MA and Part D Proposed Rule Increases Plan Flexibility, Reduces Regulatory Burden

Olga Walther

The Centers for Medicare & Medicaid Services (CMS) recently released the highly anticipated Medicare Advantage (MA) and Prescription Drug Benefit Program (Part D) Proposed Rule for 2019. A big focus of the proposed regulation included increasing plan flexibility and reducing regulatory burden. Comments on the proposed rule are due to CMS by January 16, 2018.

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Four Actions That Could Sabotage Your Member’s Experience

Julie Billman

It’s the Annual Election Period (AEP) for Medicare Advantage (MA), and like many health plans, those of us in the industry are often busy. Family members on Medicare are often asking about changes or concerns about their health plan. When I checked in with my father, he indicated he needed to change his MA plan because he owed a $36,000 hospital bill he felt should be covered by his health plan. I thought he was confused until I saw his Explanation of Benefits (EOB), and it did have a $36,000 denial for a hospitalization. The denial message indicated, “You may owe this amount. You will be billed by your provider.

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Pressure Test your 2019 Expansion Strategy in 3 Steps

Diane Hollie

Do it now! Get your benefit strawman, enrollment projections, and financial goals developed before benefit season begins!

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Benefit Administration Testing – From a Compliance, Audit, and Best Practice Perspective

Miru Monte

In 2016, 41 million individuals (72 percent of all Medicare beneficiaries) were enrolled in Medicare Part D. Of those enrolled, 60 percent were in stand-alone Prescription Drug Plans (PDPs), and 40 percent were in Medicare Advantage Prescription Drug plans (MA-PDs). Plan sponsors must adjudicate pharmacy claims for the Part D benefit in accordance with their Centers for Medicare & Medicaid Services (CMS)-approved formulary and Plan Benefit Package (PBP) bids.

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Opioid Abuse: A Growing Compliance Risk for Medicare Advantage Plans

Debra Devereaux

Opioid overutilization and the corresponding public health crisis are ubiquitous in the daily news. In September 2017, the White House declared the opioid drug crisis was a national emergency. A presidential commission report described the opioid epidemic death rate as “September 11th every three weeks.” The map below, found on Consumer Protect, illustrates the number of opioid prescriptions by state in 2016.

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As CMS Administrator Verma Announces Obama-Era Medicaid Policy Reversals, States Signal Support for Medicaid Expansion

Olga Walther

Tuesday was a big day for Medicaid policy, with both a rollback of Obama Era policy reversals and a movement toward more states adopting Obamacare’s Medicaid Expansion.

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The 2019 Proposed Notice of Benefit and Payment Parameters

Jessica Smith

The annual Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameter (NBPP) for 2019 proposed rule was released on October 27, 2017. It contains some eye-opening details about the future path of the Affordable Care Act (ACA). There have been many attempts this year to dismantle and drastically alter the course the ACA set out to achieve. The 2019 NBPP proposed regulations display the same message that has been heard all year – to make many changes to the foundational structure and administration process of the ACA.

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