Topic: Brain Food

Off-Cycle MOC Submissions – Is It Time?

Anita McCreavy

Remember, your plan must be operating from an approved Model of Care (MOC).

The off-cycle submission process allows for substantial changes such as fundamental organizational changes essential to the MOC process and functions; for example, changes to an organization’s MOC narrative that occur between approval periods (e.g., year 2 of a three-year approval) and have not expired.

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Congressional Inaction Puts Government Health Programs in Jeopardy

Olga Walther

The packed agenda for Congress promised us a whirlwind of a month, and it certainly came with its share of surprises. Despite the appearance of progress, however, we still don’t have answers to any of the pressing healthcare legislation questions as we conclude our third week of September. With one week remaining, action looks pretty grim for many of the government health programs, including the Children’s Health Insurance Program (CHIP) and the Affordable Care Act (ACA), mainly due to the sudden resurgence of ACA repeal talks.

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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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Bernie’s “Medicare for All” Proposal Is DOA

John Gorman

I worked on single-payer healthcare legislation for US Rep. John Conyers (D-MI), my hometown Congressman from Detroit and an early leader on the issue with Rep. Jim McDermott (D-WA) in the 90’s. It’s not surprising the idea has gone nowhere in the 26 years since. While my heart is in it as a means of universal coverage, Bernie’s “Medicare for All” proposal as dropped this week is a conversation piece, and that’s it. It’s DOA as legislation.

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Senate Kicks Off Substantive ACA Fix Hearings

Olga Walther

On Wednesday, September 6, the Senate HELP Committee kicked off a series of hearings on a possible bipartisan bill to address pressing issues with the individual market under the Affordable Care Act (ACA). The first hearing, the senators heard from five state insurance commissioners from both parties. Notably, the hearing largely avoided partisan rhetoric on the ACA and focused on how substantive short-term solutions should be implemented. Senator Alexander expressed his wish for draft legislation to be introduced next week. More importantly, further insight into what senators may agree on was provided in the first hearing.

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Three-Year Network Adequacy Review for Medicare Advantage Plans

Elena Martin

If the Centers for Medicare & Medicaid Services (CMS) knocked on your door today, would you be ready to submit a compliant provider network within 60 days? CMS estimates the proposed three-year network adequacy review for Medicare Advantage (MA) plans would mean just that for approximately 304 MA plans for calendar year 2019.

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Evaluating Star Ratings Performance Data

Melissa Smith

September marks an exciting season for Star Ratings as 4th quarter work plans and 2018 budgets are finalized. For these investments to be impactful, plans must carefully evaluate Star Ratings performance data to ensure action plans address the following questions: Read more

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