Opportunities for Growth in the New Administration
"Opportunities are like sunrises. If you wait too long, you miss them." ―William Arthur Ward
With the new administration coming into power this month, there is a lot of conjecture over what might happen. Overall consensus is the one business segment that is the most stable is Medicare Advantage. Trump is a supporter of Medicare Advantage, and so are Republicans, although long-term there is an opportunity to change the financing of premiums. The Marketplace (Obamacare) and Medicaid are in “limbo” until we get a better idea of what and when there will be changes and how drastic they will be for these programs. So if you are looking for growth in revenue and/or enrollment, Medicare Advantage can provide a good opportunity. The other good news is that in the past several years, the Medicare Advantage market has been stable, based on the metrics available, with few changes in average premiums, plan offerings, and insurer participation.
If you are looking at the opportunity to grow or expand, there are many parameters to consider. Whether you are a Medicare Advantage plan considering expanding either your service area or products, Medicaid plans looking to add either Medi-Medi plans or Special Needs Plans, or an Accountable Care Organization or Integrated Health System looking to jump into Medicare Advantage, now is the time to explore this opportunity. Many of our clients are finding the most prudent way to expand and grow is a strong, solid strategy and an implementation plan that begins with a feasibility study.
A feasibility study looks at the market, and that analysis helps to build a strategy going forward for three to five years. This analysis looks at the competitive, financial, and demographic factors of a market(s) to see what is the most viable. This leads to a feasibility model based on detailed financial projections, and Gorman Health Group’s feasibility study process utilizes an onsite strategy exploration to walk through the entire process of entering Medicare Advantage or expanding current products and service areas with an emphasis on risks and rewards. The next step is the development of product/network/benefit design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.
No matter what your situation, this opportunity could be your sunrise, so don’t wait and join us for our webinar on January 31, 2017 at 1:00 PM EST for an informative session on how to conduct a feasibility study and taking it to the next step. Register now >>
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2017: Taking Stock to Inform Next Steps
As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.
- The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
- Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
- Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
- Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?
This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.
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We can help your MA-PD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
Reflections on the Basics of Delegation Oversight
Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.
With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.
As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:
- Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
- Understand how your delegate will demonstrate effective, compliant activities on your behalf.
- Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.
We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.
“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.
Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:
- Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
- Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
- Complete robust testing prior to new benefit implementation.
- Partner as a team (Compliance and Operations) to ensure success together.
- Maintain a dedicated unit focused on delegation oversight.
- Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.
Bonne chance!
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Preparing For The 2017 Call Center Monitoring
On November 16, 2016, the Medicare Drug Benefit and C & D Data Group of the Centers for Medicare & Medicaid Services (CMS) issued the “2017 Part C and Part D Call Center Monitoring and Guidance for Timeliness and Accuracy and Accessibility Studies”.
In an effort to ensure continued call center compliance in 2017, CMS has contracted with IMPAQ International, LLC, to monitor plan sponsors’ call centers. Although the call center requirements are nothing new for health plans, CMS describes the elements which will be monitored and provides tips on how to prepare for the monitoring studies. IMPAQ will conduct two studies – the Timeliness Study and the Accuracy and Accessibility Study.
As we are quickly approaching January 1, now is the time for plan sponsors to identify call center compliance issues and work to not only clean up any messes but to also beef up your call center staff. Compliance actions may be on the line, but so is the face of your organization – besides providers, your call center staff engages your members and prospective members most often. A confident and well-trained call center staff is crucial to your prospective and current member experience! Carrie Barker-Settles, Director of Sales & Marketing Services, says, “One of the most important beliefs in developing a strong member experience is effective communication to the member. A health plan may want to consider what messages, tone, look, and feel they want the member to see, read, and hear with every touchpoint.
Contact us for ideas on how we can partner with you to efficiently monitor your call centers in preparation for the 2017 CMS Call Center Monitoring and to empower and revitalize your call center staff and strengthen your member experience.
