Medicare Advantage and Part D Proposed Rule for Contract Year 2015 Prepared for Healthcare Leadership Council. January 2014 Avalere Health LLC 1

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Medicare Advantage and Part D Proposed Rule for Contract Year 2015 Prepared for Healthcare Leadership Council. January 2014 Avalere Health LLC 1"

Transcription

1 Medicare Advantage and Part D Proposed Rule for Contract Year 2015 Prepared for Healthcare Leadership Council January 2014 Avalere Health LLC 1

2 Overview On January 6, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule seeking to implement key policy changes to the Medicare Advantage (MA) and Medicare Part D programs for contract year (CY) The rule proposes several significant policy changes to program requirements that will affect all industry stakeholders: o Health plans and other Part D plan sponsors o Part D drug manufacturers o Pharmacies o Providers who prescribe Part D drugs Additionally, proposed changes to Part D data access have impacts on all stakeholders. Comments on the proposed rule are due March 7. 2

3 Increased CMS Role in Plan Oversight and Market Participation 3

4 CMS Proposes Tighter Requirements for Sponsor Participation Meaningful Differences Policy o For CY 2016, would limit sponsors to one basic and one enhanced plan per region. o May require enhanced options to have higher premiums than the sponsor s basic offering. New Contracts Following Contract Termination o Would restrict Medicare Advantage organizations (MAOs) from offering any new contracts or expanding the service areas of any other contracts for two years after termination. New Sponsor Applicant Requirements o Would require any entity seeking to contract as a Part D plan sponsor to have one year of experience serving as a Part D plan sponsor or performing key Part D functions for another sponsor either by the sponsor itself or one of its contracted first-tier, downstream, and related entities (FDRs). Quality Requirements o Would require in plan contracts that plans achieve scores of 3 or higher on CMS performance standards for patient outcomes, intermediate outcomes, process, patient experience, and patient access to care. Independent Audits o Would require MAOs and Part D sponsors to hire independent auditors in order to increase the frequency of audits to once every three years. 4

5 Key Dates for Medicare Part D Plans in the 2014 Plan Year May Prove Challenging after Delayed Rule Draft CY 2015 combined 45-day Advance Notice and Call Letter Released* Final CY 2015 Combined Announcement of MA and Part D Payment Policies and Call Letter released* CY 2015 Plan Bids Due To CMS CY 2015 Marketing Materials Due CY 2015 Plan Marketing Begins CY 2015 Plan Finder Tool Launches Annual Election Period for CY 2015 Ends CY 2015 Plan Applications Due to CMS CY 2015 Plan Formularies Due To CMS Summer Formulary Update Window** CMS awards CY 2015 contracts to plans Annual Election Period for CY 2015 Begins CY 2015 Plan Year Begins Feb May 2014 July 2014 Sept Dec. 7, 2014 Feb Apr June 2014 Oct Oct. 15, 2014 Jan. 1, 2015 Expected Confirmed CY - Calendar Year CMS - Centers for Medicare and Medicaid Services MA - Medicare Advantage Assumptions: All dates based on 2013 releases for the 2014 Plan Year; timeline assumes no legislative changes. *Combined Call Letter includes formulary, transition, enrollment and marketing guidance. **Additional limitations to summer formulary update window: 1) only drugs new to summer formulary reference file (FRF) can be added to approved formularies 2) negative changes will be permitted to brand drugs only if equivalent generic is added to summer FRF 5

6 Changes to Part D Drug Coverage Policy and Medication Therapy Management 6

7 Moving Forward, the Protected Class Policy Would Apply Only to Classes Meeting Two New Criteria CMS proposes two criteria to identify drug classes of clinical concern: 1. A typical beneficiary 1 who is initiating therapy must administer a drug within the category or class in less than 7 days or failure to do so will lead to hospitalization, incapacity, disability or death. 2. Other CMS formulary requirements are not sufficient to ensure the access to an appropriate range of therapies, either due to the diversity of disease or condition manifestations or the associated specificity or variability of drug therapies necessary to treat such manifestations. After applying the new two-prong test to the universe of Part D drugs, CMS: o Proposed to eliminate the requirements for plans to cover all products in the antidepressant and immunosuppressant classes for CY 2015 o Is considering removing the requirement for the antipsychotic class for CY 2016 o Would maintain the requirement to cover all drugs within the antineoplastic, anticonvulsant, and antiretroviral drug classes 1. CMS proposes to define a typical beneficiary as an individual who has the average clinical presentation of a given disease or condition. Source: 42 CFR Parts 409, 417, 422, et al. Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs; Proposed Rule. 7

8 Expansion of MTM Eligibility Criteria MORE THAN HALF OF PART D BENEFICIARIES WOULD BE ELIGIBLE FOR MTM SERVICES Number of Chronic Conditions Current Policy Plan sets threshold of 2 or 3 May target specific conditions but must include 5 of 9 core chronic diseases: Hypertension Congestive heart failure Diabetes Dyslipidemia Respiratory disease Bone disease arthritis Mental health Alzheimer s disease End stage renal disease Proposed 2 or more, including a core chronic condition Cardiovascular disease Diabetes Dyslipidemia Respiratory disease Bone disease arthritis Mental health Alzheimer s disease End stage renal disease Number of Drugs Plan sets threshold between 2 and 8 At least 2 Minimum Annual Drug Costs Estimated Eligible Beneficiaries $3,144 $ million 18 million 8

