Topic: Part D

Bombshells from MedPAC on Medicare Advantage Retention

John Gorman

The Medicare Payment Advisory Commission (MedPAC ), the nonpartisan blue-chip Congressional uber-nerds on our favorite entitlement program, met this week and the staff report presented a couple bombshells on retention rates in Medicare Advantage (MA).

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CMS’s Star Ratings Firing Squad Gets Squirt Guns

John Gorman

Last week, in a surprise move, the Centers for Medicare and Medicaid Services (CMS) reversed its threat to terminate all Medicare Advantage and Part D health plans with 3 or fewer Stars for more than 3 consecutive years.  Roughly a dozen health plans were lined up in front of the firing squad as an example to the industry for months — and then CMS issued squirt guns to the executioners. 

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Hospice Guidance Turns 180 Degrees

Debra Devereaux

After 70 Senators signed a protest bill and the hue and cry from hospice providers, patients and prescribers got too loud, CMS rescinded its’ previous regs for hospice patients and published new guidance on 7-18-14. Previous guidance required health plans to place prior authorization edits on all medications after a member was identified as being a hospice patient. So, all the medications that the member was previously receiving under their Part D benefit were denied at point of sale. This caused a significant hardship to hospice providers who many times had to pay for the hospice member’s medications. The philosophical and medical issue continues to be what medications should be continued and which medications should be discontinued when members are in their hospice benefit. Should antihypertensive, antihyperlipidemic, diabetes and other chronic medications be continued for hospice patients? Rational and substantive arguments exist for the continuation of some chemotherapy medications which keep tumor growth in check and are considered to be palliative for some patients.

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Rejected Claims Review–You Gotta Do It!

Debra Devereaux

The question arises from almost every client, “Why do we have to do daily rejected claims review?” The answer is that there is no better way “to take the temperature” of Part D compliance than rejected claim reviews. Everything that can and will occur happens at Point of Sale. At a minimum you can detect problems with the following:

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Part D and Hospice Rules Mucking Up Beneficiaries’ Last Days

John Gorman

Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries’ last days. The National Hospice and Palliative Care Organization described the meeting as “an important first step at righting the wrongs being faced by dying Medicare patients.”

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Further Evidence That PBMs are Failing on Government Programs

John Gorman

At CMS’ oversight and enforcement conference last week Jonathan Blanar, the agency’s Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It’s further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the plans enrolling them.

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4 Points to Ponder from CMS’ Oversight and Enforcement Conference

Regan Pennypacker

On June 26, CMS hosted their MA-PD Oversight and Enforcement conference. Not one of the topics was less relevant to the audience than another – they prepared ahead of time to present current, critical information related to their data-driven approach to oversight, best practices and common findings, preparing for an audit and enforcement actions. I was glad to see CMS invite plan sponsor staff to share their experiences. They included Todd Meek of SilverScript Insurance Company; Margaret Drakeley of Kelsey Care Advantage; Shannon Trembley of Martin’s Point Health Care; Marcella Jordan of Kaiser Permanente, and Jenny O’Brien of UnitedHealthCare. Their first-hand accounts are worth your full attention.

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