Below are further details on the 2017 CMS Call Center Monitoring:
Timeliness Study
- Measures plan sponsor’s current member call center phone lines and pharmacy technical help desk lines to determine average hold times and disconnect rates.
- Conducted year-round with quarterly compliance actions.
- Plan sponsor’s will receive a compliance action for the Timeliness Study if: 1) it fails to maintain and average hold time of two minutes or less; and 2) it fails to limit the disconnect rate of all incoming calls to 5% or less.
- Results will be available quarterly through the Health Plan Management System (HPMS).
Accuracy and Accessibility Study
- Measures plan sponsor’s prospective call center phone lines to determine: 1) the availability of interpreters; 2) TTY functionality; and 3) the accuracy of plan information provided by customer service representatives.
- Conducted from February through May with compliance actions taken when an organization’s interpreter availability is less than 75%, its TTY score is lower than 65%, or its rate of accurately answering questions is below 75%.
- Results will be provided via HPMS and announced via an HPMS email.
Do this now:
- Verify the accuracy of your 2017 Part C and Part D call center phone numbers in HPMS by January 2, 2017.
- Conduct internal monitoring to identify any compliance concerns for timeliness.
- Ensure interpreter availability and monitor call center calls to ensure foreign-language calls are handled according to your policies and procedures.
- Ensure your call center staff is prepared to promptly respond to beneficiary questions – CMS has their timer set at seven minutes!
- Test all your call center lines to ensure your ability to accept calls.
- Regularly test your TTY device to ensure proper functionality.
- Ensure your call center staff is trained and ready to respond to questions regarding items listed in the Medicare Marketing Guidelines, Section 80.1.
- Ensure your call center staff is trained on the 2017 benefit information.
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At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more about our Member Experience Services >>
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Internal Controls - Taking the "Risk" out of Risk Adjustment
Risk adjustment has become more and more of a “hot topic” these days. The critical implications and takebacks that occur with submitting unsupported diagnosis information and data inaccuracies are staring to become more real for a lot of health plans. This year, the Government Accountability Office (GAO) took aim at the lackluster auditing around risk adjustment the Centers for Medicare & Medicaid Services (CMS) was providing. With this high-stakes visibility, it is quite clear the Medicare Risk Adjustment Data Validation (RADV) and Commercial Risk Adjustment Data Validation (H-RADV) will start to become stricter over time. The industry has already started to see a greater focus from CMS with developing more refined processes for the 2015 H-RADV audit that is currently being conducted. There are a lot of intricate details very specific to RADV and H-RADV processes health plans need to make sure they are monitoring and preparing for.
Auditing for risk adjustment is no longer a matter of “if” your organization will be selected but rather “when” your organization will be selected. Here we are in 2016, and CMS is initiating Medicare takeback payments for unsupported diagnoses from 2009 dates of service data submissions. The lapse of time between the data submission and payment adjustment is quite significant. Certainly not something a Chief Financial Officer likes to see.
Although the H-RADV and RADV auditing timelines and processes are significantly different, the underlying foundation of being prepared is the same. Data validations are labor intensive for many departments throughout the organization because they require optimal attention to detail. In order for a health plan to ensure all minute details are addressed appropriately, a readiness plan with specific processes and corresponding time allocation needs to be in place. This allows all departments involved to have visibility into knowing what is expected of them “when” information needs to be provided for a data validation audit. Dedicated individuals will be able to spend more time paying attention to detail in their assigned task rather than rushing to figure out a plan to produce the needed information requested by CMS.
A lot of health plans are firm believers that conducting 100% chart reviews is the golden ticket to being proactive against adverse data validation results. Conducting chart reviews and coding validations are only half of the battle. The increasing visibility of risk adjustment requires risk adjustment auditing best practices become a way of life and are visible in the day-to-day core operational and technical processes that are established.
Building foundational processes around the operational risk adjustment best practices and developing a RADV/H-RADV Readiness Plan will put your organization in a good position “when” the time comes.
