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 is introducing a major shift in how Medicare approaches obesity and metabolic health through the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) Model.

On Monday, the Centers for Medicare & Medicaid Services released the Calendar Year (CY) 2027 Advance Notice for the Medicare Advantage (MA) and Part D programs. At more than 160 pages, the document pairs a modest projected payment increase with some of the most consequential refinements to MA risk adjustment in recent years.

Medicare Advantage & Part D Advance Notice

CMS just issued its 2026 Program Audit Annual Update, and there are several major shifts that Medicare Advantage, Part D, and Cost Plans should begin preparing for now. Below are the key takeaways: 1. Audit Scoring Is Eliminated CMS is removing all audit scoring beginning in 2026. Conditions will no longer carry points, and CMS may consider alternative weighting methods in the future. 2. Condition Classifications Are Simplified CMS is retiring ICAR and ORCA categories. New st

As Medicare Part D oversight continues to intensify, formulary and benefit coding errors by Pharmacy Benefit Managers (PBMs) remain a top compliance risk for Plan Sponsors. Ensuring that claims adjudicate accurately to your CMS-approved formulary and benefit design is not just a best practice — it’s a compliance expectation. Annual benefit administration testing (BAT) continues to be one of the most effective tools to validate the accuracy of your Part D benefit before the pl

Recent statistics from the CDC show more than 38 million people in the US have diabetes and up to 9 million of that number as...

CMS’s CY 2025 Final Rule: A Quick Summary

The Centers for Medicare and Medicaid Services (CMS) published the Calendar Year (CY) 2025 Medicare Advantage (MA) Capitation Rates and...

On April 1, 2024, CMS issued their Final Calendar Year (CY) 2025 Part D Redesign Program Instructions (draft instructions issued...

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...

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

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...

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

Part D Pharmacy Directors and Formulary administrators, Rebellis is ready to assist you with your 2023 BAT testing! Benefit...

Since the Comprehensive Medication Review (CMR) completion rate became a Star measure, Part D sponsors have devoted internal and vended...

The Centers for Medicare and Medicaid Services (CMS) published the Announcement of Calendar Year (CY) 2023 Medicare Advantage (MA)...

Now that we are through the gates of AEP/OEP season, it’s time to focus on key upcoming events: Program Audits and Timeliness Monitoring...

The majority of Medicare Advantage Part D (MAPD) health plans utilize a “template formulary” configured by their PBM (Pharmacy Benefit...

Rebellis Academy offers online training to suit all organizational needs. Select from our out-of-the box courses, provide your own, or...