Medicare plan finder

It’s Time to Make your 2021 CMS Star Ratings Better Than Ever

The Centers for Medicare and Medicaid Services plans to release its 2020 Star Ratings in October. Whether you received four or five stars or lower, the clock is ticking if you want to have a positive impact on your health plan’s rating next year. 

It takes time to ensure your health plan is doing everything it can to ensure a four or five star rating. It’s a challenging task, but it’s feasible. An experienced Medicare plan consultant like the team at Tier 1 Pharmacy Consulting can help you prepare for rating season – and ensure the best outcome possible. 

What are Star Ratings? 

Most Medicare Part D and Medicare Advantage plans understand the importance of Star Ratings. The ratings are put out annually by the Centers for Medicare and Medicaid Services to give beneficiaries a look at the quality of the health plan before they sign up. Star Ratings focus on aspects of high-quality care within the control of the plan. They provide a complete, accurate, reliable, and valid picture of a program. Star Ratings also are used for compliance and monitoring, and measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement, and specifications.

Star Ratings are displayed on the Medicare Plan Finder – which recently got a huge facelift – so seniors may consider both quality and cost in their enrollment decisions. In other words, Star Ratings are very important.

Here are a few tips going into 2021. 

If it’s broken, fix it – with help. If your  health plan has been using the same tactics year after year and not seeing a ratings increase, it’s time to change your strategy. Look at your data, measure it, and seek an outside consultant to give you an objective picture as well as an action plan moving forward. 

Capture the right data. Many plans fail to earn four stars because they don’t capture HEDIS, PDE, and other important information. It takes time, and health plans have enough going on during a busy fourth quarter. Hire someone to look at issues and resolve them for you – before it’s too late. 

Invest in CAHPS. CAHPS are weighed more heavily now, making up a huge portion of the overall Star Rating. Make sure your CAHPS performance is as strong as your HEDIS investment. If you need, look for someone who can help make sure your CAHPS performance is solid.

Find a Star Ratings expert. As we mentioned in the three previous tips, there’s a lot of work to be done and a lot at stake. Why risk earning a low Star Rating due to lack of time, expertise, oversight, experience, or knowledge? The right consultant can make the difference between one and three stars and beyond.

The Time is Now 

If you didn’t achieve four stars this year, you have time to improve and influence your 2021 ratings with the right strategy, data, and attention to detail. It’s important that you review your current performance figures and use the right resources moving forward. 

If you earned four stars this year – congratulations! However, now is not the time to sit back and relax. Star Ratings is a competitive process, and the health plans who get top billing have already started taking steps to ensure the same if not better performance next year. 

Get Started 

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve your goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be complicated or overwhelming. It’s important that you earn the highest rating possible.

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS unveils new-and-improved Medicare Plan Finder

Seniors will have an easier time shopping for health plans and drug coverage thanks to a major overhaul of one of the government’s key online services.

The Centers for Medicare & Medicaid Services last month unveiled a new-and-improved Medicare Plan Finder on the Medicare.gov website. The move is part of the government agency’s eMedicare initiative to create a modern, personalized, and seamless customer experience for Medicare recipients. 

It’s the first time in a decade that CMS has made changes to the system, and the new plan finder and related technology facelift comes just ahead of annual open enrollment when seniors begin in October to choose their plans for 2020. 

A Needed Makeover

The plan finder upgrades include: 

– A more simple login process to Medicare recipients’ online accounts. 

–  A fast drug list builder that reviews recipients’ prescriptions over the previous 12 months and suggests generic alternatives to name-brand drugs. 

– More details on the different Medicare Advantage plans so seniors can easily compare benefits and choose the plan that is right for them. 

– A guide for seniors to compare original Medicare, supplemental policies and Medicare Advantage plans, as well as up to three drug plans or three Medicare Advantage plans side-by-side. 

Why Now? 

In July, the Government Accountability Office (GAO) in a study determined that the Medicare Plan Finder was challenging for beneficiaries to navigate. It also provided incomplete information and information that was tough to find and even tougher to understand. 

The Medicare Plan Finder was created to provide all of the health plans available in a person’s zip code, with crucial information about premiums and out-of-pocket costs, particularly for prescription drugs. Pricing is different for every health plan, so the tool aims to help consumers make informed decisions about what kind of health and pharmacy care plan they need – and how much they can afford. Plan Finder drug prices are updated regularly from October through August. Pricing for the current year is frozen in September in preparation for the new plan year’s display.

Under the changes, the new Plan Finder makes choosing a plan much easier and more user friendly. It’s also a welcome change for health plans, who have spent time and money trying to improve their own networks to offer people over age 65 private Medicare Advantage coverage, according to Forbes. Experts predict enrollment in private Advantage plans could rise as high as 70 percent between 2030 and 2040. If all goes as expected, the now easy-to-use Plan Finder could boost Medicare Advantage enrollment even further. 

“The new Plan Finder walks users through the Medicare Advantage and Part D enrollment process from start to finish and allows people to view and compare many of the supplemental benefits that Medicare Advantage plans offer,” CMS said in a statement. 

What Health Plans Need to Do

To keep the Plan Finder information current, Medicare requires health plans to submit files that update the costs of prescription drugs every two weeks. Many plans delegate this function to their PBM, but it’s important that health plans stay engaged in this process and ensure that there are effective processes to oversight these frequent submissions. Medicare wants to make sure enrollees are provided the most accurate information when making the decision on what prescription drug plan works best for them.

If a health plan fails to update its prescription drug pricing and other information, it could be suspended or removed from the Medicare Plan Finder. The plan won’t show up when consumers do a search using the tool, so they won’t even know your health plan exists. That means less money going into your health plan and an overall loss of revenue over time.

