CMS Working on Managed Care, Drug Rules
For Private Plan Packages, Conference Told     

The Centers for Medicare & Medicaid Services is working on three final regulations to be published before marketing begins for 2009 private plan benefit packages, Abby L. Block, director of CMS's Center for Beneficiary Choices, said July 30.

"Our current challenge is to develop the policies applicable to the 2009 plan year by the time marketing begins on Oct. 1, 2008," she said at a conference, "Medicare Today & Tomorrow," sponsored by the World Research Group Inc.

The final regulations will be based on proposals for Medicare Advantage (MA) and Part D drug plans that CMS had published before a new law, the Medicare Improvements for Patients and Providers Act (MIPPA), was cleared by Congress on July 15, as well as from the new law itself, Block said.

"The passage of MIPPA means that CMS must act quickly to develop an implementation strategy in order to meet the statutory timeframes," the CMS official said.

Working With Industry

CMS also intends to work closely with private plan industry representatives on the many technical issues that pre-dated MIPPA, such as reporting requirements, data collection, and medical documentation, Block said.

She said that agency officials are reviewing comments on a notice of proposed rulemaking (NPRM), published in May, two months before MIPPA, that discussed such issues as MA and Part D marketing activities, eligibility determinations for low-income subsidy programs, standards for special needs plans, and negotiated prices for Part D drugs (73 Fed. Reg. 28,556).

MIPPA also dealt with many of those issues. "With the passage of the new law, CMS is able to implement immediately some of the provisions of the proposed rule," she said.

CMS staff is "hard at work developing regulations and policy guidance to ensure that all the marketing provisions of both the NPRM and the legislation are in effect at the beginning of marketing for the 2009 plan year," she added.

On a specific MA issue, MIPPA changed the network requirements for one type of MA plan--the private fee-for-service (PFFS) plan.

Block said that, because of these statutory changes, CMS will begin assessing PFFS plans in the same way it does coordinated care plans, such as preferred provider organizations and health maintenance organizations, to ensure that they have adequate provider networks.

"We see no basis for using different standards," she said.

New Network Requirements

Starting in plan year 2011, MIPPA requires that employer-union sponsored PFFS plans demonstrate that they have written contracts with a sufficient number and range of health care providers in their areas to meet accessibility and availability requirements.

PFFS plans have been exempt from network formation requirements, and medical providers had been automatically "deemed" to have agreed to the plans' fee schedule, billing procedures, and other rules if they knowingly treated an enrollee of a PFFS plan.

MIPPA ended deeming for employer group plans and for those in the individual market serving beneficiaries in areas having at least two network-based plans, such as PPOs and HMOs.

Overall, Block said that private plans should resist merely meeting "short term goals" and develop business strategies on demographics and costs that not only consider the 2009 marketplace but "the environment as it is likely to evolve in the years to come."

This attitude will help demonstrate value offered by Medicare Advantage plans, she said.

"Growing pains," she added, "are no longer an excuse."