Compliance
Risk Management for Health Plans – Part 3
In Part 2 of our Risk Management for Health Plans series, we provided a high-level understanding of how to approach risk management from a tactical perspective. This week we will provide you with a strategic framework to apply to your program. The 5 Pillars of Risk Management Keep in mind, Risk Management is a continuous…
Read MoreRisk Management for Health Plans – Part 2
In Part 1 of our Risk Management for Health Plans series, we focused on risk culture. This week we will get more tactical and breakdown the operational approach to risk management. Organizational Approach to Identifying & Managing Risk The day-to-day operational approach to risk management requires people, processes, and systems for any organization to properly…
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 MoreRisk Management for Health Plans – Part 1
Recently, CODY® conducted, through our partnership with the Association for Community Affiliated Plans (ACAP), a webinar titled Identifying & Managing Risk. These are a few of the questions regarding risk management for health plans that we considered: How effective is your organization at identifying and managing risk within your health plan from an operational and…
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 More2024 AEP – Now is the Time to Prepare!
It may seem early to start preparing for the 2024 Annual Enrollment Period (AEP), but after the Memorial Day holiday, the season comes quickly. Now is the time to prepare by—identifying your resource needs, updating your training programs, and planning for system changes. Don’t wait until July to start these activities; begin now to ensure…
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 Final Rule—CY 2024 Policy and Technical Changes
The Calendar Year 2024 Policy and Technical Changes (CMS Final Rule) was released by the Centers for Medicare & Medicaid Services (CMS) on April 12, 2023. The final rule includes major revisions to regulations governing Medicare Advantage, Medicare Prescription Drug Benefit, Medicare Cost plans, and Programs of All-Inclusive Care for the Elderly (PACE). Some proposed…
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