Bids were turned in the first Monday in June and now it is time to implement those benefits, plan designs and formularies that your organization has been hard at work developing. Open enrollment is only 4 months away and the new plan year begins in 6 short months. There is still a lot of work to be done in a short time. BluePeak has your definitive guide on how to be ready for 1/1.

How Healthy is Your HIPAA Program?

On April 30, 2019, Health and Human Services (HHS) published a final rule in which they are exercising their discretion in how they apply regulations concerning the assessment of Civil Money Penalties (CMPs) for HIPAA violations. This final rule reduced the annual limit for three of the four levels of culpability on which HIPAA violation Civil Money Penalties (CMPs) are based, as follows:

  1. The person did not know (and, by exercising reasonable diligence, would not have known) that the person violated the provision (annual limit reduced from $1.5M to $25K);
  2. the violation was due to reasonable cause, and not willful neglect (annual limit reduced from $1.5M to $100K);
  3. the violation was due to willful neglect that is timely corrected (annual limit reduced from $1.5M to $250K); and
  4. the violation was due to willful neglect that is not timely corrected (annual limit remains at $1.5M).

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 drug pricing to additional telehealth benefits. Amidst this busy season of rulemaking, there has been one proposed rule that has surprisingly not generated much buzz, despite the fact that it will require health plans to undertake significant changes if finalized: the proposed rule focused on improving interoperability and member access to health care data [1]

[1] 84 Fed. Reg. 7610 (March 4, 2019) (available at : ). 
Call Centers Beware

On May 10, 2019, CMS published a final rule on Drug Pricing Transparency. The rule, effective July 9, 2019, requires direct-to-consumer television advertisements of prescription drugs and biological products payable by Medicare or Medicaid to include the Wholesale Acquisition Cost, otherwise known as the “list price”, of such drug or product. Although the rule requires such television advertisements to contain a statement that if health insurances covers the cost of the drug, the cost charged to the beneficiary may be different from the list price, some level of member confusion is still expected. This member confusion is likely to result in increased call volume to Plans and PBMs once advertisements complying with the new rule begin in July. 

Make sure your call center knows about this final rule and is prepared for these member calls through scripts and training. Your grievances department should also be prepared for potential volume increases if members express dissatisfaction with the Plan’s prescription drug price(s). 

During the CMS Spring Conference on May 1, 2019, CMS reviewed some of the revisions that are being made to Plan Finder. The redesigned Plan Finder will be used this fall for the annual enrollment period and most of the changes are designed to improve the user experience. However, plans will experience some changes as well.
  • Primary changes for MA plans:
  • Pricing data will be uploaded to HPMS, not Plan Finder or Plan Finder backend
  • Plan Preview functions will all be moved to HPMS
  • Enrollment transactions / Open Enrollment Center will be done through HPMS

Medicare Advantage and Prescription Drug Plan Appeals Guidance— Prepare Now!

Chapter 13 of the Medicare Managed Care Manual (MMCM) and Chapter 18 of the Prescription Drug Benefit Manual (PDBM) along with other guidance not previously updated within the chapters have been consolidated into one chapter. CMS announced the release of the final Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in an HPMS Memo published February 22, 2019. Any changes or updates from the prior chapters are not expected to be audited until January 2020, unless the final guidance provides clarification that is to the plan’s benefit.

Are you Ready? The HPMS memo also announced CMS’ intent to hold a webinar to discuss the consolidated guidance. What can the plan do to prepare while awaiting the details of the CMS webinar? 

Click Here for a summary of the updates, as well as BluePeak’s tips to prepare while you wait.

BluePeak Can Help
  • BluePeak can help plans identify issues in their policies and procedures or operations by performing an operational assessment. Additionally, BluePeak can help with a mock program audit to ensure the sponsor is prepared to undergo a program audit.
  • Don’t wait until CMS has a call to discuss the final guidance or until you receive your program audit notice. BluePeak can help you prepare now. BluePeak is experienced in CMS interpretive chapters and CMS program audits. BluePeak can review universes, identify risk and outliers, and coach your team and your vendors (FDRs) on how to present the data. BluePeak can conduct annual formulary and benefit testing to ensure set up is as expected.
  • Contact BluePeak for more information about how we can help you navigate the updated guidance.
BluePeak Service Spotlight: Member Material Review

Are you drowning in developing and reviewing member material?

Accuracy and timeliness are critical in all member communications. BluePeak’s consultants have experience reviewing member materials from their work at Plans and for CMS. We can help you populate and/or review the annual required materials, as well as other member communications, such as Explanation of Benefits (EOBs), transition letters, denial notices, and more. If CMS requires it, BluePeak can review it! This could be a huge saver in both time and money for your organization.  Contact us today or click here to learn more. 
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