Medicare Part D

Subscribe to Medicare Part D RSS Feed

Medicare Part D Preemption: Supreme Court Review Uncertain  

By Michele Munk on Posted in 10th Circuit, 1st Circuit, 8th Circuit, Medicare Part D, U.S. Supreme Court
On July 29, 2024, Pharmaceutical Care Management Association (“PCMA”) filed an opposition to Oklahoma’s petition for writ of certiorari in the United States Supreme Court, seeking review of the Tenth Circuit decision PCMA v. Mulready, 78 F.4th 1183 (10th Cir. 2023). Oklahoma seeks review of both ERISA and Medicare Part D preemption.[1] Mulready held that … Continue Reading

CMS Proposes to Lower Drug Prices and Reduce Out-of-Pocket Drug Spending with Respect to Medicare Coverage

By John Wyand and Doug Anderson on Posted in CMS, Medicare Advantage, Medicare Part D, Pharmaceutical, Proposed Rule
On Friday, November 30, 2018, the US Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (Proposed Rule) to revise Medicare Part D (Part D) and Medicare Advantage (MA) regulations to promote health plan negotiation of lower drug prices and to reduce out-of-pocket spending for enrollees. The Proposed Rule contains four areas of … Continue Reading

CMS Updates the Part D Prescription Drug Benefit Manual – Chapter 13 & 14

By Squire Patton Boggs on Posted in Insurance, Medicare Part D, Payer/Insurance Reform
Last month, CMS updated Chapters 13 and 14 from the Part D Prescription Drug Benefit Manual (PDBM). These updates affect Part D plan sponsor operations as well as network and non-network pharmacies. In Chapter 13, CMS updated its guidance on premium and cost sharing subsidies for low-income beneficiaries under the Part D program. In Chapter … Continue Reading

The New Federal Blueprint to Lower Drug Prices

By John Wyand, John Bunch and Doug Anderson on Posted in 340B Program, CMS, Drug, EU, International Healthcare, Legislation, Medicare Part D, Pharmaceutical, Policy, Reimbursement
On Friday, May 11, 2018, President Trump vowed to fix “the injustice of high drug prices” by announcing the “Blueprint to Lower Drug Prices” (the Blueprint) to address the following challenges: Excessively high drug prices Seniors and government programs overpaying for drugs High out-of-pocket costs for consumers Lack of transparency in drug pricing Free-riding by … Continue Reading

House Ways and Means Committee Advances Opioid Bills

By John Wyand on Posted in Medicare Advantage, Medicare Part D
On Wednesday, May 16, the House Ways and Means Committee advanced four opioid crisis-related packages. The bipartisan measures, which are expected to move with other House bills under consideration, largely focus on combating the epidemic through strengthened prevention, provider and beneficiary education, and treatment options. During the markup, Ways and Means Chairman Kevin Brady (R-TX) … Continue Reading

Largest National Health Care Fraud Take-Down in History Focuses on Medicare Part D

By Squire Patton Boggs on Posted in Anti-kickback Statute, Civil Monetary Penalties Law, False Claims Act, Fraud and Abuse, Medicare Part D
On the heels of its announcement that it is “hiring additional lawyers to look into taking more administrative actions against” physicians, the Office of Inspector General (OIG) recently filed 75 indictments and 14 complaints against various parties. The OIG’s “national sweep” yielded prosecution of $712 million in false billings and led to charges against 46 … Continue Reading

CMS Finalizes Medicare Part C and Part D Program Changes for Contract Year 2015: Moderate Deviations from Proposed Rule

By Squire Patton Boggs on Posted in ACA, Compliance, Department of Health and Human Services, False Claims Act, Fraud and Abuse, Insurance, Managed Care, Medicare Part D, Payer/Insurance Reform, Pharmaceutical, Publications, Reimbursement
On January 8, 2014, we noted several proposed changes to the Medicare Part C and D programs as delineated in CMS’ January 8th proposed rule (hereinafter “Proposed Rule”). On Monday, May 19, 2014, CMS issued the final rule, titled Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare … Continue Reading

Is Your Name on the List?

By Squire Patton Boggs on Posted in Compliance, Department of Health and Human Services, False Claims Act, Fraud and Abuse, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Physician Practice, Reimbursement
Given the 880,000 names of physicians released by Medicare Wednesday, physicians who treat Medicare patients can expect their names to be on the list.  The list, searchable here, contains the name of the provider, the specialty area, the city, county and state as well as the total payments made to the provider by Medicare for … Continue Reading

Florida Proposes Pharmacy Audit Rights Legislation

By Kimberly Donovan on Posted in Compliance, Fraud and Abuse, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Pharmaceutical
The Florida legislature is currently considering proposed legislation that may affect the way in which managed care organizations, insurers, third-party payors, pharmacy benefit managers and other entities audit pharmacies in Florida.  The Florida House of Representatives, Health Innovation Subcommittee, is reviewing HB 745, which proposes to create a “Pharmacy audit bill of rights.”  The Health … Continue Reading

CMS Ushers in the New Year with Medicare Part C and Part D Proposed Rules: HHS Hopes to Save $1.3 Billion

By Squire Patton Boggs on Posted in ACA, Compliance, Department of Health and Human Services, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Regulatory Compliance, Reimbursement
On January 10, 2014, CMS will publish the proposed rule titled Medicare Program: Contract Year 2015 and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs (the “Proposed Rule”).  The Proposed Rule propositions extensive reforms to the Medicare Advantage (“Part C”) and Medicare Prescription Drug Benefit Program (“Part D”), partly through … Continue Reading

HHS Releases "Rate Review" Impact Data: Policyholders Save $1.2 Billion Nationwide

By Squire Patton Boggs on Posted in ACA, Accountable Care Organizations, Department of Health and Human Services, Hospitals, Insurance, Managed Care, Medicare Advantage, Medicare Part D, Payer/Insurance Reform, Reimbursement
Last Thursday, September 12, 2013, the Department of Health and Human Services (“HHS”) reported that the rate review provisions (the “Rate Review Provisions”) of the Affordable Care Act (“ACA”) saved an estimated $1.2 billion on health insurance premiums in 2012 for 6.8 million policyholders.  The Rate Review Provisions are intended to increase transparency behind premium … Continue Reading

In Case You Were Wondering, CMS Takes Compliance Seriously: Lessons from a Medicare Part D Plan Sponsor’s Contract Termination for all Medicare Contractors and Providers

By Squire Patton Boggs on Posted in 9th Circuit, Compliance, Fraud and Abuse, Medicare Part D
The Centers for Medicare and Medicaid Services (“CMS”) has historically used its authority to immediately terminate Part D plan sponsors only sparingly.  In fact, it has done so only once.  However, when it chooses to exercise this authority, plan sponsors should not count on courts to come to their aid.  In Fox Insurance Co., Inc. … Continue Reading
LexBlog