9 Enhanced Scrutiny of Pharmacy Contracting and Operations 9

10 Rule Includes Several Provisions Regulating Part D Pharmacies Interpreting Non-Interference Provision o CMS may not be a party to, or arbitrate at a later date, negotiations between manufacturers and pharmacies, or between drug manufacturers and Part D sponsors, except as necessary to enforce applicable CMS requirements. o This prohibition does not apply to negotiations between Part D sponsors and pharmacies. Any Willing Pharmacy Standard for Preferred Cost-Sharing Pharmacies o Would require sponsors to include any pharmacy willing to meet the terms of the preferred pricing arrangement in their preferred networks. o Would require that negotiated prices for preferred pharmacy networks not exceed prices at non-preferred pharmacies. Pharmacy Price Concessions to Factor into Negotiated Price o Would include in the definition of negotiated price all price concessions sponsors receive from network pharmacies, including administrative fees. Mail-Order Timeframes o Would require mail order pharmacies to fill 99 percent of mail order prescriptions within three business days (from receipt of prescription to order shipment), or five business days for prescriptions that require additional intervention (e.g., illegible orders, third party rejection, and coordinating with multiple providers as part of drug utilization management). 10

11 Provider Requirements for Participating in Part D 11

12 New Policies Will Result in New CMS and Plan Sponsor Scrutiny of Prescribers of Part D Drugs Prescriber Enrollment Requirements o ACA requires that prescriptions covered by Part D must be prescribed by a physician or an eligible professional. o Rule would require Part D sponsors to deny claims for Part D drugs that do not include a valid and active physician or eligible professional national provider identifier (NPI). o Part D sponsors must also deny claims for Part D drugs if the physician or eligible professional is not either enrolled in Medicare in an approved status or has a valid opt-out affidavit on file with a Part A/B Medicare Administrative Contractor (MAC). Improper Prescribing Practices o Would provide CMS authority to deny or revoke a provider s Medicare enrollment in any of the following cases: The provider s Drug Enforcement Agency (DEA) certificate is suspended or revoked. His/her ability to prescribe has been suspended. He/she has a pattern of prescribing Part D drugs in an abusive manner. He/she fails to meet Medicare requirements. 12

13 Expanded Access to Part D Data 13

14 Rule Promotes Expanded Access to Utilization Data for the Part D Program Proposed Data Access Rules o Would allow CMS to release unencrypted prescriber, pharmacy, and plan identifier information included in PDE records to all categories of requestors Categories include other HHS entities, Congressional oversight agencies, non-hhs executive branch agencies, states, and external entities o Would maintain current policy to not release beneficiary identifiable data, drug cost data of Part D sponsors, and other data perceived as commercially sensitive for Part D sponsors (e.g., rebate and price concessions). o Requests comment on current restrictions on the release of PDE data for commercial purposes, unless a commercial firm funds a researcher who is free to publish the results regardless of findings 14

15 Conclusion 15

16 The Rule Proposes Significant Changes Affecting All Aspects of the Healthcare Industry Health Plans Limitations on number of plans Restrictions on new sponsors and those with terminated contracts CMS oversight of pharmacy contracting and concessions Manufacturers Narrowing of protected classes Expansion of Medication Therapy Management eligibility Downstream impacts of plan/pharmacy policies Pharmacies Any willing pharmacy requirement for preferred cost sharing CMS oversight of contracts with Part D sponsors Inclusion of all concessions in negotiated prices Providers Sponsor requirement to ensure Medicare enrollment for Part D prescribers Increased CMS authority to revoke Medicare enrollment for improper prescribing practices 16

17 For More Information Contact Us: Matt Eyles Executive Vice President Lisa Murphy Director 17

MEDICARE PART D THE BASICS

MEDICARE PART D THE BASICS THE BASICS Participation is voluntary. The income level and assets of beneficiaries determine the level of prescription assistance they will receive. Beneficiaries with incomes over 150% of the Federal

More information

Frequently Asked Questions: Medicare Supplement & Medicare Advantage

Frequently Asked Questions: Medicare Supplement & Medicare Advantage Frequently Asked Questions: Medicare Supplement & Medicare Advantage Who is eligible for CBIA s Medicare program? A CBIA Health Connections participant is eligible for either plan if they are qualified

More information

O n Oct. 12, the Centers for Medicare & Medicaid

O n Oct. 12, the Centers for Medicare & Medicaid BNA s Medicare Report Reproduced with permission from BNA s Medicare Report, BNA s Medicare Report, 11/30/2012. Copyright 2012 by The Bureau of National Affairs, Inc. (800-372-1033) http://www.bna.com

More information

Prescription Drug Program

Prescription Drug Program Prescription Drug Program August 2011 This publication supersedes all previous pharmacy provider handbooks. Published by the Montana Department of Public Health & Human Services, July 2001. Updated October

More information

E-ALERT Health Care HEALTH CARE REFORM: MEDICARE PART D DONUT HOLE AND PROTECTED CLASSES. Executive Summary. Closing the Medicare Part D Donut Hole

E-ALERT Health Care HEALTH CARE REFORM: MEDICARE PART D DONUT HOLE AND PROTECTED CLASSES. Executive Summary. Closing the Medicare Part D Donut Hole E-ALERT Health Care April 2010 HEALTH CARE REFORM: MEDICARE PART D DONUT HOLE AND PROTECTED CLASSES On March 23, 2010, President Obama signed into law Pub. L. No. 111-148, the Patient Protection and Affordable

