The Centers for Medicare & Medicaid Services (CMS) recently released its 2027 ACA Notice of Benefit and Payment Parameters Final Rule, introducing significant changes aimed at reducing costs, strengthening program integrity, cracking down on fraud, and increasing state flexibility across ACA Exchanges.

In just the past few weeks, several AI companies reached out to our compliance practice for support in building formal compliance programs. Both were responding to health plan RFPs. Both were being asked essentially the same question: “Do you meet our FDR compliance requirements?”

Two recent CMS enforcement actions highlight a key compliance risk: operational breakdowns in Part D and PACE programs. Here’s what organizations need to know to stay audit-ready

CMS’s CY 2025 Final Rule: A Quick Summary

We are pleased to invite you to our free webinar on April 3, 2024 from 1:00 to 2:30 pm EDT.

Join our webinar on Mar 19, 2024 at 1:00 PM EDT. Registration Beginning in 2025 all Medicare Part D plans must offer the option to pay...

New Guidance Released on Encounter Data Submission of Supplemental Benefits

On November 15, 2023, CMS issued a proposed rule that proposes revisions to regulations governing Medicare Advantage (MA or Part C), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly (PACE), in Contract Year 2025 with a limited number of provisions to be applicable beginning with CY 2026. The proposed rule includes policies that would modify Star Ratings, marketing and communications guidance, agent/broker

Risk Adjustment: Is Your Organization Ready For The Transition from V24 to V28?

The United States GAO (General Accountability Office) released their report on Rebates in the Medicare Part D Program this month (September 2023). GAO-23-105270, MEDICARE PART D: CMS Should Monitor Effects of Rebates on Plan Formularies and Beneficiary Spending The study was conducted utilizing 2021 Part D Formulary data and included the review of 2020 rebate agreements negotiated between six drug manufacturers and six Part D plan sponsors, or PBMs on their behalf, for 24 bra

When most of us think about artificial intelligence (AI) in healthcare, we don’t usually think about an algorithm determining if our 85-year-old grandmother [1] will be kicked out of the nursing home or if your father will be approved for the scan needed to determine the progression of cancer. We all agree that medical costs are out of control and rising faster than salaries and outpacing retirement savings and there is no doubt that a shortage of registered nurses, general p

Beginning in contract year 2024, there will be CMS changes mandated to Special Needs Plans (SNPs) Health Risk Assessments (HRAs) to...

Looking ahead to 2025 for Part D benefits, things don’t look too rosy for health plans. The Inflation Reduction Act of 2022 will be...

A bipartisan bill has recently been introduced by Senators Bill Cassidy, MD (R-LA) and Jeff Merkley (D-OR) aimed at addressing risk...

Did you know that CMS provides nearly 100 different reports to Medicare Advantage and Part D plans? These reports cover membership,...

The Centers for Medicare and Medicaid Services (CMS) published Final Rule 4201-F (88 FR 22120) on April 12 revising the Medicare...

2024 Submission The 2024 Medication Therapy Management Program (MTMP) submission date is June 7 and the MTMP attestations are due June 21. The 2024 annual MTM program cost threshold is $5,330 ($444.16 per month). Website Requirements The health plan website should have a separate page or section describing their MTM program using a font that is easily read and information that is easily understood. The website information should include: What the MTMP is, the purpose of the p

On March 31, 2023, the Centers for Medicare & Medicaid Services (CMS) issued its Announcement of Calendar Year (CY) 2024 Medicare...

On January 30th, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS),...

Here’s a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean...