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Each year, the Centers for Medicare and Medicaid Services (CMS) issues its Part C and Part D Program Audit and Enforcement Report. I liked how CMS did it in years past, where actual plan audit scores as well as average scores by audit area were released. It gave you a great feel for where plans were struggling the most. Nonetheless, the report continues to be a good tool for Medicare Advantage (MA) and Part D plans (MA-PD or standalone PDP) to review and hone their compliance chops. Here are the major findings from this most recent report (link at bottom). As well, I will go through what I heard about 2024 audits from plan friends and contacts. Background CMS has been expanding the audits it does, using both internal and external expertise.  In 2023, a total of 69 MA-PD contracts were audited — 31 of these contracts offered special needs plans (SNPs). CMS also

Major concerns are emerging that standalone Part D (PDP) plans are seeing skyrocketing premiums due to the unintended consequences of major Part D restructuring and out-of-pocket (OOP) cost reduction passed as part of the Inflation Reduction Act (IRA). A new report by the Council for Affordable Health Coverage (CAHC) asks Congress to intervene on what will be growing impacts in 2025 after premium rises in 2024. The increased costs in Part D are tied to a number of changes in the IRA. I went in-depth on all the Part D changes included in the IRA in an earlier blog on April 15, 2024: https://www.healthcarelabyrinth.com/major-changes-occurring-in-medicare-part-d/ . New costs to plans in Part D due to IRA Here is a brief summary of additional costs in the IRA now borne or will be borne in whole or part by plans since the IRA passed: 2023: 2024: 2025: In addition, PBMs are now

For those involved in politics, candidates and parties fear what is known as the October Surprise, a scandal or national or world event that threatens to upend candidacies and partisan control of federal and state bodies. These events can be planned (e.g., by opponents) or unplanned (e.g., a terrorist attack or other world event). With the election very close, especially with the change at the top of the Democratic ticket due to President Biden’s lagging performance, many are thinking these types of events could be potential game changers on Election Day. But are the Democrats forgetting about a potential October Surprise they themselves may have created that could impact their electoral chances? Let me explain. Medicare enrollment season Each October, the enrollment season begins for Medicare Advantage (MA) and Part D plans. In the MA world enrollment is fully voluntary for individual policies. In the standalone Part D (PDP) world,

I have talked often about horizontal and vertical integration in healthcare in these blog pages and on my podcast. One major blog I wrote on vertical integration is here from December 21, 2023: https://www.healthcarelabyrinth.com/do-health-plans-relationships-with-owned-entities-open-up-more-scrutiny/ . Let me recap a little as background before I get to an extremely interesting infographic Jared Strock did recently. Jared is an actuary and health insurer/Medicare Advantage market and finance expert. He posts daily and is well worth following. I posted his graphic, his LinkedIn, and a recent post he did on LinkedIn below. Key background on vertical integration from my earlier blog In comes Strock’s analysis Strock used his financial skills to comb public company financial disclosures to show just how big related-party transactions have become. Here is a summary of what Strock said in his LinkedIn post (link right below the graphic): Graphic source and notes: Q1 2024 financial information for seven major