More information

PRESCRIPTION MEDICINES: COSTS IN CONTEXT

PRESCRIPTION MEDICINES: COSTS IN CONTEXT PRESCRIPTION MEDICINES: COSTS IN CONTEXT 2015 Since 2000, biopharmaceutical companies have brought MORE THAN 500 NEW TREATMENTS AND CURES to U.S. patients In the last 100 years, medicines have helped raise

More information

2016 Group Retiree Medicare Plans

2016 Group Retiree Medicare Plans 2016 Group Retiree Medicare Plans Blue Cross MedicareRx (PDP) Medicare Part D Prescription Drug Plans Anthem Blue Cross is a stand-alone prescription drug plan with a Medicare contract. Enrollment in Anthem

More information

Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244

Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 March 7, 2014 Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD 21244 Re: Dear Sir or Madam: On behalf of the American Heart Association (AHA), including the American Stroke

More information

PROPOSED US MEDICARE RULING FOR USE OF DRUG CLAIMS INFORMATION FOR OUTCOMES RESEARCH, PROGRAM ANALYSIS & REPORTING AND PUBLIC FUNCTIONS

PROPOSED US MEDICARE RULING FOR USE OF DRUG CLAIMS INFORMATION FOR OUTCOMES RESEARCH, PROGRAM ANALYSIS & REPORTING AND PUBLIC FUNCTIONS PROPOSED US MEDICARE RULING FOR USE OF DRUG CLAIMS INFORMATION FOR OUTCOMES RESEARCH, PROGRAM ANALYSIS & REPORTING AND PUBLIC FUNCTIONS The information listed below is Sections B of the proposed ruling

More information

The Medicare Drug Benefit (Part D)

The Medicare Drug Benefit (Part D) THE BASICS The Medicare Drug Benefit (Part D) The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established a voluntary outpatient prescription drug benefit for Medicare

More information

Medicare Coverage Gap Discount Program (Filling the Donut Hole)

Medicare Coverage Gap Discount Program (Filling the Donut Hole) Medicare Coverage Gap Discount Program (Filling the Donut Hole) Summary: Requires drug manufacturers to provide a 50 percent discount to Part D beneficiaries for brand name drugs and biologics purchased

More information

Notice of Imposition of Civil Money Penalty for Medicare Advantage-Prescription Drug Contract Number: H5985

Notice of Imposition of Civil Money Penalty for Medicare Advantage-Prescription Drug Contract Number: H5985 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PARTS C AND D OVERSIGHT AND ENFORCEMENT GROUP November 6,

More information

Statement Of. The National Association of Chain Drug Stores. For. U.S. Senate Special Committee on Aging. Hearing on:

Statement Of. The National Association of Chain Drug Stores. For. U.S. Senate Special Committee on Aging. Hearing on: Statement Of The National Association of Chain Drug Stores For U.S. Senate Special Committee on Aging Hearing on: 10 Years Later: A Look at the Medicare Prescription Drug Program 2:30 p.m. 366 Dirksen

More information

Update on Medicare Part D: 2009 and Beyond

Update on Medicare Part D: 2009 and Beyond Update on Medicare Part D: 2009 and Beyond 2009 NACDS Pharmacy & Technology Conference Christine C. Rinn Donald L. Bell, II Outline of Presentation» Introduction/Background on Part D» Trends in Part D»

More information

Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers

Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers Exceptions and Appeals for Drug Therapies: A Guide for Healthcare Providers Table of Contents Introduction... 5 Prior Authorization... 7 Overview... 7 Step Therapy... 7 Quantity Limits... 7 The Prior Authorization

More information

Making Sense of Medicare

Making Sense of Medicare Making Sense of Medicare Stephanie M. Turnbull Manager, Member Benefits 1 Highlights Medicare Eligibility Types of Medicare Coverage Medicare Part A Medicare Part B Medicare Part C Medicare Part D Medicare

More information

Basic Reimbursement - Medicare Part D Specifics

Basic Reimbursement - Medicare Part D Specifics Basic Reimbursement - Medicare Part D Specifics 60889-R8-V1 (c) 2012 Amgen Inc. All rights reserved 2 This information is provided for your background education and is not intended to serve as guidance

More information

Medicare doesn t have to be complicated. This guide is provided to help you better understand Medicare and how a Medicare Advantage plan may offer

Medicare doesn t have to be complicated. This guide is provided to help you better understand Medicare and how a Medicare Advantage plan may offer clarity YOUR GUIDE TO MEDicare AdvantaGE Medicare doesn t have to be complicated. This guide is provided to help you better understand Medicare and how a Medicare Advantage plan may offer the coverage

More information

Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention

Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention Touchstone Health Training Guide: Fraud, Waste and Abuse Prevention About the Training Guide Touchstone is providing this Fraud, Waste and Abuse Prevention Training Guide as a resource for meeting Centers

More information

Medicare Part D Prescription Drug Coverage

Medicare Part D Prescription Drug Coverage Medicare Part D Prescription Drug Coverage Part 3 Version 7.1 August 1, 2013 Terms and Conditions This training program is protected under United States Copyright laws, 17 U.S.C.A. 101, et seq. and international

More information

Arthritis Foundation Position Statement on Biosimilar Substitution

Arthritis Foundation Position Statement on Biosimilar Substitution Arthritis Foundation Position Statement on Biosimilar Substitution The Affordable Care Act creates a regulatory pathway for the approval of a new generation of biologic medications called biosimilars.

