CMS CHANGES RULES – READ THE NEW DIRECTORY AND FORMULARY REQUIREMENTS AVOID FINES & SANCTIONS

Equally as important as the ANOC/EOC Mailings, CMS is now requiring monthly updates of Plan Provider Directory books, Pharmacy Directory books and Formulary books. The 2017 Final Call letter to Medicare Advantage Organizations continued to emphasize the importance of material accuracy in Formularies and Plan Provider/Pharmacy Directories. The increased monitoring and enforcement actions especially as to Provider Directories and Pharmacy Directories has been launched due to preliminary data collected by the PNA (Pilot Program) that found severe violations with the Part D and Part C requirements. For example, 1/3 of the psychiatrists listed by a New York Health Plan as Plan Providers were in fact not affiliated with that Plan. CMS has made it clear that it will be issuing fines and enrollment sanctions against Plans that do not keep these materials updated on a monthly basis.

CRITICAL CMS UPDATE

Medicare Managed Care Manual

Chapter 4 – Benefits and Beneficiary Protections:

110.2.2 – Provider Directory Updates (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Section 110.2.2

“If new information is received – MAO’s are expected to update hardcopy provider directories…. every 30 days.”