Topic: Brain Food

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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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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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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CMS Launches Patients over Paperwork Initiative Focused on Quality Measurement

Melissa Smith

As the Centers for Medicare & Medicaid Services (CMS) embarks on its Patients Over Paperwork initiative to better focus quality measurement in all programs on meaningful measures, this is an ideal time for Medicare Advantage plans to ensure they are using their data in ways which support CMS’ plans to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience.

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How to Make Your Next MA-PD Plan Implementation a Success

Julie Billman

Friends of mine built a house. They indicated it was the most stressful event, full of decisions they didn’t know they needed to make, and struggled to agree. The timeline they hoped for was not reality and had to be reworked. While they said they were stronger having gone through the process and they love their house now, it wasn’t the fun event they thought it would be, and they never want to build a house again.

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Will We See a Resolution to Cost Sharing Subsidy Payments and does it Matter

Olga Walther

With two months of Affordable Care Act (ACA) stabilization bill efforts under the belt, it is becoming questionable whether Congress will be able to pass, or even bring to the floor, a bill President Trump will support and sign. We saw some developments this week that may shape the future of cost sharing subsidy payments as well as any other ACA fixes in the months to come.

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