More information

Medicare Part D Prescription Drug Coverage

Medicare Part D Prescription Drug Coverage Medicare Part D Prescription Drug Coverage Part 3 Version 9.0 June 22, 2015 Terms and Conditions This training program is protected under United States Copyright laws, 17 U.S.C.A. 101, et seq. and international

More information

Summary of Benefits. (PDP), Blue MedicareRx Plus SM. (PDP) and Blue MedicareRx Premier SM

Summary of Benefits. (PDP), Blue MedicareRx Plus SM. (PDP) and Blue MedicareRx Premier SM Summary of Benefits for SM, Plus SM and Premier SM Available in Maine and New Hampshire A -approved Part D sponsor. Anthem Insurance Companies, Inc. (AICI) is the legal entity who has contracted with the

More information

Minimum Performance and Service Criteria for Medicare Part D

Minimum Performance and Service Criteria for Medicare Part D Minimum Performance and Service Criteria for Medicare Part D 1. Terms and Conditions. In addition to the other terms and conditions of the Pharmacy Participation Agreement ( Agreement ), the following

More information

CMS NEWS. October, 25, 2012 (202) 690-6145

CMS NEWS. October, 25, 2012 (202) 690-6145 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 CMS NEWS FOR IMMEDIATE RELEASE Contact: CMS Media Relations October,

More information

Star Quality Ratings: Legal, Operational and Strategic Questions for MA Organizations and Part D Plan Sponsors

Star Quality Ratings: Legal, Operational and Strategic Questions for MA Organizations and Part D Plan Sponsors Where Do We Go From Here? Star Quality Ratings: Legal, Operational and Strategic Questions for MA Organizations and Part D Plan Sponsors American Health Lawyers Association 2011 Payors, Plans and Managed

More information

CMS-CMMI Releases Enhanced Medication Therapy Management (MTM) Model Test Beginning in January 2017

CMS-CMMI Releases Enhanced Medication Therapy Management (MTM) Model Test Beginning in January 2017 October 5, 2015 www.amcp.org CMS-CMMI Releases Enhanced Medication Therapy Management (MTM) Model Test Beginning in January 2017 Pursuant to a memorandum issued on September 28, 2015, the Centers for Medicare

More information

2014 Prescription Drug Schedule Humana Medicare Employer Plan

2014 Prescription Drug Schedule Humana Medicare Employer Plan 2014 Prescription Drug Schedule Humana Medicare Employer Plan Option 98 City of Newport News Y0040_GHHHEF3HH14 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS Thank you for your interest in the Humana

More information

CALIFORNIA. By the numbers: Medicare Part D. Medicare Part D is working well for beneficiaries and taxpayers And it s getting better.

CALIFORNIA. By the numbers: Medicare Part D. Medicare Part D is working well for beneficiaries and taxpayers And it s getting better. CALIFORNIA By the numbers: Medicare Part D 3,687,561 Medicare Part D beneficiaries in California 1,638,344 278 Beneficiaries enrolled in Medicare Advantage prescription drug plans in 2015 1 Number of Medicare

More information

March 7, 2014. Dear Administrator Tavenner:

March 7, 2014. Dear Administrator Tavenner: March 7, 2014 Marilyn Tavenner Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Hubert H. Humphrey Building, Room 445-G 200 Independence Avenue, SW Washington,

More information

Data Analysis Brief. Price Negotiation for the Medicare Drug Program: It is Time to Lower Costs for Seniors

Data Analysis Brief. Price Negotiation for the Medicare Drug Program: It is Time to Lower Costs for Seniors Data Analysis Brief Price Negotiation for the Medicare Drug Program: It is Time to Lower Costs for Seniors The law that established Medicare Part D explicitly prohibits the prescription drug program from

More information

Medicare Compliance and Fraud, Waste, and Abuse Training

Medicare Compliance and Fraud, Waste, and Abuse Training Medicare Compliance and Fraud, Waste, and Abuse Training Objectives Recognize laws and concepts affecting compliance and fraud, waste, and abuse (FWA) Increase awareness of FWA Use identification techniques

More information

GENERIC DRUG UTILIZATION IN

GENERIC DRUG UTILIZATION IN Department of Health and Human Services OFFICE OF INSPECTOR GENERAL GENERIC DRUG UTILIZATION IN THE MEDICARE PART D PROGRAM Daniel R. Levinson Inspector General November 2007 OEI-05-07-00130 Office of

More information

By Christina Crain, MSW. Director of Programs

By Christina Crain, MSW. Director of Programs By Christina Crain, MSW Director of Programs What we ll cover Medicare Eligibility Medicaid Eligibility Medicare Parts A, B, C and D New Improvements to Medicare under ACA The Medicare Savings Programs

More information

Submitted electronically to http://www.regulations.gov

Submitted electronically to http://www.regulations.gov Submitted electronically to http://www.regulations.gov Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-3288-NC P.O. Box 8016 Baltimore, MD 21244-8016 RE:

More information

MAPD-SNP Contract Numbers: H5852; H3132

MAPD-SNP Contract Numbers: H5852; H3132 Policy and Procedure No: 93608 PHP Transition Process Title: Part D Transition Process Department: Pharmacy Services, Managed Care Effective Date: 1/1/2006 Supercedes Policy No: PH 8.0 Reviewed/Revised

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 First Health Part D Value Plus (PDP) Plan offered by First Health Life & Health Insurance Company Annual Notice of Changes for 2015 You are currently enrolled as a member of First Health Part D Essentials

More information

Fraud, Waste and Abuse Network Pharmacy Training 2011

Fraud, Waste and Abuse Network Pharmacy Training 2011 Fraud, Waste and Abuse Network Pharmacy Training 2011 Table of Contents Centers for Medicare & Medicaid Services (CMS) Role Important Federal Statutes for Medicare Participants Fraud, Waste and Abuse Defined

