Five Universal Strategies to Move the Needle on Star Rating Improvements: A Medication Adherence Case Study
One of the surprises in the release of plans’ Star Ratings results for the 2019 open enrollment season was that Star Ratings around Part D adherence scores, on average, slipped. [1] 

The Centers for Medicare & Medicaid Services (CMS) includes three adherence measures in the Part D domains including:
  • Medication Adherence for diabetes medications
  • Medication Adherence for cholesterol
  • Medication Adherence for Hypertension

Medication Adherence Case Study
Prior to the release of this latest Star data, BluePeak was working with a Medicare Advantage plan that was targeting improvement on the Part D adherence measures, which had declined in a prior measurement period. This Plan targeted these measures as part of an overall strategy to improve their Star summary rating, recognizing that measures like these are weighted a 3, as an intermediate outcome measure, in the Star ratings. Lack of adherence or improper medication use relative to diabetes, hypertension or hypercholesterolemia can result in poor health outcomes as well as increased cost of healthcare, which is why they are targeted and measured by CMS. 

[1] Fact Sheet – CMS 2019 Part C and D Star Ratings -Based on the 2019 Star Ratings published on Medicare Plan Finder (MPF) on October 10, 2018. For details on the Medicare Advantage (MA) and Part D Star Ratings, please refer to the 2019 MA Part C & D Star Ratings Technical Notes available at http://go.cms.gov/partcanddstarratings .
Is Your Plan Ready For The New Year?

Don’t breathe a sigh of relief just yet. While 1/1 is an important day for plans, there are several changes for this year that will require testing and oversight beyond 1/1.
Prepared to Implement the CMS Preclusion List Requirement?

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 This requirement was adopted in the April 2018 final rule as an alternative to the rescinded Medicare enrollment requirement that mandated contracted providers to enroll in Medicare to ensure the prescriptions they were writing would be covered under Part D.

CMS has now extended the preclusion guidance to providers and entities for medical benefits as well as providers writing prescriptions. CMS published guidance outlining how to implement and comply with the newly adopted Preclusion List requirements in an HPMS Memo on November 2, 2018. The requirement defines that contracted and non-contracted providers will not be eligible to receive payments from a Medicare plan, 1876 Cost Plan, or PACE organizations if they are included on the Preclusion List. Additionally, this will also be a requirement for providers writing prescriptions for Part D drugs to be covered by a Part D plan. 
Transition Monitoring Program Audit

History and Methodology
The transition monitoring program analysis (TMPA) has been in effect since 2012 and will likely be a staple in the Part D program for several years to come. The program evaluates point-of-sale rejected claims to ensure Sponsors are meeting their Part D transition of care requirements for new and continuing enrollees. Based on the most recent TMPA requirements, sponsors must submit January claims that rejected for formulary reasons (non-formulary (NF), prior authorization (PA), step therapy (ST), and quantity limit (QL)). All claims must be submitted into CMS within the first two weeks of February.  
Formulary Strategy Planning for 2020-Indication Based Formulary Design Considerations

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 part of their overall formulary strategy.
 
Beginning in the 2020 contract year (CY2020), the Centers for Medicare & Medicaid Services (“CMS”) will permit Part D sponsors to implement indication-based formulary designs that tailor formulary coverage of drugs predicated on specific indications. Using this formulary design, a Part D sponsor’s formulary may cover a given drug for only certain U.S. Food & Drug Administration (FDA)-approved indications. CMS anticipates this will provide Part D sponsors with enhanced negotiating power over drug manufacturers and may help them negotiate reduced prescription drug prices, especially as related to high-cost drugs.
Service Spotlight: HIPAA Program Review
HIPAA Violations = Potential Civil Fines and Criminal Penalties

How healthy is your HIPAA Program?  BluePeak’s HIPAA Program Review can help you identify and correct privacy, security and breach policy and procedure issues that might leave you at risk for HIPAA violations and OCR compliance review.  Choose all or part of BluePeak’s three-step review process, which includes policy and procedure review, operational testing and validation, and training and process improvement.

In addition to performing a HIPAA Program Review, BluePeak offers follow-up services to clients, such as developing and implementing monitoring and mock OCR HIPAA audits to ensure any issues found during the review have been remediated.
  
Contact us for a free consultation at info@bluepeak.com
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