and detailed curriculum available and fulfills, via the internet, the CMS requirements for training, education and documentation in a cost-effective training method as outlined in Chapter 9 Part D Program to Control Fraud, Waste and Abuse of the Prescription Drug Benefit Manual. Please Note: The average length of time for training is 45 minutes unless otherwise indicated. Page 2

3 Table of Contents Overview... 1 Course Descriptions: MAO/PDP: Compliance Program Guidelines (MAPD04) MAPD: Enrollment and Disenrollment (MAPD02)... 3 MAPD/PDP: Marketing (MAPD03)... 3 Medicare Health Plan and PDP: Fraud, Waste and Abuse (MAPD01)... 4 Medicare Part D: Administration and Management (PARTD01)... 4 Medicare Part D: Bid and Benefit Package (PARTD03)... 5 Medicare Part D: Coordination of Benefits and True Out-of-Pocket Facilitation (PARTD10)... 5 Medicare Part D: Grievances, Coverage Determinations and Appeals (PARTD02)... 5 Medicare Part D: PDP Enrollment and Disenrollment (PARTD05)... 6 Medicare Part D: Pharmacy Network (PARTD07)... 6 Medicare Part D: Medication Therapy Management and Quality Improvement Program (PARTD08)... 6 Page 2

4 Course Descriptions: Listed Alphabetically MAO/PDP: Compliance Program Guidelines (MAPD04) Effective compliance programs are a requirement for Medicare Advantage Organizations (MAO) and Medicare Prescription Drug Plans (PDPs) that contract to do business with the Centers for Medicare and Medicaid Services (CMS). A properly designed and functioning compliance program has many benefits for these organizations including identification of potential problems, uniformity of operations and operational improvements, and ensures the organization meets its regulatory obligations. Firsttier, Downstream and Related entities (FDR) are also required to comply with the compliance program guidelines. Topics Include: How can plan sponsors implement an effective compliance program? What is the purpose of written Standards of Conduct? Who oversees the compliance program? What type of training is required? How can sponsors inform their organization and FDRs about the compliance program? MAPD: Enrollment and Disenrollment (MAPD02) This course describes the processes and procedures for enrollment and disenrollment from a Medicare Advantage (MA) health plan and the responsibilities that the must be met relative to enrolling and disenrolling members from the program. After completing this course you will be able to: Identify the beneficiary eligibility criteria for Medicare Advantage plan enrollment. Identify the key concepts, principles, and the MA plan s responsibility in the enrollment and disenrollment process. Identify requirements for submitting enrollment and disenrollment data to CMS. Differentiate between CMS election periods. Identify requirements for corresponding with beneficiaries. Recognize the disenrollment methods available to Medicare beneficiaries. Recognize the reasons why members are involuntarily disenrolled from a Medicare Advantage plan. Describe the involuntary disenrollment process. Identify the requirements and timelines for submitting disenrollment data to CMS. MAPD/PDP: Marketing (MAPD03) This course examines what types of marketing materials are regulated, what must be included in the materials and what is prohibited, how the Centers for Medicare and Medicaid Services (CMS) approval process works, the parameters of promotional marketing to beneficiaries and what role providers and pharmacies are permitted to play in marketing a sponsor s plan. After completing this course, you will be able to identify the marketing materials that are regulated by thecms, the information that must be included in the materials, and how the CMS approval process works. You will also be able to identify what role providers and pharmacies are permitted to play in marketing a sponsor s plan, and the marketing activities that are prohibited. Definition Marketing Material Content Review and Approval Providers Health Plans Sales Events Marketing Representatives Page 3

5 Medicare Health Plan and PDP: Fraud, Waste and Abuse (MAPD01) This course addresses fraud, waste and abuse laws, regulations and guidelines that apply to the Medicare Advantage (MA) and Prescription Drug (PD) Benefit programs. It presents information on the False Claims Act, the Federal Anti-Kickback Act, the Beneficiary Inducement Statute and the Stark Law. After completing this course, learners will recognize the increased government interest in MAPD managed care including areas of concern and how to combat fraud, waste and abuse. After completing this course, you will be able to identify fraud, waste and abuse risk areas and related laws, regulations and guidelines that apply to Medicare managed care. Finally, you will learn how you can do your part to detect, correct and prevent fraud, waste and abuse. History Government Oversight Risk Areas Promotional Activities Compliance Programs Data Reporting Self-Reporting References: Health and Human Services (HHS) Office of Inspector General Fraud Prevention and Detection (oig.hhs.gov) Centers for Medicare and Medicaid Services ( Medicare Managed Care Manual and Medicare Prescription Drug Benefit Manual Medicare Part D: Administration and Management (PARTD01) This course describes the Medicare Part D program and details the requirements that companies must meet in order to become Medicare Part D sponsor organizations. This course examines the respective roles of the Centers for Medicare and Medicaid Services (CMS), state governments, the sponsor and the sponsor s contractors. You will learn how sponsors can meet their regulatory obligation to demonstrate compliance with certain licensure and insurance-related provisions of state law in the states in which the sponsor plans to offer coverage. Overview Enrollee Protections Grievances Process Coverage Determinations Exceptions Process Appeals Process After completing this course, you will be able to identify Part D program requirements, including how Part D contracts affect our company s relationships with contractors, and the state laws and regulations with which we must comply. In addition, you will be able to identify how leasing arrangements and changes of ownership will affect a Part D contract. Length = 60 minutes Page 4

