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BluePeak Bulletin

Since its inception, BluePeak has been committed to making the complicated world of government-sponsored healthcare programs easier to navigate. BluePeak employees pride themselves on delivering outstanding consulting services to our varied clients through our motto of Knowledge, Experience, and Trust. Read through our past articles from our quarterly newsletters and news alerts.

Get the latest news and regulatory updates through our quarterly newsletter, BluePeak Bulletin, and our BluePeak News Alerts. Subscribe today to get these BluePeak publications directly to your inbox.

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As we navigate the evolving landscape of healthcare regulations, BluePeak is dedicated to helping you manage these complexities and ensure compliance with all requirements. We are preparing a special edition to deliver the latest updates and insights directly to your inbox. Subscribe today to stay informed. For more information on how BluePeak can assist you, please email us at [email protected].

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Proposed Rule Re: Medicare Program

| CMS, PACE, Part C, Part D, Winter 2024 | No Comments
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…

Risk-Adjustment Data Validation Readiness: Key Strategies for Compliance

| CMS, HCC, OIG, Winter 2024 | No Comments
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…

Navigating the Future of Utilization Management Requirements

| Part D, Utilization Management, Winter 2024 | No Comments
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…

Medicare Prescription Payment Plan – Are you ready for it?

| IRA, MPPP, Winter 2024 | No Comments
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)…

Part D Audit Insights for CY2024: Key Takeaways

| Fall 2024, Part D | No Comments
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…

Should Off-cycle MOC Submission Be a Priority, RIGHT NOW?

| Fall 2024, MOC, NCQA | No Comments
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…

2024 Audit Trends: Special Needs Plans

| Audits, Fall 2024 | No Comments
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:…

2025 Plan Readiness: Are You Prepared?

| CMS, Fall 2024, IVR, M3P, Member Materials, Part C, Part D, SSBCI | No Comments
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…

Upcoming IRA Changes for 2025: Key Considerations for Year End Testing

| Audits, CMS, Summer 2024 | No Comments
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…

Understanding Dual-Eligible Special Needs Plans (D-SNPs): Your essential guide to types of D-SNPs and the impact of MMPs Sunsetting

| CMS, D-SNP, MMP, Summer 2024 | No Comments
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…

Consultant Corner: Updates to the Plan Communication User Guide That Require Attention

| Audits, Consultant Corner, Summer 2024 | No Comments
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…

2024 Utilization Management (UM)- Focused Audits: Lessons Learned

| Summer 2024, Utilization Management | No Comments
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…

Understanding Non-Quantitative Treatment Limitations (NQTLs) and How BluePeak Advisors Can Help

| MHPAEA, NQTLs, Spring 2025 | No Comments
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)…

Perfect Storm

| CMS | No Comments
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…

Consultant Corner: Do Your ODAG Universes Have Integrity?

| Consultant Corner, November 2022, ODAG | No Comments
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

| Consultant Corner, IRA | No Comments
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…

What are you doing to improve your Star Ratings?

| EHR, EMR, MPF, Part C, Part D, Star Ratings | No Comments
As you checked your plan data that will be displayed on Medicare Plan Finder (MPF) for accuracy during the recent second plan preview, were you happy with your Star Ratings?…

Part D Operational Implications of the Inflation Reduction Act (IRA) of 2022

| IRA, November 2022 | No Comments
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)

| Uncategorized | No Comments
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…

Formulary Strategy Planning for 2020-Indication Based Formulary Design Considerations

| CMS, EOC, FDA, Part D | No Comments
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: 2024 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans

| CMS, December 2023 | No Comments
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,…

Interoperability Rule-This Could Be a Big Deal!

| CHIP, CMS, HHS, MA, MA-PD, QHP | No Comments
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 With Potential Part D Rebate Access Impact

| CMS, Medicare, Part D | No Comments
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…

Effective Strategies in Claims Quality Auditing

| MA, November 2022 | No Comments
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…

Medicare Communications Marketing Guidelines: A Primary Topic at the CMS Fall Conference

| CMS, EOC, HPMS, Marketing, MCMG, Medicare | No Comments
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…

Inflation Reduction Act (IRA): 2024 Summary of Changes and Oversight Considerations

| CMS, December 2023, IRA | No Comments
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)…

ICYMI – BluePeak’s Articles Posted Recently On LinkedIn

| LinkedIn, Uncategorized | No Comments
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…

Proposed Rule Aimed at Drug Price Transparency Could Lead to Inadvertent Member Confusion

| CMS, Medicare, Part C, Part D, PBM | No Comments
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…
prescription pills

Opioid Epidemic Spotlights Health Plans’ FWA Investigations

| CDAG, CMS, CPE, FDRs, PBM | No Comments
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…

Risks in Misclassifying First Tier, Downstream, and Related Entities (FDRs)

| MA, MCMG, Medicare, November 2022 | No Comments
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…

2024 National Average Monthly Bid Amount Impact

| PBM, September 2023 | No Comments
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…

NEWS ALERT – 12/27/2022

| News Alert | No Comments
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…

Compliance and Operational Considerations for Medicare Advantage Plans with Increasing Enrollment of End Stage Renal Disease (ESRD) Beneficiaries

| Enrollment, ESRD, MA | No Comments
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…
finger on a map

CMS Increases Scrutiny of FDRs, Finds Common Conditions During 2017 Program Audits

| CDAG, CMS, CPE, FDRs, ODAG, TPMA | No Comments
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…

Prepared to Implement the CMS Preclusion List Requirement?

| CMS, Part D | No Comments
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…

Consultant Corner: Strategic Planning: Using the Notice of Intent to Apply timing to trigger potential opportunities with your leadership and Board of Directors

| AEP, September 2023 | No Comments
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…

CMS Continues Along Its Roadmap to Address the Opioid Epidemic

| Call Letter, CMS, DMP, Medicaid, Medicare, MME, Part C | No Comments
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…

Highlights of the Final Rule

| CMS, Medicare, PACE | No Comments
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…

Highlights of CMS-Proposed Changes in Draft 2019 Call Letter

| CMS, CPE, Part C, Part D | No Comments
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…

CMS Shifts Sales and Marketing Monitoring and Oversight to Plans

| CMS, CPE, CTM, Part D | No Comments
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…

CMS to Provide Training on the New Medicare Communications and Marketing Guidelines at Upcoming Fall Conference

| ANOC/EOC, CMS, EOC, Marketing, MCMG, Medicare, Uncategorized | No Comments
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…

BluePeak Service Spotlight: Universe Monitoring Service

| Audits, CMS | No Comments
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…
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