Contact us today to learn more about how GHG can help your organization develop best practice approaches to risk adjustment and create a RADV/H-RADV Readiness Plan.
Resources
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Preparing for the 2018 Medicare Advantage and Part D Application Season
On October 31, 2016, the Centers for Medicare & Medicaid Services (CMS) posted the 30-day releases of the 2018 Medicare Advantage and Part D new application and service area expansion instructions for public comment.
While this is not an annual process for each Sponsor, it is a yearly undertaking for Gorman Health Group. It is also a busy time for CMS staff who field the Notices of Intent to Apply and subsequent application submissions. Substantive proposed changes include the following:
- Chart of Required Attestations by Type of Applicant – The chart was revised to provide the applicants with clarification in identifying fiscal soundness requirements.
- Administrative Management – CMS clarified the information for the two-year ban period and inserted the date for the two-year period for the current application cycle.
- State Licensure – CMS clarified the information regarding licensure requirements, which should reduce the number of deficiencies related to licenses that automatically renew after the applications are due.
- CMS Provider Participation Contracts and Agreements – CMS removed the attestations due to duplicative and redundant language.
- Health Services Management and Delivery (HSD) –
- CMS clarified the information for applicants regarding Medicare certification requirements based upon public comments received in response to the 60-day comment period. Medicare certification is only required for applicable providers and facilities.
- CMS clarified the information for Regional Preferred Provider Organization (RPPO) applicants regarding the network requirements and contract agreements. The volume of RPPO applicants has been extremely minimal in previous application cycles.
- CMS clarified the instructions for applicants regarding the submission and process for HSD tables and Exception Requests based upon public comments received in response to the 60-day comment period.
- Revised attestation in Eligibility, Enrollment, and Disenrollment to include an additional option for beneficiaries to make a disenrollment request by calling 1-800-MEDICARE.
- CMS revised the signature authority for a Special Needs Plan upload document to include both Chief Executive Officer (CEO) and Chief Operating Officer (COO) based upon feedback from the previous application cycle.
- CMS clarified the information for applicants related to the regulatory requirements in the development of the Model of Care (MOC).
The Part D application documents note they made no substantive changes, instead providing a redlined version to outline updates made to reflect the 2018 cycle and instruction clarifications. Keep your eyes open for the final applications to be released sometime in January, along with the no-cost training calls CMS will hold prior to the submission date of February 15, 2017.
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The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization. Don’t let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
First Year Communication – Building Loyalty and Trust
How can you deliver customized and personalized products, services, and experiences to members? You and your team need to begin with understanding your membership. Defining your membership by both value and their needs provides line of sight to information that will influence loyalty and trust.
Questions that should be asked by you and your team to better understand your customers to build loyalty and trust:
- Does the health plan know what the customer really wants and needs?
- Is there a shared understanding of who the health plan’s most valuable customers are and how to meet their needs?
- How does the health plan communicate with their members to better understand their needs?
- Is health plan customer data integrated and easily accessible across the health plan?
- Do the right employees have access to the right information about the health plan’s members?
- Does the health plan have knowledge of the current inventory of member touchpoints that exist today?
- How does the health plan define “member?” Who is the member?
- How is the health plan currently perceived in the market today, not just by current members but by prospects, providers, employers, and community influencers?
Now more than ever, websites are becoming the primary resource by which Medicare beneficiaries not only research health plans in the buying process but also seek out information regarding their coverage once they are enrolled. The member website can support member communication by being clear and easy to navigate and, most importantly, by including a password-protected Member Portal. The Member Portal should include the following:
- Calendar of local events
- Health screening reminder banners
- Monthly member newsletter
- Real-time access to:
- Eligibility
- Benefit information
- Formulary information
- Claims information and status
- Care gaps information
- Wellness resources
- Access to plan documents
Diane Hollie, Gorman Health Group’s Senior Director of Sales & Marketing Services, says, “Medicare beneficiaries, especially baby boomers, want to access information in the format they are most comfortable with, and, for many, that is the web. Many beneficiaries want to access their information online, and having a strong interactive member web experience that is easy to navigate will reinforce the health plan’s initiative to drive first year communication.” This first year communication builds a foundation for future dialog that provides the member with valuable and time-saving information relating to the member’s personal healthcare.
