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MedHOK Strategic Insights Blog

Enrollment Changes Hitting Medicare Advantage

With welcome season in October upon us, Medicare Advantage (MA) health plans are preparing for two major enrollment-related changes. One offers great opportunities for plans to increase enrollment while another may bring limitations.

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Plans Win Big on Risk Adjustment Lawsuit – But Don’t Get Too Excited


Medicare Advantage (MA) plans won a huge victory on September 7 when a federal judge set aside a 2014 healthcare rule that set much stricter standards on plans in terms of reporting on over-payments in the program. The lawsuit arose when the Centers for Medicare and Medicaid Services (CMS) established a rule that required plans to return over-payments within 60 days of identifying them. If they did not, they would be presumed in violation of the False Claims Act, which carries the threat...

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Medicare Advantage Medicaid Status Report Best Way to Track True Medicaid Status

In response to our blog last week on Medicaid dual status identification, we had a number of people inquire as to the best way to determine correct dual eligible statuses for their Medicare Advantage members.

We note that determining correct dual status is more and more important these days because:

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Effort to Rein In Drug Costs Means Major New Initiatives in Medicare Advantage and Part D

While drug costs have been relatively moderate of late, the Centers for Medicare and Medicaid Services (CMS) is ever mindful of the drug world’s increasing share of overall drug costs, especially as Americans age. As such, CMS and its parent, the Department of Health and Human Services (HHS), have announced two key initiatives to reduce overall drug costs and trends in Medicare Advantage and Part D.

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ACO Changes Draw Unfair Fire

The Trump administration announced recently that it plans on curtailing one payment model in the Accountable Care Organization (ACO) pilot – the Medicare Shared Savings Program (MSSP). Since the broader ACO program (after the Pioneer pilot) started, ACOs have had the ability to gain bonuses if they improve costs and quality or gain greater bonus if they also take on so-called downside risk. Over 80 percent are governed under the softer arrangement.

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CARA Act Implementation Gives Medicare Plans Additional Opportunities to Impact Drug Abuse

In early March, the Centers for Medicare and Medicaid Services (CMS) announced its final rule related to policy changes for Medicare Advantage and Part D plans in 2019. One key point in the rule was implementation of aspects of the Comprehensive Addiction and Recovery Act of 2016 (CARA).

The final rule’s CARA provision seeks to provide an additional tool to help Medicare Advantage (MA) and standalone Part D plans (PDP) to combat the growing opioid epidemic in America.

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You’ve Got Mail: CMS Boldly Goes Digital

Just out -- the Centers for Medicare and Medicaid Services (CMS) has endorsed a digital strategy for Medicare Advantage and Part D plans. This will be a game changer and mean huge savings for health plans over time.

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A Few Changes Between the Final Call Letter and the January Proposal

The release of the final Centers for Medicare and Medicaid Services (CMS) 2019 Call Letter for Medicare Advantage and Part D revealed a few significant changes from the draft of the February Call Letter previously released. In this blog, we focus only on the significant changes identified between the previous draft and the proposed final. Read the original blog on the draft letter here

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HHS Secretary Endorses Value-Based Healthcare Transformation

When Donald Trump took office as President in January 2017, many (including this blogger nonetheless) predicted the end of (at least the intense threat to) a quiet transformation to value-based care. There was the following:

  • The intense dislike for government healthcare program expansions in general.
  • The attack on anything Obamacare.
  • The push by the GOP House to “reform” Medicaid by stripping it of the entitlement as well as applying a growth factor to the remake that would have spelled...

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Provider Network Review: The Next Great Compliance Bogey

Another compliance headache hits plans! The Centers for Medicare and Medicaid Services (CMS) completed its second round of Medicare Advantage (MA) online provider directory reviews between September 2016 and August 2017. The review looked at the accuracy of 108 providers and their locations selected in 64 MA plans’ directories (about 1/3 of MA plans, 6,841 providers, and 14,869 locations). 

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