More information

Medicare Compliance Training and Fraud, Waste, and Abuse Training. Producer Training 2012-2013

Medicare Compliance Training and Fraud, Waste, and Abuse Training. Producer Training 2012-2013 Medicare Compliance Training and Fraud, Waste, and Abuse Training Producer Training 2012-2013 CMS, PHP and You Providence Health Plans (PHP) contracts with the Centers for Medicare & Medicaid Services

More information

Michigan Medicare Medicaid Assistance Program (MMAP)

Michigan Medicare Medicaid Assistance Program (MMAP) Michigan Medicare Medicaid Assistance Program (MMAP) Parts A& B Medicare Part A (hospital insurance) Solvent until 2030 4 years beyond last year s projection Suggests cost-savings measures are working

More information

Improving Medicare Part D. Shinobu Suzuki and Rachel Schmidt March 3, 2016

Improving Medicare Part D. Shinobu Suzuki and Rachel Schmidt March 3, 2016 Improving Medicare Part D Shinobu Suzuki and Rachel Schmidt March 3, 2016 Future challenges require changes to Part D s original structure Designed to encourage broad participation by plans and beneficiaries

More information

Chapter 20 Public Employees' Benefit and Insurance Program Act. Part 1 General Provisions

Chapter 20 Public Employees' Benefit and Insurance Program Act. Part 1 General Provisions Chapter 20 Public Employees' Benefit and Insurance Program Act Part 1 General Provisions 49-20-101 Title. This chapter is known as the "Public Employees' Benefit and Insurance Program Act." Renumbered

More information

Beneficiaries: those who receive benefits through government programs like Medicare

Beneficiaries: those who receive benefits through government programs like Medicare Terminology: Beneficiaries: those who receive benefits through government programs like Medicare Deductible: a fixed monetary amount set by Medicare or a private insurer. You are responsible for all medical

More information

National Policy Library Document

National Policy Library Document Page 1 of 7 National Policy Library Document Policy Name: Medicare Programs: Compliance Element III Training and Education Policy No.: HR329-83615 Policy Author: Author Title: Author Department: Laetitia

More information

Summary of benefits. 2009 idaho, utah. Health Net orange prescription drug plan

Summary of benefits. 2009 idaho, utah. Health Net orange prescription drug plan Health Net orange prescription drug plan Summary of benefits 2009 idaho, utah Benefits effective January 1, 2009 (S5678-064) PDP Option 1 (S5678-063) PDP Value Option 2 Section I INTRODUCTION TO SUMMARY

More information

January 12, 2009. VIA: FEDERAL EXPRESS DELIVERY EMAIL (krista.bowers@wellpoint.com) AND FACSIMILE (805-557-6823)

January 12, 2009. VIA: FEDERAL EXPRESS DELIVERY EMAIL (krista.bowers@wellpoint.com) AND FACSIMILE (805-557-6823) DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Center for Drug and Health Plan Choice 7500 Security Boulevard, Mail Stop C4-23-07 Baltimore, Maryland 21244-1850 VIA: FEDERAL

More information

Prescription drugs are a critical component of health care. Because of the role of drugs in treating conditions, it is important that Medicare ensures that its beneficiaries have access to appropriate

More information

Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training

Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training Overview This Medicare Advantage and Part D Fraud, Waste and Abuse Compliance Training for first-tier, downstream and related entities

More information

Introductory Guide to Medicare Part C and D

Introductory Guide to Medicare Part C and D Introductory Guide to Medicare Part C and D Elizabeth B. Lippincott Emily A. Moseley Lippincott Law Firm PLLC Contents Introduction... 3 Instructions on Using the Guide... 3 Glossary and Definitions...

More information

Introduction. Plan sponsors include employers, unions, trust funds, associations and government agencies, and are also referred to as payors.

Introduction. Plan sponsors include employers, unions, trust funds, associations and government agencies, and are also referred to as payors. Maintaining the Affordability of the Prescription Drug Benefit: How Managed Care Organizations Secure Price Concessions from Pharmaceutical Manufacturers Introduction The purpose of this paper is to explain

More information

Medicare Part D Prescription Drug Coverage

Medicare Part D Prescription Drug Coverage Medicare Part D Prescription Drug Coverage Part 3 Version 6.0 September 25, 2012 Terms and Conditions This training program is protected under United States Copyright laws, 17 U.S.C.A. 101, et seq. and

More information

Medicare. What you need to know. Choose the plan that s right for you GNHH2ZTHH_15

Medicare. What you need to know. Choose the plan that s right for you GNHH2ZTHH_15 Medicare What you need to know Choose the plan that s right for you GNHH2ZTHH_15 Choosing a Medicare plan is a lot like buying a car. There are lots of options to consider. And what s right for you may

More information

The Seven Elements of a Vendor Oversight Program

The Seven Elements of a Vendor Oversight Program The Seven Elements of a Oversight Program DST Health Solutions September 2014 The Seven Elements of a Oversight Program The Seven Elements of a Oversight Program Medicare Advantage plans must gain efficiencies

More information

First Health Part D Value Plus (PDP) offered by First Health Life & Health Insurance Company

First Health Part D Value Plus (PDP) offered by First Health Life & Health Insurance Company First Health Part D Value Plus (PDP) offered by First Health Life & Health Insurance Company Annual Notice of Changes for 2016 You are currently enrolled as a member of First Health Part D Value Plus (PDP).