Trust is essential to Medicare beneficiaries, and building relationships with members will harvest that trust. Taking an interest in your clientele, cultivating shared values, and implementing solutions to customer inquiries will support any customer service department in exceeding member expectations.
Instead of waiting for problems to occur, implement preventive services that can eliminate problems before they happen. By creating a path for customer inquiry resolution, you and your team can ensure member loyalty and trust, which ultimately results in member retention. There are two options for the member retention-focused customer resolution:
- Option One: Utilizing Existing Customer Service Department
- Enable existing customer service department to solve customer issues
- Become the customer’s trusted advisor and build customer loyalty
- Reduce customer complaints and create solutions to common customer problems
- Online communication – “click to chat”
- Option Two: Designated Member Experience Department
- Assign each member a single point of contact
- Execute on key member communication
- Drive attendance to member meetings
- Second-tier customer resolution
- Monthly complaints review
- Denied claims outreach, if applicable
- Welcome home call after discharge from hospital or nursing home
- Help navigate inquiries about provider access
This Annual Election Period (AEP), don’t just think about how to get new membership, think about how you will build that loyalty and trust for years to come.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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Gorman Health Group's member experience assessment is designed to meet a health plan’s concerns for retention and service to the member while remaining compliant and also providing strategies to enhance cultural competence, presenting opportunities for the health plan and providers to efficiently deliver healthcare services that meet the social, cultural, and linguistic needs of members. Visit our website to learn more >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
PBM-Supported Part D Measures Impact Quality Bonus Payment Revenues
Regulatory time frames around coverage determinations and appeals have existed since the inception of the Part D benefit. Timely access to medications has been a hallmark of the “member protective” stance the Centers for Medicare & Medicaid Services (CMS) has taken since Day 1. So how is it, even 10+ years into the delivery of the program, compliance with these time frames continues to be the bane of health plan Compliance and Star Ratings teams?
When CMS posted the 2017 ratings in October, the Medicare Advantage Prescription Drug (MA-PD) plan averages actually fell from 4.5 and 3.3, respectively, in 2016 to 3.9 and 2.9 in 2017. How can this trend be accounted for in the wake of ongoing CMS pronouncements regarding its dismay at the large number of auto-forwards sent for external review and that it would closely watch outliers and take vigorous enforcement actions against plans?
Even with all of the prodromal warnings by CMS, we have started to see the impact of low scores in these two measures in the newly released 2017 Star Ratings. Thirty-four plans that earned ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Of these, 53% earned only 1 star on both the Part D Appeals Upheld and Appeals Auto-forward measures, which, even if “artificially” reduced via unsatisfactory performance in CMS audits, were found to have substandard performance in this area.
Are Pharmacy Benefit Managers (PBMs) the culprit? Minimally, it must be restated the origin of these Star Ratings stemmed from compliance and member protection concerns, and if they were performing adequately, would have gone the way of, say…. call center hold times (by the same PBMs), which improved enough to be dispatched to the display measure list. Even with performance guarantees, intensive oversight by plans, onsite inspections, and internal audits, these misadventures continue to occur, and dire consequences follow. In general, PBM performance guarantees cannot begin to compensate for the potential lost bonus revenue, and plans are re-evaluating performance criteria, degree of health plan oversight required, and, in some cases, pondering the insourcing of all coverage determination-related activities. It may be time for “zero tolerance” in the health plan stance toward vendor-provided coverage determination services, as even one missed time frame may be a harbinger of more to come.
For questions or inquiries about how Gorman Health Group can support your organization’s Part D Star Ratings efforts, please contact me directly at lerwin@ghgadvisors.com.