How We Can Help 

The team at Tier 1 Pharmacy Consulting can be the liaison between the health plan and the pharmacy benefit manager to help oversee the steps needed to ensure CMS compliance, including regular updates  to the Medicare Plan Finder. We can offer solutions on how to properly and effectively institute the appropriate process for oversight and ensure drug prices are, at all times, accurate and up-to-date all year. We are experts in Medicare. Avoid a Plan Finder suppression by partnering with us. We can help you stay compliant at all times, so you can focus on running your health plan.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

New CMS Rules to Increase Transparency and Lower Drug Costs

The Centers for Medicare and Medicaid Services (CMS) recently published a final rule intended to increase transparency and lower drug prices. This announcement has been in the works since CMS first posted their proposal in November 2018. Now that the final ruling has arrived, it’s important for health plans to understand what’s changed and how the rule may affect their business. Tier 1 is available to consult with health plans about these important updates. In the meantime, here’s a brief look at what this final rule means for health plans and the health care industry more generally.

What Does the Final Rule Mean for Your Health Plan?

If you’ve been following along with this blog, this topic will already be familiar to you—we’ve been keeping you posted about its various updates since the proposal was first announced. Published on May 23, the CMS’s final rule is formally entitled, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” As the title suggests, the amendments within the final rule pertain to both Part C (Medicare Advantage program) and Part D (Prescription Drug Benefit program) regulations. The amendments aim to help health plans negotiate for lower drug prices and reduce out-of-pocket costs for enrollees of Part C and Part D programs. The CMS ruling achieves this aim by improving regulatory frameworks and facilitating the development of products that meet patient needs while also reducing their fees. Health plans only want the best for their members—and reducing patients’ out of pocket costs help minimize the expenditures of Part C and Part D programs.

What Does the Final Rule Say that Your Health Plan Needs to Know?

On the same day they published their final rule, CMS posted a helpful fact-sheet outlining significant changes that your health plan needs to consider moving forward. Key takeaways include:

  • Part D policy relating to six classes of drugs has now been codified.
  • Part D plans are now required to adopt one or more electronic Real Time Benefit Tools that have the capability to inform prescribers when lower-cost therapies are available under their drug benefit.
  • Policy is now being finalized that would allow Medicare Advantage plans to implement step therapy for Part B drugs as a recognized utilization management tool.
  • CMS will now require Part D plans to inform members of drug price increases and lower-cost therapeutic alternatives in their Explanation of Benefits.
  • A new prohibition against gag clauses in pharmacy contracts now restricts Part D sponsors from prohibiting or penalizing a pharmacy from disclosing a lower cash price to an enrollee.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

The Medicare Plan Finder: When Drug Prices are Wrong, Consumers Lose

Medicare’s Plan Finder remains the best consumer tool to search for a Medicare Part D and Medicare Advantage Plan. The government wants to keep it that way.

Plan Finder lists all of the health plans available in a person’s zip code and includes crucial information about premiums and out-of-pocket costs, particularly for prescription drugs.

Pricing is different for every health plan, so the tool aims to help consumers to make informed decisions about what kind of health and pharmacy care plan they need – and how much they can afford.

But Plan Finder is only as accurate – or as useful – as the information it receives. Plan Finder drug prices are updated regularly from October through August. Pricing for the current year is frozen in September in preparation for the new plan year’s display.

During the active months, Medicare requires health plans to submit files that update the costs of prescription drugs every two weeks. Many plans delegate this function to their PBM, but it’s important that health plans stay engaged in this process and ensure that there are effective processes to oversight these frequent submissions.

Why? Because Medicare wants to make sure enrollees are provided the most accurate information when making the decision on what prescription drug plan works best for them. .

Let’s say a drug on the Medicare Plan Finder for your health plan is shown to cost  $4, but when CMS retrospectively reviews a claim for that drug they see that the member paid$10. This discrepancy can negatively impact your plan performance when it comes to the measure of accuracy of the Plan Finder information, not to mention the potential for member grievances with a cost discrepancy like this.

Here’s what CMS wants plans to do:

  • Ensure timely and accurate CY 2018 pricing data for posting on Medicare’s Plan Finder.
  • Identify preferred cost-sharing pharmacy arrangements in the Plan Finder pricing files.
  • Confirm pricing and pharmacy network data files for the Plan Finder are up-to-date, correct and accurate, and that only pharmacies under contract are included in the tool. Incorrect data may result in suppression from the Plan Finder tool, as well as appropriate compliance actions.
  • Establish a routine process for sampling a subset of drugs and comparing the pricing on the Plan Finder site versus what is being adjudicated by your PBM at the pharmacy counter.
  • Evaluate your Plan Finder accuracy ratings report available for your plan to identify any potential areas of improvement.

If a health plan fails to update its prescription drug pricing and other information, it could be suspended or removed from the Medicare Plan Finder. The plan won’t show up when consumers do a search using the tool, so they won’t even know your health plan exists. That means less money going into your health plan and an overall loss of revenue over time.

How we can help

The team at Tier 1 Pharmacy Consulting can be the liaison between the health plan and the pharmacy benefit manager to help oversee the steps needed to ensure CMS compliance, including regular updates  to the Medicare Plan Finder. We can offer solutions on how to properly and effectively institute the appropriate process for oversight and ensure drug prices are, at all times, accurate and up-to-date all year.

We are experts in Medicare. Avoid a Plan Finder suppression by partnering with us. We can help you stay compliant at all times, so you can focus on running your health plan.

About Tier 1

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.