CMS Prepares for 2024 and Beyond

As 2023 comes to an end, the Centers for Medicare and Medicaid Services (CMS) is checking off activities to round out the year and prepare for 2024. The following lists the latest CMS actions and how Elixir is responding to prepare for changes, so we are best equipped to help our clients.

Program and Validation Audits

CMS issued its last engagement letters for 2023 program audits in July. Audit fieldwork is complete, and the audits are in their final phases of reporting, validation and closeout. When released, Elixir will provide a review of the 2023 Audit Enforcement Report. In the meantime, Elixir is implementing our reporting updates and preparing for the 2024 program audit overview from CMS, which defines the audit engagement period.

In September 2023, CMS also released a 2023 Data Validation Audits summary, which showed mean scores above 99%.^[1] These positive results are consistent with the results Elixir received from our clients.

CY2024 Readiness Checklist

On October 13, 2023, CMS issued the CY2024 Readiness Checklist,^[2] which outlines the following changes that are effective January 1, 2024:

• Section 11201 of the Inflation Reduction Act (IRA) eliminates beneficiary cost-sharing in the catastrophic phase. Elixir's adjudicator has been configured to correctly adjudicate this change to the Part D benefit.

• Due to the required application of all pharmacy price concessions at the point of sale, if payment to a Part D pharmacy may be reduced up to a certain amount, the maximum possible reduction in payment must be treated as a pharmacy price concession and reflected in the negotiated price available at the point of sale. Then the reduction must be reported to CMS on a PDE record. This means Elixir will not have any pharmacy price concessions to report at point of sale for 2024.

Looking Ahead

Payment Plan Options: Beginning January 1, 2025, the Medicare Prescription Payment Plan requires Medicare prescription drug plans to offer Part D enrollees the option to pay out-of-pocket (OOP) Part D drug costs through monthly payments over the plan year instead of as upfront payments at the pharmacy point of sale. Elixir stands ready to work closely with our plan sponsors to support a smooth and timely implementation of this change.

Expanded PDE File Layouts: Effective January 1, 2025, Part D sponsors will be required to submit certification (CERT) test files before submitting production PDE files. Testing for this process is expected to begin on July 1, 2024. CMS has stated they will provide testing requirements in advance and then Elixir will make the required updates for 2025.

Part C & D Operation Monitoring: Between January 1 and January 3, 2024, we expect CMS to establish a Part C and D operations monitoring program and the subsequent issue reporting requirements. As the 2024 configuration goes live, Elixir will monitor Medicare claim processing with an additional focus on any IRA-related transactions. We will advise plan sponsors of any issues and their resolution with the new reporting requirements in mind.

Elixir monitors and advises on CMS activities to make sure our clients understand the latest changes and remain in compliance, which can save time and help avoid unnecessary fines. Please contact your designated Elixir Account Team or Compliance Officer for more information.