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GHG anticipates that CMS will continue adjusting thresholds, curving the Star Ratings year after year in an effort to separate the remarkable from the ordinary. Now is a critical time – MA Plans must examine not just this year’s score and what contributed to it, but their Plan’s score history in the Stars program and what it says about the enterprise’s overall approach to key issues. Visit our website to learn more about how we can help your organization >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Provides Reminders on Key Dates in the MA-PD Application Process
Open Enrollment for the Affordable Care Act Marketplaces and the Annual Election Period for Medicare is underway. But this month also marks the start of required Centers for Medicare & Medicaid Services (CMS)-facing activities necessary for the application process.
Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group, points out “for many MA-PD applicants, activities are already underway. Oftentimes, Sponsors do not realize that the application requires all hands on deck until it is too late. It is a multi-disciplinary effort that requires attention to detail and collaboration at all levels of the organization.”
CMS recently released the following memos, providing reminders on key dates in the application process.
Release of Notice of Intent to Apply for Contract Year 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) and Related CY 2018 Application Deadlines
CMS released information and key dates about the Contract Year (CY) 2018 Notice of Intent to Apply (NOIA) web tool and key dates for the CY 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) application cycle.
2018 Application Activity Key Dates
NOI deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails…………………………........................................November 30, 2016
CMS User ID connectivity form submissions must be received.....................................December 2, 2016
CY 2018 applications posted on CMS websites..................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline.......................................................................February 15, 2017
Medicare-Medicaid Plan (MMP) Notice of Intent to Apply for CY 2018
CMS released information and key dates about the CY 2018 NOIA web tool and key dates for the CY 2018 MMP application cycle.
CY 2018 Application Key Dates
NOIA deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails……………………...............................................November 30, 2016
CMS User ID connectivity form submissions must be received by...................................December 2, 2016
CY 2018 applications posted on CMS websites................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline........................................................................February 15, 2017
Value-Based Insurance Design (VBID): Year 2 (CY 2018) Request for Applications
The Center for Medicare and Medicaid Innovation also announced the release of the Medicare Advantage (MA) VBID model test’s Request for Applications (RFA) for CY 2018. MA-VBID is an opportunity for plans to offer supplemental benefits or reduced cost sharing to enrollees with certain chronic conditions. Organizations that wish to participate in the model test in 2018, including those participating in 2017, must respond to the CY 2018 RFA by January 20, 2017, at 4:00 p.m. Eastern Time.
The application process is an arduous one. Completing the application requires cooperation from your entire organization. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow-up questions. As always, Gorman Health Group is here to assist your organization with the application process.
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Don’t let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Open Enrollment for the Health Insurance Marketplace Begins: Issuers and Enrollees Forge Onward with the Chaos
Beginning next week, consumers will start actively enrolling in the Health Insurance Marketplace for the fourth year of the Affordable Care Act (ACA). The open enrollment period for the Marketplace begins November 1, 2016, and runs through January 31, 2017. Consumers who would like to actively enroll for January 1 coverage are encouraged to enroll through healthcare.gov by December 15 to ensure they will have coverage in their selected plan the first of the year.
Specific to Qualified Health Plan (QHP) Issuers in the Marketplace, the Centers for Medicare & Medicaid Services (CMS) will once again challenge Issuers with navigating through a multitude of enrollee stressors this season. Here are just a few challenges:
- Redistribution of Enrollees to an Alternate QHP Issuer:Based on a number of QHP Issuers either exiting the Marketplace in specific counties/states or exiting altogether, 2016 enrollees are left to identify a new plan for next year en masse. As a means to encourage consumers to choose a new plan, CMS has targeted November 16 as the next notice date to urge consumers to actively select a new 2017 plan because their current plan will not be available through the Marketplace. Unique to other notices consumers have received, this notice will be the first time CMS will communicate an “Alternate Plan Option” by defining the health plan name CMS has matched to the enrollee for each member currently enrolled in the household. Included in the notice is language related to how the alternate plan will communicate with the consumer through a welcome letter and a bill for the first month of coverage if they choose to activate. Enrollees are encouraged to either select a new plan altogether or activate the alternate plan to avoid a gap in coverage.Issuers have the opportunity to gain membership in this scenario, but there is no way to predict consumer behavior, especially for consumers who have been inundated by communications regarding this shift.
