A multi-state Medicaid plan faced a competitive bid for contract renewal. The state is moving to mandatory managed Medicaid for its standard Medicaid population as well as dual-eligible and long-term services and supports’ enrollees who need home- and community-based services. It was a substantial rebid with a
Read More →The demand for administrative simplification, particularly related to prior authorization, continues to increase On December 15, 2022, the Department of Health and Human Services (HHS) issued a proposed rule for the Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and
Read More →Building on previous interoperability regulations, CMS on Dec. 13 published a proposed rule that seeks to improve the efficiency and transparency of prior authorization processes in Medicare Advantage and other federally funded health care programs. Industry experts say the rule should ultimately speed access to care, potentially
Read More →As required by CMS, each state is developing its plans for the 12-month unwinding period in anticipation of the end of the public health emergency (PHE). On October 13, 2022, the U.S Department of Health and Human Services announced the renewal of the PHE, extending it an
Read More →Medicare Advantage is likely to make up more than half of total Medicare enrollment in 2023 as open enrollment gears up this week. As enrollment surges, plans are facing increased scrutiny over risk adjustment practices, with regulators turning up the heat on payments in the program. Plus,
Read More →After observing a high volume of marketing-related complaints that the federal government believes are driven by the actions of third-party marketing organizations (TPMOs), CMS this month is implementing several new requirements aimed at protecting Medicare beneficiaries as they compare coverage options during the 2023 Annual Election Period
Read More →With telehealth utilization at 38x what it was pre-pandemic, plan sponsors should address telehealth fraud as part of overall anti-fraud, waste and abuse plans The pandemic had a tremendous impact on healthcare delivery. Fee-for-service Medicare previously offered telehealth services on a limited basis—mostly to beneficiaries in rural
Read More →CMS in a recent bulletin unveiled a “suite of new resources” aimed at guiding states and CMS in their oversight of Medicaid and CHIP programs, including managed care programs. Two items of particular interest to managed care organizations in a July 6 Center for Medicaid and CHIP Services
Read More →The Centers for Medicare & Medicaid Services (CMS) requires that all health plans have written standards for access to care timeliness and member services. Your health plan is required to: Most states have a standard set requirement for primary and specialty care access and availability. Is your
Read More →Shifts in the managed care landscape have reinforced the need for health plans to engage providers to drive the accuracy of risk scores at the point of care. As health plans and providers adopt value-based reimbursement and risk-sharing models, ensuring the accuracy of risk scores becomes an
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