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Proposed Rule Re: Medicare Program; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive…
Did you know that there are publicly accessible resources identifying highly scrutinized Hierarchical Condition Category (HCC) codes that may be problematic for your plan? Did you know there’s an annual…
As 2024 comes to a close, the Centers for Medicare & Medicaid Services (CMS) Utilization Management (UM) requirements remain as high priority, and 2025 brings with it new considerations for…
The Inflation Reduction Act (IRA) introduced several changes to the Medicare landscape. One of the biggest changes that impacts members and plans alike is the Medicare Prescription Payment Plan (MPPP)…
As the CY2024 audit season wraps up, the Centers for Medicare and Medicaid Services (CMS) has been publishing both draft and final reports for those selected for program audits. We…
December 1, 2024, signals closure of the 2024 the National Committee for Quality Assurance (NCQA) Model of Care (MOC) Off-Cycle submission window, but there is still time to update if you…
The 2024 the Centers for Medicare and Medicaid Services (CMS) audit season brought a diverse array of trends for Special Needs Plans (SNPs) yet one consistent and notable emphasis prevailed:…
As you put the final touches on Plan Year 2025 implementation, it is crucial for Medicare plans to stay ahead of the game and be prepared for the changes that…
Since its passage, the Inflation Reduction Act (IRA) of 2022 has ushered in changes to the Medicare Part D benefit each contract year (CY) and 2025 is no different. Now…
In May of 2022, CMS finalized the rule that will sunset Medicare-Medicaid Plans (MMPs). This rule proposes that required states transition their MMP enrollees to integrated Medicare Advantage dual eligible…
Meryl Chick is a Consultant with BluePeak Advisors, a division of Gallagher Benefit Services, Inc. Are you monitoring the Batch Completion Status Summary (BCSS)? If the answer is no and…
The annual Centers for Medicare and Medicaid Services (CMS) Audit Season has been in full swing since the beginning of the year with a focus on Utilization Management. CMS is…
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In the evolving landscape of healthcare coverage, ensuring parity between mental health/substance use disorder (MH/SUD) and medical/surgical (Med/Surg) services is crucial. The Mental Health Parity and Addiction Equity Act (MHPAEA)…
The last quarter of 2020 will likely be the most significant and the most challenging testing season plans have experienced. Unfortunately, there may be a perfect storm brewing that is…
Jaymie Billbrough, RN, is a BluePeak senior health plan services consultant. Prior to 2022, The Centers for Medicare and Medicaid Services (CMS) provided Sponsoring Organizations (SO) with a 20% “margin…
Consultant Corner: Inflation Reduction Act Implementation Best Practices and Planning for the Future
Jeff Baker, is a BluePeak Senior Health Plan Services Consultant. On August 16th, the Inflation Reduction Act of 2022 (IRA) was signed into law. The text of the bill is…
On August 16th, the Inflation Reduction Act of 2022 (IRA) was signed into law. The text of the bill is located here and includes changes that, among other things, would…
CMS announced they will be performing a 2021 transition of care audit using the Transition Requirements Analysis (TR) that was piloted back in 2019. Although the 2019 TRA did not…
The 2019 plan year has not commenced, yet plans are already developing formulary strategies for 2020. Indication-based formulary designs will add a new twist for plan sponsors to consider as…
The Centers for Medicare & Medicaid Services (CMS) released the CY2024 Medicare Parts C and D Readiness Checklist on October 13, 2023. Although this is a busy time of year,…
The Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) have published several new proposed and final rules on various topics, ranging from prescription…
Two rules have the potential to impact how Part D price concessions and pharmaceutical rebates are managed and how these changes, when implemented, will subsequently impact a Part D sponsor’s…
In light of ever rising benefit costs, employers and Medicare Advantage (MA) plans should consider regular claims quality auditing as part of an overall benefits and cost-containment strategy. Claims audits…
BluePeak Highlights the Changes to MCMG Requirements The Centers for Medicare & Medicaid Services (CMS) 2018 Medicare & Prescription Drug Plan Fall Conference and Webcast kicked off on Thursday, September…
The Centers for Medicare & Medicaid Services (CMS) has released significant guidance to support the Inflation Reduction Act (IRA) provisions that impacts Medicare enrollees, health plans, pharmacy benefit managers (PBM)…
Looking for more articles and insight from us? Head over to our LinkedIn page to discover more. Here are some of the recent articles posted there: Audit Tip #3-- It’s…
On October 18, 2018, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule which, if finalized, will amend the Medicaid and Medicare Parts A, B, C, and…
On October 26, President Donald Trump declared the nation’s opioid epidemic a public health emergency. The opioid epidemic is the deadliest drug epidemic in American history. Deaths from opioid overdose…
There are a number of criteria outlining the oversight of First Tier, Downstream and Related Entities for Medicare Advantage Organizations. Chapters 21 / 9 and 11 of the Medicare Managed…
On July 31, 2023, Centers for Medicare & Medicaid Services (CMS) released the National Average Monthly Bid Amount (NAMBA) for contract year (CY) 2024. For 2024, the national average bid…
BluePeak’s releases index on the entire proposed rule contents December 27, 2022, CMS published proposed rule CMS FRDOC 001 regarding Medicare Program; Contract Year 2024 Policy and Technical Changes to…
For the first time, starting in 2021, the 21st Century Cures Act allows beneficiaries diagnosed with ESRD to enroll in MA plans. These beneficiaries have previously been required to stay on Medicare Fee-for-Service…
During the 2017 audit season, BluePeak observed increased CMS increased scrutiny on plans and their First Tier, Downstream and Related Entities (FDRs), as well as repeated Common Conditions. With limited changes from…
Along with the new year also comes a new CMS requirement known as the Preclusion List. This requirement was adopted in the April 2018 final rule as an alternative to…
Wendy Edwards, MPA, CHC, CHPC, is Director of Internal Operations at BluePeak Advisors, a division of Gallagher Benefit Services, Inc. Preparing for 2025 may not be at the top -of-mind…
Effective January 1, 2019, the Centers for Medicaid & Medicare Services (CMS) required plan sponsors to implement new opioid policies as part of the agency’s continued efforts to address the…
Contract Year 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the…
The Centers for Medicare and Medicaid Services (CMS) proposes changes to Star Ratings, validation audits, annual Compliance Program Effectiveness (CPE) audits, Part D opioid overutilization policy, and more in the…
Executive Summary Since 2013, the Centers for Medicare & Medicaid Services (CMS) has steadily shifted direct monitoring and oversight of sales and marketing from the agency to plans. The removal…
As plans work through the biggest changes to the Medicare Marketing Guidelines since its inception – including changing the name of the guidance to the Medicare Communications and Marketing Guidelines…
On February 8, 2019, CMS released “CMS Program Audits Frequently Asked Questions (FAQs). One of the questions addressed was: “Will sponsoring organizations always have the opportunity to submit universes up…