Looking Ahead to 2023: Medicare Readiness

The 2022 audit cycle is coming to a close. CMS issued its last engagement letters for 2022 program audits at the end of July. Field work is complete, and the audits are in their final phases of reporting, validation and close out. We will provide a review of the 2022 audit enforcement report upon its release.

In the meantime, Elixir is implementing universe reporting updates and preparing for the 2023 program audit overview from CMS, which defines the 2023 program audit engagement time period.

CMS released its summary of 2022 Data Validation Audits in September[1]. Although CMS does not publish plan-specific results, mean scores were above 99%, which is consistent with the very strong results Elixir has received from our clients.

On October 17, CMS issued the CY2023 Readiness Checklist[2]. Elixir delivered the PBM response to clients on November 16. Among other items of note for the PBM, the Readiness Checklist reiterates Inflation Reduction Act (IRA) requirements related to vaccine and insulin cost-sharing, i.e., no deductible with $0 cost sharing for adult ACIP-recommended vaccines, and no deductible with $35 maximum cost-sharing per one-month supply for each covered insulin product, respectively.

In addition to the various channels CMS uses to provide updates, CMS hosted calls with plan sponsors to review preparedness for the IRA requirements. Elixir joined these calls in support of our plan sponsor clients to share details of our work to meet the IRA requirements. Configuration is complete and tested to validate that member cost sharing and resulting PDE data align with IRA requirements. Elixir has also implemented a proactive reimbursement process to review IRA-eligible claims and effect timely member reimbursement as needed.

As in previous years, CMS has established a Part C and D operations monitoring program for January 1, 2023 through January 3, 2023.[3] In addition to the customary issue reporting requirements, CMS also advises plan sponsors to report any and all issues, regardless of size or length of issue, related to vaccine and insulin cost-sharing requirements. As we do each year, Elixir will monitor all Medicare claim processing from the moment 2023 configuration goes live, with additional focus on IRA-related transactions so that we can identify and advise of any issues and their resolution in support of this reporting requirement.

Elixir thanks you for your business and your partnership as we look forward to a successful 2023!

[1] HMPS Memo: 2022 Part C and D Reporting Requirements Data Validation Results. September 23, 2022.

[2] HMPS Memo: CY 2023 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, Medicare-Medicaid Plans, and Cost Plans. October 17, 2022.

[3] HPMS Memo: Reporting of IRA Implementation and Emergency Part C and D Issues for January 1 through January 3, 2023. December 12, 2022.