In the Contract Year 2027 Proposed Rule (CMS-4212-P), CMS introduced significant changes to how provider network changes are handled, which will directly impact health plan operations and enrollment stability. For health plan leaders, the headline is clear: the proposed changes remove historical guardrails around network stability, potentially
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Charles Baker, VP, Compliance Solutions Congress may be stuck in partisan stalemates, but risk adjustment reform is one area where the gears are still turning. The No UPCODE Act (S.1105), introduced this spring, has quickly become the focal point for Medicare Advantage payment debates. What’s in the Bill? Chart reviews
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Charles Baker, VP, Compliance Solutions Tammy Hall, Sr. Consultant, Compliance & Health Plan Operations CMS began a deeper dive into utilization management (UM) for Part C services with the implementation of new UM requirements released in the 2024 Final Rule. On May 30, 2025, CMS raised the red
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In the 2025 Final Rule, CMS released its expectations and reporting requirements to ensure timely access to care. By the second Friday in June each year, issuers that offer Qualified Health Plans (QHPs)—including stand-alone dental plans—in the federally-facilitated exchanges or the federally-facilitated Small Business Health Options Programs
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Subbu Ramalingam, Managing Director, ATTAC Consulting Group As we enter the second half of 2025, health plans and provider organizations are approaching a critical strategic inflection point. With the final push to close out 2026 health plan products, HEDIS® seasons and CAHPS® surveys—and the ongoing need for
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Charles Baker, VP, Compliance Solutions | Victoria Nadzam, MSN, RN, Sr. Consultant On January 22, 2025, the Department of Health and Human Services was instructed to pause non-essential public communications and website updates. Though framed as a temporary, precautionary measure, this pause has real-world ripple effects on
Read More →In the first few weeks of Donald Trump’s second presidency, Medicare Advantage plans faced a tremendous amount of uncertainty as the White House threatened to pause federal financial assistance activities, issued multiple executive orders outlining the new administration’s priorities, and targeted diversity, equity and inclusion (DEI) initiatives
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On November 5, CMS updated URLs in the following CY 2025 EOC models: CY2025_1_HMO_MAPD_ISNP_CSNP_EOC_Correcting URLs_11042024 CY2025_2_PPO_MAPD_ISNP_CSNP_EOC_Correcting URLs_11042024 CY2025_3_DE_SNP_EOC_Correcting URLs_11042024 CY2025_4_Cost_Plan_EOC_Correcting URLs_11042024 CY2025_5_PFFS_EOC_Correcting URLs_11042024 CY2025_6_MSA_EOC_Correcting URLs_11042024 CY2025_7_HMO_MA_EOC_Correcting URLs_11042024 CY2025_8_PPO_MA_EOC_Correcting URLs_11042024 CY2025_9_PDP_EOC_Correcting URLs_11042024 The URLs required replacement due to an error in links of the previous models. For example,
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Dec 05, 2024 issue of RADAR on Medicare Advantage While the Joe Biden administration has applied many regulatory tweaks to the Medicare Advantage program in the name of improving the consumer experience, industry observers expect the incoming Donald Trump administration will take a more plan-friendly approach from
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Charles Baker, VP, Compliance Solutions | Victoria Nadzam, MSN, RN CMS has announced significant revisions to Medicare Advantage Part C and Prescription Drug plans. These changes, related to enrollee grievances, organization/coverage determinations, and appeals guidance, will take effect on January 1, 2025 and will affect plans nationwide.
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