More information

Medicare Advantage 101. Michael Taylor, PhD Medicare Advantage Branch Manager Centers for Medicare & Medicaid Services Atlanta Regional Office

Medicare Advantage 101. Michael Taylor, PhD Medicare Advantage Branch Manager Centers for Medicare & Medicaid Services Atlanta Regional Office Medicare Advantage 101 Michael Taylor, PhD Medicare Advantage Branch Manager Centers for Medicare & Medicaid Services Atlanta Regional Office Objectives General Overview of Medicare Advantage CMS 5 Star

More information

Pharmacy Administrative Manual

Pharmacy Administrative Manual Pharmacy Administrative Manual January 2013 TABLE OF CONTENTS Section I. GENERAL INFORMATION Assistance.......................................... 1.1 Fraud, Waste, and Abuse...............................

More information

National Policy Library Document

National Policy Library Document Page 1 of 9 National Policy Library Document Policy Name: Medicare Programs: Compliance Element IV Effective Lines of Communication Policy No.: HR329-81145 Policy Author: Author Title: Author Department:

More information

Your Retiree Health Care Travel Guide

Your Retiree Health Care Travel Guide SPECIAL EDITION for Individuals Not Yet Eligible for Medicare Your Retiree Health Care Travel Guide 2010 Enrollment for BorgWarner Pre-Medicare Health Care Coverage Welcome to 2010 Pre-Medicare enrollment!

More information

PHARMACY DEPARTMENT Sheryl D. Waudby, MS, RPh Pharmacy Director

PHARMACY DEPARTMENT Sheryl D. Waudby, MS, RPh Pharmacy Director PHARMACY DEPARTMENT Sheryl D. Waudby, MS, RPh Pharmacy Director Pharmacy Benefit Manager (PBM) Formulary Generics Prior Authorization Process Specialty Pharmacy UPHP Web Site Reasons Why a Prescription

More information

Managed Care Pharmacy. Objectives. Health Plans Some Background 4/7/2015. Kim Moon, PharmD Spring 2015

Managed Care Pharmacy. Objectives. Health Plans Some Background 4/7/2015. Kim Moon, PharmD Spring 2015 Managed Care Pharmacy Kim Moon, PharmD Spring 2015 Objectives Describe the role of pharmacists in managed care plans Discuss the role of quality ratings systems in managed care pharmacy Explain some of

More information

The Honorable Alphonso Maldon, Jr. Chairman Military Compensation and Retirement Modernization Commission P. O. Box 13170 Arlington, Virginia 22209

The Honorable Alphonso Maldon, Jr. Chairman Military Compensation and Retirement Modernization Commission P. O. Box 13170 Arlington, Virginia 22209 The Honorable Alphonso Maldon, Jr. Chairman Military Compensation and Retirement Modernization Commission P. O. Box 13170 Arlington, Virginia 22209 Dear Chairman Maldon: The National Association of Chain

More information

Medicare Advantage Program. Michael Taylor, PhD Medicare Advantage Manager

Medicare Advantage Program. Michael Taylor, PhD Medicare Advantage Manager Medicare Advantage Program Michael Taylor, PhD Medicare Advantage Manager Objectives General Overview of Medicare Advantage CMS 5 Star Ratings Medicare Part C & D Audit Process Coping with Contract Terminations

More information

Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population

Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population November 18, 2013 Diana Dennett EVP, Global Issues and Counsel America s Health Insurance Plans (AHIP) America

More information

Prescription Drug Benefits Under Part D of the Medicare Modernization Act The Genie s Out of the Bottle

Prescription Drug Benefits Under Part D of the Medicare Modernization Act The Genie s Out of the Bottle ISSUE BRIEF VOL. 5, NO. 10, 2005 This ongoing series provides information on how to develop programs to educate Medicare beneficiaries and their families. Additional information about this and other projects

More information

Fraud Waste and Abuse Training Requirement. To Whom It May Concern:

Fraud Waste and Abuse Training Requirement. To Whom It May Concern: RE: Fraud Waste and Abuse Training Requirement To Whom It May Concern: This letter is to inform you about a new requirement being implemented by the CMS program (Centers for Medicare and Medicaid Services)

More information

Health Care Communiqué

Health Care Communiqué Health Care Communiqué STAR Ratings 2015 and Beyond 1 CMS First Public Use File (PUF) of Plan-Reported Data 3 Medicare Part D Hospice Claims 4 STAR RATINGS 2015 AND BEYOND UL and the UL logo are trademarks

More information

Natalie Pons, Senior Vice President, Assistant General Counsel, Health Care Services. CVS Caremark Corporation

Natalie Pons, Senior Vice President, Assistant General Counsel, Health Care Services. CVS Caremark Corporation Prepared Statement of Natalie Pons, Senior Vice President, Assistant General Counsel, Health Care Services CVS Caremark Corporation Before the Subcommittee on Regulatory Reform, Commercial and Antitrust

More information

Health Care Reform Update January 2012 MG76120 0212 LILLY USA, LLC. ALL RIGHTS RESERVED

Health Care Reform Update January 2012 MG76120 0212 LILLY USA, LLC. ALL RIGHTS RESERVED Health Care Reform Update January 2012 Disclaimer This presentation is for educational purposes only. It is not a complete analysis of the material contained herein. Before taking any action on the issues

More information

GAO MEDICARE ADVANTAGE. Relationship between Benefit Package Designs and Plans Average Beneficiary Health Status. Report to Congressional Requesters

GAO MEDICARE ADVANTAGE. Relationship between Benefit Package Designs and Plans Average Beneficiary Health Status. Report to Congressional Requesters GAO United States Government Accountability Office Report to Congressional Requesters April 2010 MEDICARE ADVANTAGE Relationship between Benefit Package Designs and Plans Average Beneficiary Health Status

