Topic: Part D

50/50 Just Won’t Cut It – You Have to Commit 100%. The Top 5 Components for Successful, Compliant, Committed Operations

Julie Billman

If you weren’t able to make it to the Gorman Health Group 2016 Forum this year, you missed a dynamic time. More than just relevant topics, it included engaged participants who added a wealth of depth to our discussions. The topic garnering a lot of audience participation was “Can Operational Efficiencies and Compliance Co-Exist?”  The struggle to align the two is real and takes constant, diligent effort, but the success it can create is priceless.

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Takeaways from the Gorman Health Group 2016 Client Forum

John Gorman

The Gorman Health Group 2016 Forum concluded last week with over 200 of our closest clients and partners. There was great news and rough news, so here are a few takeaways: Read more

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CMS Largely Holds Firm on Most Proposed MA Payment & Policy Changes for 2017

Olga Walther

On April 4th, the Centers for Medicare & Medicaid Services (CMS) issued the Final Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies, and 2017 Call Letter. This is the final notice of changes in rates of payment and overall policy.

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Risk Adjustment Methodology: Reviewing Proposed and Current Model Improvements

Jessica Smith

On Thursday, March 24, 2016, the Centers for Medicare & Medicaid Services (CMS) released a white paper regarding the risk adjustment methodology. There has been a lot of criticism and discussion about the U.S. Department of Health & Human Services (HHS) risk adjustment program working appropriately. As indicated in the 2017 Notice of Benefit and Payment Parameters (NBPP), the white paper addresses the comments HHS has received regarding the risk adjustment methodology and serves as the basis for discussion for the Thursday, March 31, 2016, meeting. This document provides the story of the evolution of the HHS risk adjustment program, including a summary of historical information on how the HHS risk adjustment program was developed, changes made to the model thus far, and further discussions and considerations for enhancements in the future.

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MA Plans’ Must-Fix: the Member Experience

John Gorman

Now more than ever, it’s clear to us health plans and their stakeholders will thrive or die based on the member experience they provide. The member experience, especially with drug benefits, now represents more than half of a health plan’s Star Rating in Medicare Advantage (MA), with millions in bonuses and bid rebates hanging in the balance.  It also drives member retention and thereby acquisition expense (now averaging $1,200 per/member, or more than an average month’s premium), so how members are treated now determines both health plan revenues and costs. Read more

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Star Ratings: Moving the Needle

Melissa Smith

Now more than ever before, plans must streamline their Star Ratings programs to meet member expectations while encompassing all aspects of care delivery and breaking down internal silos.  This requires innovation amidst a backdrop of the ever-changing Centers for Medicare & Medicaid Services (CMS) landscape. CMS continues to treat Star Ratings as an ever-evolving, dynamic measurement program that is consistently expanding to include challenging new clinical areas, the impact of socio-economic status on Star Ratings, and operational evolution within the risk assessment processes.

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Compliance Highlights of the CY 2017 Draft Call Letter

Regan Pennypacker

According to the Centers for Medicare & Medicaid Services (CMS), the Call Letter activities follow four major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections. This means implementing creativity and doing more with less while enhancing the beneficiary experience.  To borrow from one of the earliest reality shows, this is the time when CMS stops being nice and starts getting real.  There are some of the key items of which your Compliance Department needs to be aware outlined below; however, it is not all inclusive and a thorough read of the document is required.

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