Why is the CMS Readiness Checklist important? What value does it bring to health plans?

4 minute read
Why is the 2023 CMS Readiness Checklist important? What value does it bring to health plans?


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.

What is the CMS Readiness Checklist?

The CMS Readiness Checklist, used for Medicare compliance, is not all-inclusive, but is used to remind the industry of key requirements 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 CMS Readiness Checklist is more of an annual event. Medicare 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 checklist also begs plans’ attention to what CMS may formally audit or informally monitor in the future.

What are MAO’s responsibilities when presenting readiness to CMS?

Health plans subject to this event must be prepared to respond to the CMS Readiness 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.

CMS changes to the communications

CMS-required Readiness Checklist communications for members and annual marketing materials are among the many beneficiary-facing documents Toppan Merrill supports. Some of the subpoints in the CMS checklist have flexed in response to regulatory changes, so it’s important to have experienced personnel examining updates to ensure Medicare compliance. 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. 

  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

Checkbox= 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 example, in 2023 we saw 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, it appeared 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

With more than 30 years of 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 Compliance 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, Corrective Action Plans, and training with re-education formats following CMS disciplines. Summer brings expertise on policies and procedures, auditing compliance programs and has measurably reduced plan member complaints to CMS through remedial initiative.

Summer Beach – Associate Director, Medicare Compliance Solutions's Photo

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