- Renewals to 2017 Coverage Year:A week leading up to the opening of enrollment on November 1, QHP Issuers are receiving state-by-state files detailing current enrollees who are being passively re-enrolled into 2017 plans. As the renewal process is a constant challenge for Issuers and CMS, ensuring the right members are being rolled into the correct plan is critical. A major component of the renewal process is to pause and identify inaccurate renewal data and ensure membership is updated within both systems (Issuer and CMS). This also includes recalculated eligibility for Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR).
Now that policy-based payments (PBPs) are in place, errors generated from inaccurate Batch Auto Renewal (BAR) processing will create an immediate financial impact to the Issuer for January 2017 payment. Financial impacts based on bad membership data were not realized in previous Q1 periods, but with operationalized PBPs, CMS now pays Issuers based on the Federally-Facilitated Marketplace (FFM) system. In other words, if CMS passively enrolls a member but the Issuer does not, it will automatically generate a non-member payment to the plan.
- Unaffiliated Issuer Enrollments (UIEs) or Issuer Orphans:Based on comparing Marketplace membership data between the Issuer system and the FFM system through the reconciliation process each month, UIEs are identified which represent members who are present on the Issuer system but not found on the FFM. Understanding UIEs represent enrollees who would not receive an initial 1095A notice for coverage nor would the Issuer receive payment from CMS for providing the benefit, CMS has acknowledged a solution needs to be extended to all interested parties this year. While guidance is still pending, CMS has assured the industry 2016 members will receive a manual 1095A, and Issuers will receive a payment adjustment through an undefined process.
As for the good news, CMS is addressing the fix prior to year-end, but it is yet to be seen whether the solution includes a front-end fix to end the generation of UIEs altogether.
- Periodic Data MatchingOn a periodic basis, CMS uses data criteria to identify individuals who are receiving financial assistance by enrolling in the Marketplace but at the same time are eligible or are enrolled in other Minimum Essential Coverage (MEC) such as Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). If enrollees choose to stay dually-enrolled in a Marketplace plan, they will no longer receive APTCs or income-based CSRs per the regulation.
Issuers continue to receive files from CMS to aid in outreach efforts to elicit action by the consumer and ensure they understand the loss of financial assistance before receiving a bill. Part of the process is helping consumers understand they are eligible for other coverage and to determine the appropriate MEC for them.
With the interim processes that are all too common for QHP Issuers, one fact is evident with managing membership – the data always tells the truth. Issuers will commit to working through the requirements as detailed above, support all open enrollment functions, and diligently work to resolve immediate membership issues that arise with January coverage. As with every new challenge that impacts enrollment, Issuers who have a robust reconciliation process to detect and resolve issues will be best positioned to measure and respond.
In parallel, the member experience leading into 2017 will be reacting to the some of the same challenges and a few more, including a 25 percent rise in premiums as stated by Health and Human Services (HHS) this week. Some enrollees will need a new plan, receive a manual 2016 tax notice, or be confused by notifications regarding their re-enrollment or other data matching issues. Others may receive a welcome kit and bill from a plan they did or did not select. When you review all the consumer touchpoints, it is evident the work ahead is a shared responsibility between the Marketplace, the member, and the QHP Issuer to ultimately get the member record right on all fronts. Collectively, the industry has made great progress this year, but we are still dealing with the chaos of a new government program.
Gorman Health Group’s proprietary tool, Valencia™, which currently reconciles 45 percent of the 11.1 million Marketplace enrollees, supports clients’ reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes – and the resulting payment – are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
Resources
To learn more about our Valencia™ product, reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
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