Topic: Part D

Narrow Networks 2017: Will Narrow Pharmacy Networks Evolve from Reduce-Reimbursement to Performance Networks?

Wayne Miller

Part D Sponsors to the Medicare Part D program must ensure that their retail pharmacy networks meet the convenient access criteria established under 42 CFR §423.120. These metrics stem directly from the statutory requirement that Medicare Part D sponsors’ entire retail pharmacy networks meet the TRICARE standard for convenient access: Sponsors and applicants must ensure that their networks have a sufficient number of pharmacies able to dispense drugs directly to patients (other than by mail order) to ensure convenient access to Part D drugs. CMS rules require that sponsors establish retail pharmacy networks in which: Read more

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Pharma Shakedown ‒ What’s Next for Part D?

Olga Walther

Most of the attention on drug pricing quickly fizzled when President-Elect Donald Trump partnered with Speaker Paul Ryan and set an ambitious healthcare agenda for the new administration. The pharma industry let out a sigh of relief when Republicans swept the House and Senate. Because Trump’s transition site made no mention of the pharmaceutical industry, it was assumed drug pricing would be left off the agenda with the Affordable Care Act (ACA), Medicare, and Medicaid facing the spotlight this term.

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The Trump De-Regulators and Medicare Advantage

Steve Balcerzak

Hmm, you’re asking what will the Trump de-regulators do to Medicare Advantage? Given the confusion about ObamaCare non-replacement for three years and the selection of a Medicaid maven for Administrator, we haven’t heard much about Medicare Advantage and Part D. However, Trump said he wants a list of wasteful and unnecessary regulation. Even with that, we may not see a lot of actual regulatory change during 2017 in either of these programs. Changing regulations in a major way takes too much time to propose, review, and finalize anything of substance in a short period. However, there are other actions the new Administrator can take. First and foremost, de-regulators are interested in slowing the process or moderating its effects, so here are some potential actions.

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2017: Taking Stock to Inform Next Steps

Regan Pennypacker

As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde. Read more

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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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New CMS Industrywide Appeals Timeliness Monitoring ‒ What You Should Do Today

Julie Billman

There are some surprises that are good, like winning the lottery or getting a promotion. There are other surprises that are not so good. These include things like a leaking roof or an unexpected bill. At the office, a negative surprise is someone finding out about a problem in your department before you do. It is even worse when it is identified by a Centers for Medicare & Medicaid Services (CMS) regulator.

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January 1 Is Here

Debra Devereaux

“There’s no harm in hoping for the best as long as you’re prepared for the worst.”—Stephen King

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