The infamous CMS Readiness Checklist was created by the Centers for Medicare & Medicaid Services (CMS) as a tool for health plans to confirm operations critical to their performance will meet regulatory and beneficiary expectations. While the list is not all-inclusive, this reminds the industry it’s now showtime to ensure key functions can be performed compliantly in the coming plan year.
The process for Medicare Advantage Organizations (MAO) completing the CMS Checklist provides a number of safeguards for health plans and their enrollees, to ensure Medicare Advantage Organizations (MAOs) are ready to fulfill their promises for the coming year.
When is the CMS Readiness Checklist issued and what are MAOs committing to when telling CMS they are ready to service enrollees for the coming year?
The checklist is more of an annual event. Compliance teams make the rounds in a health plan’s departments performing the listed functions in the Checklist, to gather a thumbs’ up from all contributors that the plan is poised and ready to execute everything listed, and more. The annual document also begs plans’ attention to what CMS may formally audit or informally monitor in the future. (Click here to review the 2022 CMS Checklist)
What are MAO’s responsibilities when presenting readiness to CMS?
Health plans subject to this event must be prepared to respond to the CMS checklist either in writing or during a conference call scheduled by CMS. (CMS is currently trending to making calls.). Regardless of how CMSs contacts the health plan, the departmental volley between a health plans compliance and operational teams should reveal what the plans must self-disclose to CMS during the CMS readiness review, for areas meetings, and not meeting the CMS requirements. The Checklist process definitely presents an element of vulnerability to CMS regulators, so plans should prepare their remediation strategy for solving shortfalls, before disclosing their findings with CMS.
2023 CMS changes to the communications
CMS edits the Checklist each year, and thankfully we’re not seeing significant changes where the usual communications checkpoints dwell. CMS-required communications for members and annual marketing materials are among the many beneficiary-facing documents Toppan Merrill supports. Our team keeps a close eye on CMS notices regarding member communications and marketing materials, particularly those required by Medicare Advantage and Part D plans. Yes, some of the subpoints in the CMS Checklist have flexed in response to regulatory changes, however looking at segments I-VI below, CMS focus remains primarily the same. The exception is the addition of this year’s Beneficiary Real Time Benefit Tool (BRTBT):
| CY 2023 CMS Readiness Checklist Elements Under Section H:
Communications Consistent with CFR Parts 422 and 423, Subparts V |
||||||
| Plan Year | I. | II. | III. | IV. | V. | VI. |
| 2020 | Model Materials: Medicare Advantage Organizations and Part D Sponsors | Referencing Star Ratings in Marketing Materials – Medicare Advantage Organizations and Part D Sponsors (Excludes MMPs) | Websites – Medicare Advantage Organizations and Part D Sponsors | Agents and Brokers – Medicare Advantage Organizations and Part D Sponsors | Access to Preferred Cost Sharing Pharmacies – Disclaimers – Part D Sponsors (Excludes MMPs) | N/A |
| 2021 | N/A | |||||
| 2022 | √ | √ | √ | √ | Beneficiary Opioid Education – Part D Sponsors | N/A |
| 2023 | I. Required Materials – Medicare Advantage Organizations and Part D Sponsors | √ | √ | Beneficiary Real Time Benefit Tool | Agents and Brokers – Medicare Advantage Organizations and Part D Sponsors | Beneficiary Opioid Education – Part D Sponsors |
= Same as Previous Year
When we see CMS change direction in this Checklist year-over-year, it’s usually due to trends identified through CMS findings or overall changes in regulation. For 2023, we see CMS added a new appliance to the kitchen remodel for the Beneficiary Real Time Benefit Tool (BRTBT), requiring Part D sponsors to implement what is essentially a lookup tool on their websites or apps for beneficiaries to estimate costs and research the following:
- Enrollee cost-sharing amounts
- Formulary medication alternatives for a given condition
- Formulary status (showing utilization requirements for alternative medications)
With only one significant change to the Communications section, we see it appearing in the CMS Checklist due to a change in the Code of Federal Regulations in early 2022, officially implementing this requirement for health plans. Tools like this have been available for some time, however CMS is officially reminding health plans the BRTBT must be confirmed through CMS readiness check-ins, likely via a conference call directly with CMS, scheduled by your assigned CMS representative.
How Toppan Merrill can help
With respect to Part D benefits and support, Toppan Merrill services formulary development and publishing for Medicare Advantage Organizations, with Part D compliance experts on staff who understand your challenges. At Toppan Merrill we will support your formulary questions and are prepared to administer monthly formulary updates. Please contact us to see how we can help your organization stay compliant and timely with your formulary development, monthly updates and distribution.
Summer Beach, Associate Director, Medicare Compliance Solutions at Toppan Merrill
With more than 25 years of the insurance industry experience, Summer Beach is an industry thought leader and expert on Medicare-related compliance. Her background includes past roles as Regulatory Compliance Manager and Director for state, regional and national insurers. Her areas of expertise include CMS-regulated documents and guidelines, agent/broker and sales compliance, designing CMS-approved investigation processes, audits and Corrective Action Plans, and training with re-education formats following CMS disciplines. Summer brings expertise i on policies and procedures, auditing compliance programs, and has measurably reduced plans’ member complaints to CMS through remedial initiatives. Well-versed on CMS insights, she identifies risks to avoid, for staying compliant. Summer’s experience supports Toppan Merrill and our clients in staying compliant with CMS and regulatory requirements.
