Update on CMS Spotlight on Provider Directories and Network Adequacy

As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage plans’ provider network with emphasis on both online provider directories and network adequacy.

Repatha’s Path to Patients: Via Value?

Amgen’s Repatha is “well tolerated” and a “welcome alternative” for some, admits the U.K.’s National Institute for Health and Care Excellence (NICE).  Yet, the British cost watchdog this week told Britain’s National Health Service (NHS) not to pay for the new super cholesterol reducer.

2016 Readiness Review Smaller Size, Bigger Punch.

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year.

Influencing Your 2017 Star Ratings: It’s Not Too Late

We are officially in the throes of the unavoidable, and much dreaded, 4th quarter Star Ratings “fire drill.” While health plan leaders (again) promise their staff and providers this year will be the last a Star Ratings fire drill will be needed, the day-by-day countdown to year-end has officially begun. As even more evidence year-end is almost upon us, Star Ratings leaders throughout the nation are putting the finishing touches on their 2016 Star Ratings work plans and counting down the days until Star Ratings measure rates and denominators are reset and the annual cycle begins again.

Proposed Changes to the CMS-HCC Risk Adjustment Model

Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.

Mergers Pave Way for Good Opportunity to Enter Medicare Advantage Market

While the largest insurance companies await their fate at the hands of federal regulators, other plans and investors should pay close attention to the opportunity to acquire divested plans from the two deals.

Walgreens: Purveyor or Provider?

An intriguing question emerged from last week’s merger announcement from Walgreens Boots Alliance and Rite Aid.  Led by CEO Stefano Pessina and his largely European executive team, will Walgreens be purveyor focused on retail sales or provider engaged with a transforming U.S. health care system?

A New Report by Kaiser Family Foundation Found Part D Premiums Will Rise an Average of 13% in 2016

We blogged earlier this month about Medicare Advantage (MA) premiums showing slight decreases to no decreases across the board for 2016 based on the Centers for Medicare & Medicaid Services (CMS) estimates.  But what does the landscape look like for Part D?

2015-2016 CMS Program Audit Protocols Update

It’s Christmas in October (and Hanukkah, too) if you’ve been waiting for the revised 2015-2016 Program Audit process and protocols. Let’s get right down to it!

You’ll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?

10 Millon People Expected to Have Marketplace Coverage in 2016

The 2016 Health Insurance Marketplace open enrollment is right around the corner, opening on November 1, 2015. With premium rate increases well above 10% for 2016, it’s no surprise the 2016 enrollment projections for the Marketplace are estimated to increase by less than a million from the total current 2015 enrollment, bringing the total individuals enrolled by the end of 2016 to 10 million.