Best Available Evidence BAE Monitoring Project

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Best Available Evidence (BAE)Monitoring Project
Deborah Larwood CMS Project Officer-- BAE
Monitoring Contract CPC, Medicare Drug Benefit
Group
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Background

• CMS BAE policy is intended to ensure that
  Medicare beneficiaries entitled to the low-income
  subsidy (LIS) have access to covered Part D drugs
  at a reduced level of cost sharing if the
  sponsors systems and CMS systems do not yet
  reflect LIS eligibility.

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Project Objective

• This project permits CMS to monitor the extent to
  which Part D sponsors are correctly implementing
  CMS best available evidence (BAE) policy.

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Approach

• This monitoring effort will expand the current
  CMS evaluation of the Part D sponsors LIS
  eligibility match rates to assess sponsor
  compliance with CMS BAE requirements for
  sponsors to
• Accept and use BAE to correct LIS eligibility
  data in the sponsors system.
• Submit a request for manual correction of the CMS
  system if the correction does not occur
  automatically within 30-60 days.

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Project Contractor

• CMS has entered into a contractor with Acumen,
  LLC to assist with this project.
• Participating sponsors may direct technical
  questions to Acumen via email at
  BAE_at_AcumenLLC.com.

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Methodology- Sponsor Sample

• A sample of Part D sponsors was selected from
  those sponsors with at least 100 more favorable
  beneficiaries per month in the period
  (February-June 2008).
• This group of sponsors includes
• Sponsors with at least 100,000 LIS enrollees, and
• Sponsors with an LIS mismatch rate of greater
  than 5.5, representing 15 parent organizations.

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Methodology- Beneficiary Sample

• Of the sponsors with at least 100,000 LIS
  enrollees, the sample includes
• 20 beneficiaries per state with Medicaid related
  mismatches, and
• 30 beneficiaries with SSA related mismatches.
• Of the sponsors with an LIS match rate greater
  than 5.5, the sample includes 30 beneficiaries
  from each of the 15 parent organization.

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Methodology- Data Submission

• Selected sponsors will submit BAE documentation
  for their sample enrollees via a secure project
  website during announced submission timeframes.
• Acumen project staff will provide ad hoc
  technical assistance via phone, email and website
  discussion boards.

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Methodology- Data Review

• Acumen in consultation with CMS will review
  submitted documentation to determine if the
  evidence substantiates the LIS level in the
  sponsors system.
• The project team will review data from
  IntegriGuard to determine if the sponsor
  requested an LIS status correction when the
  mismatch continues for more than 60 days.

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Methodology- Follow-up Sample

• A follow-up sample will be selected from the
  group of beneficiaries with more favorable LIS
  levels during the period April-June 2009.
• BAE documentation will be requested from the
  sponsors for these beneficiaries and the review
  will be repeated for this sample.

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Methodology- Outlier Analysis

• Acumen will also be performing an analysis of LIS
  match rate and enrollment data for sponsors that
  appear to be outliers.
• This analysis will focus on sponsors with less
  than 100 beneficiaries at a more favorable LIS
  level some of these sponsors have a significant
  Part D enrollment, including a significant
  percent of LIS eligibles.

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Sponsor Requirements

• Authorize users for the BAE website.
• Review the BAE Website User Guide and
  documentation submission guide.
• Identify and submit BAE documentation for the
  sponsors sample beneficiaries.
• Download reports from the BAE website.
• Resubmit data, if necessary.
• Use the sponsors own website discussion boards.

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Key Dates

• 11/2008- Announcement of BAE monitoring
  initiative
• 12/2008- Completion of website user authorization
• 12/2008- Sponsors received disk with sample
  beneficiaries
• 01-02/2009- Data submission for initial
  beneficiary sample
• 05/2009- Initial summary report

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Key Dates (cont.)

• 07/2009- Follow-up beneficiary sample selected
• 07/2009- Data submission for follow-up
  beneficiary sample
• 09/2009- Final summary report

Contact Deborah.Larwood_at_cms.hhs.gov