More information

SHIBA. Statewide Health Insurance Benefits Advisors. Medicare, Health Insurance, & the Affordable Care Act Updates for Summer 2013

SHIBA. Statewide Health Insurance Benefits Advisors. Medicare, Health Insurance, & the Affordable Care Act Updates for Summer 2013 SHIBA Statewide Health Insurance Benefits Advisors Medicare, Health Insurance, & the Affordable Care Act Updates for Summer 2013 Liz Mercer Regional Trainer Sponsored by the: 8/8/2013 1 Today s overview

More information

Navig vig ting ting the the Medica Medic re r Plan Plan Finder September 2014

Navig vig ting ting the the Medica Medic re r Plan Plan Finder September 2014 Navigating the Medicare Plan Finder September 2014 What is the Medicare Plan Finder? Internet tool on official Medicare web site Helps people learn about coverage and Review current Medicare enrollment

More information

Strategies for Success in the CMS Medicare Advantage Star Quality Ratings

Strategies for Success in the CMS Medicare Advantage Star Quality Ratings Strategies for Success in the CMS Medicare Advantage Star Quality Ratings The National Pay for Performance Summit February 20, 2013, San Francisco, CA Theresa C. Carnegie Mintz, Levin, Cohn, Ferris, Glovsky

More information

Frequently Asked Questions (FAQs) Medicare First Tier, Downstream, and Related Entity (FDR) Compliance Program Requirements

Frequently Asked Questions (FAQs) Medicare First Tier, Downstream, and Related Entity (FDR) Compliance Program Requirements TABLE OF CONTENTS I. FDR General Compliance & Fraud, Waste, and Abuse Training and Standards/Code of Conduct 1. Why am I receiving notice to complete training for Aetna? 2. Why is this training necessary?

More information

March 7, 2014. [Submitted electronically to AdvanceNotice2015@cms.hhs.gov]

March 7, 2014. [Submitted electronically to AdvanceNotice2015@cms.hhs.gov] March 7, 2014 [Submitted electronically to AdvanceNotice2015@cms.hhs.gov] Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-4159-P P.O. Box 8013 Baltimore,

More information

National Policy Library Document

National Policy Library Document Page 1 of 11 National Policy Library Document Policy Name: Medicare Programs: Compliance Element VI Monitoring and Auditing Policy No.: HR810-84520 Policy Author: Author Title: Author Department: Laetitia

More information

FREQUENTLY ASKED QUESTIONS (FAQs) About Your New Retiree Prescription Drug Plan

FREQUENTLY ASKED QUESTIONS (FAQs) About Your New Retiree Prescription Drug Plan DRAFT: 4B World Bank Group RMIP DATE: 9/08/15 FAQS for Pre-pre-enrollment mailing Sept 2015 FREQUENTLY ASKED QUESTIONS (FAQs) About Your New Retiree Prescription Drug Plan On January 1, 2016, SilverScript

More information

I. INFORMATION ABOUT THE DEMONSTRATION

I. INFORMATION ABOUT THE DEMONSTRATION EVALUATION DESIGN FOR THE WISCONSIN SENIORCARE SECTION 1115 PHARMACEUTICAL BENEFIT DEMONSTRATION I. INFORMATION ABOUT THE DEMONSTRATION This Evaluation Design is for project number 11-W-00149/5, the Wisconsin

More information

The Discount Drug Card

The Discount Drug Card Medicare Prescription Drug, Improvement, and Modernization Act of 2003 The Discount Drug Card January 2004 Background The Medicare Prescription Drug Discount Card and Transitional Assistance Program was

More information

SCAN Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005

SCAN Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005 Health Plan Policy and Procedure Number: CRP-0067, False Claims Act & Deficit Reduction Act 2005 Approver Approval Stage Date Chris Zorn Approval Event (Authoring) 12/09/2013 Nancy Monk Approval Event

More information

Overview of Gateway Health Plan Medicare Assured HMO SNP

Overview of Gateway Health Plan Medicare Assured HMO SNP Overview of Gateway Health Plan Medicare Assured HMO SNP Training Objectives To provide training on Gateway Health Plan Medicare Assured. To provide training on Gateway s Medicare Compliance Program. To

More information

Health care reform for large businesses

Health care reform for large businesses FOR PRODUCERS AND EMPLOYERS Health care reform for large businesses A guide to what you need to know now DECEMBER 2013 CONTENTS 2 Introduction Since 2010 when the Affordable Care Act (ACA) was signed into

More information

Supreme Court upholds the Affordable Care Act in its entirety:

Supreme Court upholds the Affordable Care Act in its entirety: Supreme Court upholds the Affordable Care Act in its entirety: What does this mean for Seniors? The Supreme Court s decision to uphold the Affordable Care Act (ACA) in its entirety is a huge victory for

More information

Let s consider two situations

Let s consider two situations Employee Benefits Report 232 Center St. Suite D, Advisory services offered through Investment Advisors, a division of ProEquities, Inc., a registered investment advisor. Securities offered through ProEquities,

More information

Choosing the Best Plan for You: A Tool for Purchasing Coverage in the Health Insurance Exchange

Choosing the Best Plan for You: A Tool for Purchasing Coverage in the Health Insurance Exchange Choosing the Best Plan for You: A Tool for Purchasing Coverage in the Health Insurance Exchange The Affordable Care Act (ACA) makes health insurance available to nearly all Americans and the law requires

