Tag Archives: Centers for Medicare & Medicaid Services (CMS)

2018 Medicare Marketing Guidelines

Regan Pennypacker

It was a hot summer night when the Centers for Medicare & Medicaid Services (CMS) released the final version of the calendar year 2018 Medicare Marketing Guidelines (MMG), and a few hot summer days have passed while the industry digests the changes. Don’t make the mistake and only share the MMG with sales and marketing; those handling enrollment, customer service, mailings, printing, Star Ratings and quality, compliance and oversight, legal affairs, provider relations, and finance (including delegates handling these functions) all have a stake in this chapter.

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Three Compliance-Minded Steps to Take for 2018 Marketing and Sales

Regan Pennypacker

Is it me, or is time flying by? Applications are done, bids are in, new plans are in planning stages, and existing plans are getting ready for the launch of the next benefit year.

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Highlights from 2017 CMS Audit and Enforcement Conference

Regan Pennypacker

The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics: Read more

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CMS Puts Plans on Notice with Recent Enforcement Actions

Regan Pennypacker

The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, and each year, leadership wants to know how they fared compared to others, when they are due for an audit notice, and what some of the most pervasive conditions were identified. How many of you, dear compliance-minded readers, have been asked, “What will it cost us if we stay non-compliant?” By the numbers: Read more

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CMS Proposes Several Key Changes for Star Ratings in 2018 Medicare Advantage (MA) Draft Call Letter

Melissa Smith

The potential changes to the Star Ratings program announced by the Centers for Medicare & Medicaid Services (CMS) last week in the annual Advance Notice may look minor at first glance but are sending shock waves through Star Ratings teams this week. Although most changes proposed for the 2018 Star Ratings (for which measurement periods are generally already complete) are unsurprising, CMS has proposed several key changes worthy of feedback during the comment period: Read more

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The Foundation Stone of Solid Medicare Implementation

Julie Billman

Home repair becomes far more complex when something is out of square. Everything is more difficult, and work-arounds become standard. That is why a foundation stone is so important in construction – it is the first stone set, and all other stones will be built around it. Making sure it is in perfect alignment is critical. Implementing a Medicare Advantage (MA) or Prescription Drug Plan (PDP) requires the same precision. If you don’t start with things perfectly aligned, you will always be fighting a battle to keep things straight, compliant, and productive.

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The Part D Shell Game

Debra Devereaux

Top of mind when we are talking about Medicare compliance should be that the ultimate customer is the taxpayer who funds this program. That’s why the Centers for Medicare & Medicaid Services (CMS) has to attempt to account for every nickel that comes into or goes out of the programs. One of the murkiest finance areas is in Medicare Part D – that is Direct and Indirect Remuneration (DIR). CMS published a memo on January 19, 2017, with this very title.¹ DIR is the additional compensation – besides a partially capitated payment from CMS – received by a plan sponsor or Pharmacy Benefit Manager (PBM) after the pharmacy point of sale (POS) transaction. This changes the final cost of the drug for the plan sponsor or the price of the drug paid to the pharmacy. DIR has grown significantly in the past few years in large part because of the growth of preferred network pharmacies. CMS states they have observed “a growing disparity between gross Part D drug costs, calculated based on costs of drugs at the POS, and net Part D drug costs, which account for all DIR.”

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