Tag Archives: Medicare Part D

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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Will Trump and Price Pull Out the Scalpels for Star Ratings?

John Gorman

Star Ratings have driven the market in Medicare Advantage (MA) and Part D since the Affordable Care Act turned the consumer information tool into the biggest experiment in value-based payment on the planet. There’s little argument Star Ratings is working, and MA quality has improved. The program is being adopted in the ObamaCare Health Insurance Marketplace, and the Medicare Access and CHIP Reauthorization Act (MACRA) included the Quality Reporting System, or Stars for Medicaid, starting in 2019. Then Trump got elected President and appointed Tom Price the Department of Health and Human Services (HHS) Secretary. Could they pull out the scalpels for Star Ratings?

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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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A Vendor’s Oversight is Never Done

Regan Pennypacker

There are many industry voices adding their perspectives about the new administration and changes to come. However,  the Compliance Officers I know do not have the luxury of stopping and truly considering the potential impact as they are managing the continuous pressures of their daily directives. Today I address a group of very industrious Compliance professionals not often addressed, and those are the staff responsible for Compliance Programs at first tier, downstream and related entities, or “FDRs.” Under Medicare regulations, plan sponsors may enter into contracts with FDRs to provide administrative or healthcare service functions on their behalf.

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The New “80/20 Rule” in Government Health Programs

John Gorman

The New “80/20 Rule” in Government Programs

Everyone in health finance and policy knows the “80/20 Rule:” 20% of patients account for 80% of health expenditures. It’s also well-established that about one-third of health outcomes are determined by genetics and access to healthcare. That means two-thirds of outcomes are attributable to social determinants of health. For 2017, we need a new 80/20 rule for Medicare Advantage and Medicaid health plans and their delegates: 80% of the services we provide beneficiaries should address social determinants and make the health services we provide more effective.

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Reflections on the Basics of Delegation Oversight

Regan Pennypacker

Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.

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Hot Takes on Medicare Advantage and Part D in 2017

John Gorman

The Centers for Medicare & Medicaid Services (CMS) released its annual Medicare Advantage (MA) and Part D “landscape files” with data on plans and bids for 2017. It’s a picture of programs that are rock-solid and driving insurers’ revenues and earnings, offering better supplemental benefits for no increase in price for two-thirds of beneficiaries. Interestingly, CMS appears to be sandbagging its enrollment projections and assumed no growth for MA in 2017. We think we’re heading to 4.2-4.5% enrollment growth, continuing a steady, winning drumbeat for the industry.

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