6 Medicare Part D: Bid and Benefit Package (PARTD03) This course explains the benefits available to individuals who are eligible for Part D and presents the requirements for bidding to become a plan sponsor. After completing this course, learners will be able to recognize the benefits offered under both standard and alternative prescription drug coverage. Learners will also be able to identify the requirements for successful bidding and recognize what Centers for Medicare and Medicaid Services (CMS) examines during the bid review process. After completing this course, you will be able to recognize the benefits offered under both standard and alternative prescription drug coverage. You will also be able to identify the requirements for successful bidding and recognize what the CMS examines during the bid review process. Overview Standard Coverage Alternative Coverage Bidding Process Bid Requirements Actuarial Requirements CMS Authority Challenge Length = 90 minutes Medicare Part D: Coordination of Benefits and True Out-of-Pocket Facilitation (PARTD10) This course examines the procedures required by the Centers for Medicare and Medicaid Services (CMS) that Part D sponsors (MAPDs and PDPs) must follow when coordinating benefits with other providers of prescription drug coverage. The course also discusses the Part D True Out-Of-Pocket (TrOOP) facilitation process. Sponsor Responsibilities TrOOP Balances Claims Processing After completing this course, you will recognize CMS process for coordinating prescription drug benefits among payers and understand the requirement for calculating and maintaining accurate TrOOP information. Medicare Part D: Grievances, Coverage Determinations and Appeals (PARTD02) The Medicare Part D program provides prescription drug coverage for eligible Medicare beneficiaries. This course describes the grievances, coverage determinations, and appeals processes that are in place to protect Medicare Part D program enrollees and ensure that they have access to medically necessary prescription drugs.. After completing this course, you will be able to identify what constitutes coverage determinations, recognize and meet our responsibilities in the appeals and grievances processes, and identify the steps we must take during all processes to ensure that Part D enrollees rights are protected. Enrollee Protections Grievances Process Coverage Determinations Exceptions Process Appeals Process Length = 60 minutes Page 5

7 Medicare Part D: PDP Enrollment and Disenrollment (PARTD05) The Medicare Part D program provides prescription drug coverage for eligible Medicare beneficiaries. This course describes the processes and procedures for enrollment and disenrollment from a Medicare Prescription Drug Plan (PDP). After completing this course, you will be able to identify the eligibility requirements individuals must meet in order to enroll in a PDP. You will also be able to recognize when people may enroll in PDPs, and what information our organization must collect and distribute prior to enrollment. Finally, you will be able to identify the procedures we must follow to disenroll members from our PDP. Length = 60 minutes Member Eligibility Enrollment Periods Enrollment Vehicles Assisted Enrollments Enrollment Process Disenrollment Provisions Medicare Advantage Prescription Drug (MARx) System Medicare Part D: Pharmacy Network (PARTD07) Part D sponsors must develop a network of pharmacies so beneficiaries have convenient access to drugs covered under Part D. After completing this course, learners will be able to identify the types of pharmacies that can be included in a network as well as the requirements Part D sponsors must meet to contract with pharmacies and create a pharmacy network. After completing this course, you will be able to identify the types of pharmacies that can be included in a network as well as the requirements Part D sponsors must meet to contract with pharmacies and create a pharmacy network. Length = 60 minutes Pharmacy Types Access Requirements Contract Requirements Challenge Medicare Part D: Medication Therapy Management and Quality Improvement Program (PARTD08) This course identifies primary cost control provisions in detail, including drug utilization management (UM) and medication therapy management programs (MTMPs). This course also identifies the quality assurance requirements applicable to Part D sponsors and introduces participants to CMS s electronic prescribing program. How does drug utilization management affect Part D sponsors? How does CMS evaluate formularies? What is a Medication Therapy Management Program (MTMP)? How do fees associated with MTMPs affect beneficiaries? What is the purpose of the quality assurance program? How does CMS intend to improve the quality of Part D plans? How does e-prescribing benefit beneficiaries? Page 6

8 About UL EduNeering UL EduNeering is a business line within UL Life & Health s Business Unit. UL is a global independent safety science company offering expertise across five key strategic businesses: Life & Health, Product Safety, Environment, Verification Services and Enterprise Services. UL EduNeering develops technology-driven solutions to help organizations mitigate risks, improve business performance and establish qualification and training programs through a proprietary, cloud-based platform, ComplianceWire. For more than 30 years, UL has served corporate and government customers in the Life Science, Health Care, Energy and Industrial sectors. Our global quality and compliance management approach integrates ComplianceWire, training content and advisory services, enabling clients to align learning strategies with their quality and compliance objectives. Since 1999, under a unique partnership with the FDA s Office of Regulatory Affairs (ORA), UL has provided the online training, documentation tracking and 21 CFR Part 11-validated platform for ORA-U, the FDA s virtual university. Additionally, UL maintains exclusive partnerships with leading regulatory and industry trade organizations, including AdvaMed, the Drug Information Association, the Personal Care Products Council and the Duke Clinical Research Institute. 202 Carnegie Center Suite 301 Princeton, NJ UL and the UL logo are trademarks of UL LLC uleduneering.com LG/122713/HC