More information

They re Not For the Faint of Heart Christine Rinn Chandra Westergaard

They re Not For the Faint of Heart Christine Rinn Chandra Westergaard Medicare Advantage and Part D They re Not For the Faint of Heart Christine Rinn Chandra Westergaard Introduction Changes to the Medicare Advantage and Part D programs may make participation less attractive

More information

Finally... maybe? The Long Awaited 340B Mega Guidance. Georgia Healthcare Financial Management Association. October 2015

Finally... maybe? The Long Awaited 340B Mega Guidance. Georgia Healthcare Financial Management Association. October 2015 Finally... maybe? The Long Awaited 340B Mega Guidance Georgia Healthcare Financial Management Association October 2015 Disclaimer This webinar assumes the participant is familiar with the basic operations

More information

CMS Mandated Training for Providers, First Tier, Downstream and Related Entities

CMS Mandated Training for Providers, First Tier, Downstream and Related Entities CMS Mandated Training for Providers, First Tier, Downstream and Related Entities I. INTRODUCTION It is the practice of Midwest Health Plan (MHP) to conduct its business with the highest degree of ethics

More information

Getting Started with Medicare Beginning Medicare Training

Getting Started with Medicare Beginning Medicare Training Getting Started with Medicare Beginning Medicare Training This Medicare Counselor Training program was developed under a grant from UnitedHealthcare through a joint project with the National Association

More information

SENATE FILE NO. SF0078 A BILL. for. AN ACT relating to prescription drug practices; creating a

SENATE FILE NO. SF0078 A BILL. for. AN ACT relating to prescription drug practices; creating a 00 STATE OF WYOMING 0LSO-00 SENATE FILE NO. SF00 Prescription drug practices. Sponsored by: Senator(s) Mockler A BILL for AN ACT relating to prescription drug practices; creating a fiduciary duty for pharmacy

More information

STAR RATINGS FOR MEDICARE ADVANTAGE PLANS

STAR RATINGS FOR MEDICARE ADVANTAGE PLANS 11 STAR RATINGS FOR MEDICARE ADVANTAGE PLANS A Medicare Advantage (MA) Plan is offered by private health insurance companies that are approved by Medicare which is a social insurance program administered

More information

2015 Open Enrollment Checklist

2015 Open Enrollment Checklist Brought to you by Benefit Administration Company, LLC. 2015 Open Enrollment Checklist To prepare for open enrollment, health plan sponsors should become familiar with the legal changes affecting the design

More information

Center for Medicare & Medicaid Innovation Request for Information on Health Plan Innovation Initiatives at CMS

Center for Medicare & Medicaid Innovation Request for Information on Health Plan Innovation Initiatives at CMS Center for Medicare & Medicaid Innovation Request for Information on Health Plan Innovation Initiatives at CMS Agency/Office: Type of Notice: Department of Health and Human Services Centers for Medicare

More information

UPMC for Life HMO Deductible with Rx (HMO) offered by UPMC Health Plan

UPMC for Life HMO Deductible with Rx (HMO) offered by UPMC Health Plan UPMC for Life HMO Deductible with Rx (HMO) offered by UPMC Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a member of UPMC for Life HMO Deductible with Rx. Next year, there

More information

The Centers for Medicare & Medicaid Services (CMS) strives to make information available to all. Nevertheless, portions of our files including

The Centers for Medicare & Medicaid Services (CMS) strives to make information available to all. Nevertheless, portions of our files including The Centers for Medicare & Medicaid Services (CMS) strives to make information available to all. Nevertheless, portions of our files including charts, tables, and graphics may be difficult to read using

More information

Prescription Drugs Medicare- Eligible Participants

Prescription Drugs Medicare- Eligible Participants State Retiree Health Benefits Program Fact Sheet #8A Prescription Drugs Medicare- Eligible Participants As a Medicare-eligible participant in the State Retiree Health Benefits Program, what are my choices

More information

About NEHI: NEHI is a national health policy institute focused on enabling innovation to improve health care quality and lower health care costs.

About NEHI: NEHI is a national health policy institute focused on enabling innovation to improve health care quality and lower health care costs. 1 Aaron McKethan PhD (amckethan@rxante.com) About NEHI: NEHI is a national health policy institute focused on enabling innovation to improve health care quality and lower health care costs. In partnership

More information

State Medicaid Agencies Medicare Modernization Act Final Rule Fact Sheet

State Medicaid Agencies Medicare Modernization Act Final Rule Fact Sheet State Medicaid Agencies Medicare Modernization Act Final Rule Fact Sheet Guidance for States to Implement the Medicare Drug Benefit CMS is announcing new steps to assist states with the implementation

More information

Description of a First Tier, Downstream, and Related Entity

Description of a First Tier, Downstream, and Related Entity We at Health Partners Plans (HPP) would like to thank you for your partnership with HPP and helping us to provide exceptional service to our Medicare beneficiaries. The Centers for Medicare and Medicaid

More information

Medicare Updates Massachusetts Health Care Training Forum. October 2012

Medicare Updates Massachusetts Health Care Training Forum. October 2012 Medicare Updates Massachusetts Health Care Training Forum October 2012 1 Topics Covered Overview of Medicare A, B & C Newest Preventive Services Medicare Part D 2013 Standard Benefit Impact of ACA on the

More information

Affordable Care Act Reviews

Affordable Care Act Reviews Appendix A: Affordable Care Act Reviews Appendix A: Affordable Care Act Reviews New Programs and Initiatives Created by the Affordable Care Act... 1 Pre-Existing Condition Insurance Plans, 1101...2 Controls

More information