On April 4, 2025, the Centers for Medicare & Medicaid Services (“CMS”) released the contract year (“CY”) 2026 final rule for the Medicare Advantage (“MA”) program, Medicare Prescription Drug Benefit Program (“Part D”),...more
4/18/2025
/ Centers for Medicare & Medicaid Services (CMS) ,
Drug Pricing ,
Final Rules ,
Healthcare ,
Healthcare Reform ,
Medicare ,
Medicare Advantage ,
Medicare Part D ,
Prescription Drugs ,
Proposed Rules ,
Regulatory Requirements
On November 26, 2024, the Centers for Medicare & Medicaid Services (“CMS”) released the contract year 2026 proposed rule for the Medicare Advantage (“MA”) program, Medicare Prescription Drug Benefit Program (“Part D”),...more
12/17/2024
/ Artificial Intelligence ,
Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
Medicare ,
Medicare Advantage ,
Medicare Part D ,
Medicare Payment Reform ,
Mental Health Parity Rule ,
Pharmaceutical Industry ,
Pharmacies ,
Pharmacy Benefit Manager (PBM) ,
Prescription Drugs ,
Proposed Rules ,
Transparency
On July 3, 2024, a federal court in Texas stayed provisions of the Centers for Medicare & Medicaid Services’ (“CMS”) contract year 2025 Final Rule that amended the longstanding Medicare Advantage (“MA”) and Part D agent and...more
7/8/2024
/ Broker-Dealer ,
Centers for Medicare & Medicaid Services (CMS) ,
Compensation ,
Contract Terms ,
Department of Health and Human Services (HHS) ,
Final Rules ,
Medicare Advantage ,
Medicare Part D ,
Popular ,
Stays ,
Texas
On April 4, 2024, the Centers for Medicare & Medicaid Services (“CMS”) issued the contract year 2025 (CY2025) Medicare Advantage and Part D final rule (the “Final Rule”). In addition to finalizing its CY2025 proposed rule,...more
4/16/2024
/ Agents ,
Beneficiaries ,
Biosimilars ,
Brokers ,
Centers for Medicare & Medicaid Services (CMS) ,
Chronic Care Managment (CCM) ,
Compensation ,
Competition ,
Fair Market Value ,
Final Rules ,
Health Care Providers ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part C ,
Medicare Part D ,
Mental Health ,
Policies and Procedures ,
Reporting Requirements ,
Supplemental Benefits ,
Third-Party
On November 6, 2023, the Centers for Medicare and Medicaid Services (“CMS”) released the contract year 2025 proposed rule for Medicare Advantage (“MA”) organizations and Part D sponsors (the “Proposed Rule”). The Proposed...more
The Inflation Reduction Act (the “IRA”) requires drug manufacturers to pay rebates to Medicare when the prices of their Part B and Part D prescription drug increase faster than the rate of inflation. We recently discussed the...more
3/16/2023
/ Centers for Medicare & Medicaid Services (CMS) ,
Drug Pricing ,
Healthcare Reform ,
Inflation Reduction Act (IRA) ,
Manufacturers ,
Medicare ,
Medicare Part B ,
Medicare Part D ,
Pharmaceutical Industry ,
Prescription Drugs ,
Proposed Regulation ,
Rebates
On February 9, 2023, the Centers for Medicare and Medicaid Services (“CMS”) released two highly-anticipated guidance documents (the “Guidance”) detailing the agency’s proposed implementation of the Medicare Part B (“Part B”)...more
Just in time for the holidays, the Centers for Medicare and Medicaid Services (“CMS”) issued the Contract Year 2024 Proposed Rule for Medicare Advantage organizations (“MAOs”) and Part D sponsors (the “Proposed Rule”). The...more
On Monday, we discussed that the Centers for Medicare and Medicaid Services (“CMS”) has heightened oversight of Medicare Advantage (“MA”) organizations’ and Part D sponsors’ marketing practices. We also noted that the United...more
In May, we discussed the final rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (the “Final Rule”) issued by the Centers for Medicare and...more
The Inflation Reduction Act (“IRA”) was signed into law by President Biden on August 16, 2022. The expansive legislation includes key health care provisions, including drug pricing reforms, inflationary rebates, Medicare Part...more
On April 29, 2022, the Centers for Medicare and Medicaid Services (“CMS”), issued the final rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs...more
5/16/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Compliance ,
Coronavirus/COVID-19 ,
Drug Pricing ,
Final Rules ,
Marketing ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part D ,
Out-of-Pocket Expenses ,
Prescription Drug Coverage ,
Prescription Drugs ,
State and Local Government ,
Third-Party ,
Transparency
On January 6, 2022, the Centers for Medicare and Medicaid Services (“CMS”) issued the proposed rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs...more
