CMS
Enhancing Health Plan Compliance Through Comprehensive Risk Assessment and Management: Navigating New Guidelines and Expectations
While risk assessment has always been a core component of compliance programs, recently the Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS) and the compliance community have emphasized the importance of a formal risk assessment in prioritizing resources and developing work plans. The Office of Inspector General (OIG) released guidance at…
Read MoreCMS Program Audit Prep: Leveraging Your Appeals & Grievances Software
Happy New Year and ‘tis the season for CMS Program Audits! In the 2024 CMS Program Audit Updates memo released on December 19, 2023, CMS confirmed their plans to conduct both routine and focused audits of health plans in 2024. The new focused audits will assess compliance with the coverage and utilization management (UM) requirements finalized…
Read More2024 Oversight Activities – Utilization Management Changes
CMS notified Medicare Advantage Organizations (MAOs) on October 24, 2023, that it will be conducting strategic conversations on the new Utilization Management (UM) requirements effective January 1, 2024. Following these conversations, CMS will start conducting routine and focused audits of the new prior authorization and related rules published in April of this year in the…
Read MoreProposed Change to CMS CY2024 Part C Reporting Requirements – NEW Category Added
CMS Regulatory Change: CMS is proposing an additional Part C reporting requirement for supplement benefits. This is scheduled to be an annual reporting requirement, due the last Monday in February of the following calendar year. Published in the Federal Register Vol. 88, No. 184 on September 25, 2023 and also on the CMS web site,…
Read MoreCMS Model Materials—Changes for CY24
CMS issued the CY24 Model Materials last week Released Model Materials include Annual Notice of Change (ANOC); Evidence of Coverage (EOC); ANOC Errata Notice; EOC Errata Notice; Provider Directory; Part D Explanation of Benefits (EOB); Excluded Provider Model, Formulary (Comprehensive and Abridged); Low Income Subsidy (LIS) Rider; Pharmacy Directory; LIS Premium Summary Table; Prescription Transfer…
Read MoreIs Your Behavioral Health Network Data—Accurate?
Based on the CY24 Final Rule—the Centers for Medicare & Medicaid Services (CMS) is cracking down on Network Adequacy to improve access to Behavioral Health. In order to build strong Medicare Advantage (MA) Behavioral Health networks that improve timely access to services—CMS is finalizing policies to strengthen network adequacy requirements and reaffirm MA organizations’ responsibilities…
Read MoreCY24 ANOC & EOC Proposed Models—Second Round Available for Comment
A link to the latest CY24 ANOC & EOC proposed models was included in the Federal Register on Friday, April 28, 2023, for a 30-day comment period. Comments are due by May 30, 2023. Proposed CY24 models for the 60-day comment period were published in December 2022. To access the drafts, summary of edits, and…
Read MoreComing Soon – CY24 Model Materials
In May, CMS expects to release the Contract Year (CY) 2024 model materials. These will be posted on the CMS site, CMS Marketing Models, and will include: Annual Notice of Change (ANOC) Evidence of Coverage (EOC) ANOC and EOC standardized model instructions Provider Directory Also expected to be released in May are the CY24 Part…
Read MoreCMS’s Plan Benefit Package (PBP) Software—Technical Redesign Coming to HPMS
CMS is modernizing its Plan Benefit Package (PBP) bid submission module for Contract Year (CY) 2024 Going live on April 7, 2023—the new web-based Plan Benefit Package (PBP) Software Technical Redesign will live within the Health Plan Management System (HPMS) and include updates to the user interface and data entry workflow. In previous years, users…
Read MoreCMS CY 2024 Advanced Notice — The Inflation Reduction Act Requirements on Member Communications
Comments are due by March 3, 2023. The final notice will be released by April 3, 2023. The Inflation Reduction Act (IRA) of 2022 provides many provisions to reduce prescription drug costs for Medicare beneficiaries and Medicare Advantage (MA) members. The CMS CY 2024 Advance Notice included updates related to the IRA that should be…
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