Regulatory & IRA Sessions

Actuarial Insights and Financial Modeling

Illustration of IRA modeling at the book-of-business and individual plan level and an overview of financial modeling options available for individual clients

Key takeaways:

IRA plan design changes will significantly increase plan liability, with a disproportionate impact for members receiving low-income subsidies (LIS). Higher CMS premium subsidies and risk scores will help offset higher plan liability.

Group retiree insurance (aka EGWP) should remain an integral part of your overall Medicare/Commercial strategy as these plans are not as severely impacted by IRA-related changes. Reach out to your account team to engage the Commercial/EGWP Growth Solutions team.

To help clients better plan for the changes in their 2025 bids, the PBM developed IRA modeling analytics, which are available for individual clients.

Click to download more information on CVS Caremark IRA Financial Modeling Options.

Don’t miss our Actuarial Forum Webinar on Wednesday, November 15. – Contact your Account Team for details

Becky Justice, Executive Director, PBM Actuarial Services

Pallav Tatapudi, Executive Director, Commercial and EGWP Growth Solutions

Becky Justice, Executive Director, PBM Actuarial Services

Jack Shamshoian, Executive Director, Product Management

Risk Adjustment and Financial Performance

Understanding risk score challenges and optimizing financial performance

Key takeaways:

With higher plan liability under the Part D benefit redesign, the portion of plan payments financed through risk adjustment (RA) will rise substantially.

Clients can prepare for and mitigate the impact of increased plan liability with advanced analytics, targeted outreach, enhanced provider coding and risk-adjustment solutions.

The PBM’s new Risk Optimizer is designed to maximize RA performance by identifying member risk and increasing health screenings.

Click to download more information on CVS Caremark Risk Optimizer.

Leveraging Formulary Solutions to Mitigate Regulatory Impact

Trends and information on utilization management, supporting adherence and CAHPS measurements and strategies to prepare for IRA changes

Key takeaways:

The PBM relies on client feedback to inform our near-term formulary and utilization management (UM) strategies.

The use of GLP-1 medications will continue to expand, given their efficacy and role in the treatment of type 2 diabetes and off-label indicators such as weight loss. Our formulary strategy aims to manage the off-label utilization while minimizing member impact.

Clients should evaluate the changing Medicare Part B UM requirements and the supporting processes needed within their plans.

Key areas of focus for our 2025 formulary templates include UM strategies, Part D redesign impacts for 2025 and beyond, Stars adherence and CAHPS measures performance, specialty and biosimilar drugs, and health equity.

Yvonne Southwell, VP, Medical Affairs

Lauralie Rubel, Executive Director, Medicare Regulatory Affairs

Sara Nelson, Director, Medicare Regulatory Affairs

Regulatory Affairs

Current state of Part D regulatory changes and proposals

Key takeaways:

The PBM is ready for 1/1/24 implementation of the new 2024 Medicare Final Rule requirements for utilization management of Part B drugs, including continuity of care and approval of prior authorization criteria.

Successful implementation of the 2025 Medicare Prescription Payment Plan depends heavily on health plan operations. Clients should examine their systems to determine IT or system configuration changes that may be needed.

Regulatory Affairs will continue to share regular communications to clients about new or revised CMS guidance in 2024, status updates for 2025 requirements and other material information. If you do not currently receive these communications, reach out to your account manager.

Government Affairs

How federal and state policy implications may affect the PBM and Medicare payers

Key takeaways:

Pay close attention to Part D changes in pending Congressional PBM legislation, particularly potential “de-linking” implications.

Continue to work with CMS on operational challenges with IRA provisions such as the Medicare Prescription Payment Plan (MPPP), which allows members to spread their out-of-pocket prescription drug costs over the calendar year instead of at point-of-sale.

Focus on improvements in Part D risk adjustment to prepare for Part D redesign implementation.

Don’t miss our Actuarial Forum Webinar on Wednesday, November 15. – Contact your Account Team for details

Bonnie Washington, VP, PBM Public Policy and Regulatory Affairs

Joy Enright, Director, Client Audit

Nancy Nichols, Senior Manager, Client Audit

CMS Program Audit Experience

Play, listen and learn about the 2023 audit season

Key takeaways:

Enrollment is a focus area for CMS program audits, with a high likelihood of being cited. Clients should conduct mock audits to ensure readiness, with a focus on enrollment.

Clients should determine if their audit playbook includes readiness for a program integrity audit notice. This includes evaluating their plan’s actions, risk assessments and the oversight and monitoring elements of an effective compliance program.

Clients should establish a clear outline for each audit session where the plan will be required to speak. Establish the appropriate spokesperson who is equipped to present appropriate and thorough responses to CMS inquiries.