1/12/2022
/ Affordable Care Act ,
Centers for Medicare & Medicaid Services (CMS) ,
CLIA ,
Coronavirus/COVID-19 ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part A ,
Medicare Part B ,
Medicare Part D ,
Out-of-Pocket Expenses ,
Proposed Rules ,
Public Health Emergency ,
Risk Assessment
On September 14, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued the Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D...more
The Centers for Medicare and Medicaid Services (CMS) and the Office of Personnel Management (OPM) issued guidance to their contracting carriers on various issues surrounding the novel coronavirus or COVID-19. These guidance...more
3/17/2020
/ Centers for Medicare & Medicaid Services (CMS) ,
Coronavirus/COVID-19 ,
Emergency Management Plans ,
Health Care Providers ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part A ,
Medicare Part B ,
Medicare Part D ,
OPM ,
Prescription Drugs ,
Public Employees
As promised, here is a summary of some key provisions in CMS’ proposed rule relating to the Medicare Advantage and Part D programs for contract years 2021 and 2022. CMS is soliciting comments on a number of issues and we urge...more
2/14/2020
/ 21st Century Cures Act ,
Bipartisan Budget Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
ESRD ,
Health Care Providers ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part D ,
Past Performance ,
Proposed Regulation
In an evening email that is sure to ruin the weekend for many, CMS announced on February 5, 2020, that it is proposing changes to the Medicare Advantage and Part D Programs for CY 2021 and 2022. CMS will not issue a Call...more
2/7/2020
/ Call Letter ,
Centers for Medicare & Medicaid Services (CMS) ,
Healthcare Reform ,
Medical Loss Ratio ,
Medicare ,
Medicare Advantage ,
Medicare Part D ,
Prescription Drug Coverage ,
Prescription Drugs ,
Regulatory Agenda ,
Regulatory Burden ,
Rulemaking Process
The House and Senate continue to focus on prescription drug pricing though it is unclear whether any of the proposals currently pending in either chamber will become law. On December 6th, Senators Grassley and Wyden...more
12/30/2019
/ Congressional Budget Office ,
Consumer Price Index ,
Drug Pricing ,
Health Plan Sponsors ,
Medicare ,
Medicare Part D ,
Nancy Pelosi ,
Pending Legislation ,
Pharmaceutical Industry ,
Prescription Drugs ,
Rebates
In a rare act of bipartisanship, Senate Finance Committee Chairman Chuck Grassley, R-Iowa, and Ranking Member Ron Wyden, D-Ore., introduced on July 23rd a chairman’s mark, the Prescription Drug Pricing Reduction Act (PDPRA)...more
7/26/2019
/ Ambulatory Surgery Centers ,
Conflicts of Interest ,
Congressional Budget Office ,
Drug Pricing ,
Health Insurance ,
Hospitals ,
Managed Care Contracts ,
Manufacturers ,
Medicaid ,
Medicare ,
Medicare Part D ,
Outpatient Services ,
Pharmaceutical Industry ,
Pharmacy Benefit Manager (PBM) ,
Physician Fee Schedule ,
Prescription Drug Coverage ,
Prescription Drugs ,
Price Transparency ,
Public Disclosure ,
Rebates ,
Risk-Sharing
The Centers for Medicare and Medicaid Services (“CMS”) released the much-anticipated proposed rule to lower Part D and Medicare Advantage (“MA”) drug prices and beneficiary out-of-pocket expenses on November 26, 2018 (the...more
11/29/2018
/ Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
Drug Pricing ,
Electronic Prescribing ,
Gag Clauses ,
Health Insurance ,
Health Plan Sponsors ,
Medicare ,
Medicare Advantage ,
Medicare Part D ,
Out-of-Pocket Expenses ,
Pharmaceutical Industry ,
Prescription Drugs ,
Proposed Rules ,
Public Comment
On October 26, 2018, the Centers for Medicare and Medicaid Services (“CMS”) released for viewing a proposed rule that includes significant changes for Medicare Advantage organizations (“MAOs”), Part D prescription drug plan...more
10/30/2018
/ Audits ,
Bipartisan Budget Act ,
Centers for Medicare & Medicaid Services (CMS) ,
Fee-for-Service ,
Health Care Providers ,
Managed Care Contracts ,
MCOs ,
Medicaid ,
Medical Records ,
Medicare ,
Medicare Advantage ,
Medicare Advantage Organizations (MAOs) ,
Medicare Part C ,
Medicare Part D ,
Overpayment ,
Pharmaceutical Industry ,
Pharmacies ,
Prescription Drug Coverage ,
Prescription Drugs ,
Proposed Rules ,
Risk Adjustment Formula
In a key case being watched by the industry, Judge Collyer of the United States District Court for the District of Columbia issued an opinion today granting UnitedHealthcare’s Motion for Summary Judgment in UnitedHealthcare...more