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- William on Will Trump and Price Pull Out the Scalpels for Star Ratings?
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- Capitol Hill Healthcare Update | Gorman Health Group Blog on What Trump Could Actually Do to ObamaCare, Day One, Without Congress
Topic: Part D
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.
A little section in the Medicare Access and CHIP Reauthorization Act (MACRA) is bringing big changes to Medicare supplemental insurance, also known as Medigap, bought by more than 12 million seniors to help fill in the coverage holes in traditional Medicare. In the vast majority of cases, Medigap purchasers augment their coverage with a Medicare Part D Prescription Drug Plan (PDP). That means MACRA’s changes will cause a seismic event in senior markets – Medicare Advantage, Medigap insurers, and PDPs – nationally, starting now.
Program audits and oversight activities must be designed with many factors to balance: accuracy, consistency, efficiency, and in an effort to be least disruptive to a plan sponsor. Correspondingly, a plan should be tailoring its response to these audits with those same factors in mind. My colleague Deb Devereaux and I outline ten common risk areas we observe in plans large and small. Read more
During the presidential campaign, Donald Trump highlighted the need to address rising drug costs, stating the drug industry was “getting away with murder.” Several recent high-price drug increases for HIV/AIDS drugs, hepatitis C drugs, and the EpiPen®, among others, have also raised Congressional, state, and public concern about the issue. During the campaign, Trump discussed allowing re-importation of cheaper drugs or allowing the government to negotiate drug prices as ways to lower prices.
At the beginning, it all sounds great…the PowerPoint presentation was informative, and the staff who came to present all seemed very competent and caring with a lot of integrity. Then the negotiations begin, and there’s a lot of back and forth and he-said/she-said, and you give up. That is not a great strategy for getting a Pharmacy Benefit Manager (PBM) contract that meets your financial, compliance, and Star Ratings goals. You must have a letter of agreement if you are implementing a new plan, but the contract negotiation may stretch into the latter part of third or fourth quarter. You are better off taking your time, getting your own legal counsel review, and staying true to your plan goals.
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