Rise

Chairperson’s Opening Remarks and Day One Takeaways

Angela Lloyd, Associate Compliance Officer
Jefferson Health Plans

Navigating the 2025 Medicare Advantage Final Rule

• Analyze the key changes introduced by the 2025 Medicare Advantage Final Rule and their implications for Medicare Advantage plans 
• Develop comprehensive strategies to ensure compliance with the new regulations, including adjustments to operational, marketing, and network adequacy practices 
• Implement effective communication and training programs to educate staff, agents, and beneficiaries about the new requirements and compliance expectations  

Annie Shieh, AVP, Compliance
Molina Healthcare

Patricia Henderson, Director, Compliance 
Jefferson Health Plans

Managing Third-Party Marketing Restrictions

• Understand the new restrictions imposed on Third-Party Marketing Organizations (TPMOs), including the prohibition on collecting personal data without prior express written consent
• Evaluate the impact of these restrictions on existing marketing practices and lead generation strategies, and develop action plans to ensure compliance while maintaining effective outreach efforts
• Implement best practices for managing agent and broker relationships to ensure compliance with the new rules

Shelley Segal, CEO
Segal Medicare Experts

Liza Arias, Vice President
Segal Medicare Experts

Important RADV Updates & Review of New Appeals Process

• Understand the revised RADV appeals process, including the separation of medical record review determination appeals and payment error calculation appeals 
• Implement strategies to manage the medical record review determination administrative RADV appeal process effectively before initiating a payment error calculation appeal 
• Navigate the timelines and procedural requirements for RADV appeals, including the issuance of revised audit reports  

Colleen Gianatasio, Director Clinical Documentation Integrity and Coding Compliance
Capital District Physician’s Health Plan (CDPHP)

Donna Malone, CPC, CRC, AAPC Approved Instructor, AHCCA, RAP, Director Risk Capture, Population Health Management
Mass General Brigham

Understanding the Medicare Prescription Drug Inflation Rebate Program: Implications and Compliance

• Explore the implications of non-compliance, including potential violations of the False Claims Act to highlight the risks and consequences of evading rebate requirements
• Discuss the civil monetary penalties for drug companies that fail to pay the required Medicare rebates
• Analyse past cases of whistleblower lawsuits and settlements under the Medicaid Drug Rebate Program to anticipate similar enforcement actions under the new Medicare Program, including notable blockbuster settlements, such as those involving Mallinckrodt, Eli Lilly, and Mylan

Mary Inman, Partner
Whistleblower Partners

Liz Soltan, Associate
Whistleblower Partners

Enhancing Care for Chronically Ill Members: Mastering Special Supplemental Benefits (SSBCI) Implementation and Compliance

• Understand the new requirements for Special Supplemental Benefits for the Chronically Ill (SSBCI) 
• Develop comprehensive SSBCI programs that include innovative benefits designed to improve health outcomes for chronically ill members 
• Implement effective processes for identifying eligible beneficiaries, coordinating care, and ensuring compliance with CMS guidelines  

Ana Handshuh, Principal
CAT5 Strategies

Caroline Yaun, BSN, LNC, Senior Consultant, Clinical
Rebellis Group, LLC

Assess New Outpatient Behavioral Health Network Adequacy Standards

• Understand the new network adequacy standards including the addition of the "outpatient behavioral health" category 
• Implement effective verification processes using reliable data sources such as claims data 
• Integrate telehealth providers into the behavioral health network to meet the contractual requirements and improve access to behavioral health services  

Tricia Beckmann, Principal
Faegre Drinker

Kacey B. Dugan, Director - Policy & Regulatory Affairs
Faegre Drinker

Yavar Moghimi, MD, Medical Director, Behavioral Health
AmeriHealth Caritas Family of Companies

Closing Remarks

Angela Lloyd, Associate Compliance Officer
Jefferson Health Plans