A New Report by Kaiser Family Foundation Found Part D Premiums Will Rise an Average of 13% in 2016
We blogged earlier this month about Medicare Advantage (MA) premiums showing slight decreases to no decreases across the board for 2016 based on the Centers for Medicare & Medicaid Services (CMS) estimates. But what does the landscape look like for Part D?
CMS stated in a September 2015 article, "Premiums in the Medicare Prescription Drug Program (Part D) will [also] be stable next year." Earlier this year, CMS announced the average basic Medicare prescription drug plan premium in 2016 is projected to remain stable at $32.50 per month.1 CMS' Part D average premium estimates include both Medicare Advantage Prescription Drug plans (MA-PDs) and Prescription Drug Plans (PDPs). If we carve out PDPs from the Part D premium average reported by CMS in September, data shows, for most PDP enrollees, premiums are projected to be higher in 2016 than in 2015, and many will also see higher deductibles and more cost-sharing tiers with coinsurance.2 As cited in a recent Kaiser Family Foundation study on Medicare Part D plan offerings for 2016, the average PDP premium is projected to increase by 13 percent from 2015 to 2016, from $36.68 to $41.46 per month. When looking at the $0 premium PDP options, low-income subsidy (LIS) enrollees will have fewer to choose from. This means either plan reassignment or beneficiary plan switches will occur for beneficiaries to continue without a premium.
What will this mean for MA plans offering Part D coverage in 2016? Increased 2016 PDP premiums may contribute to a potential shift in membership from PDPs to MA-PDs this Annual Election Period (AEP). Leveraging this opportunity will require time investment from MA-PDs, educating beneficiaries on how making plan changes could lead to beneficiary cost savings and still meet their Part D coverage needs.
"Premium" may be the first category beneficiaries are looking at, but it is not the only thing beneficiaries consider when comparing Part D options. The entire point of AEP is to offer Medicare beneficiaries the opportunity to evaluate their plan options and choose a plan which best meets their needs. This means, in addition to premiums, beneficiaries are looking at deductibles, cost-sharing, formularies, and network pharmacies.
In 2016, 84 percent of PDPs will use tiered pharmacy networks, with lower cost-sharing in selected network pharmacies and higher cost-sharing in other network pharmacies. Two-thirds of all PDPs will have deductibles, with a growing share of PDPs imposing the maximum deductible allowed by law, which increased from $320 in 2015 to $360 in 2016, the largest increase in the deductible since the start of the program.2
Now that the cards are on the table, your immediate strategy, as well as that for next AEP, should be examined. Are you at risk for losing members to competition due to pricing increases? Are your retention efforts aligned to address this issue? Have you identified opportunities to gain membership and benefit from your competitors' increases?
Have questions or need information? Contact me directly at nlennig@ghgadvisors.com or Charro Knight-Lilly, Senior Vice President of Client Services, at cknightlilly@ghgadvisors.com.
1 CMS, "Medicare Prescription Drug Premiums Projected to Remain Stable" available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-29.html.
2 Oct. 13, 2015 | Jack Hoadley, Juliette Cubanski, and Tricia Neuman, Medicare Part D: A First Look at Plan Offerings in 2016, http://files.kff.org/attachment/issue-brief-medicare-part-d-a-first-look-at-plan-offerings-in-2016
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The Transition From RAPS to EDS: New Offering Helps Your Plan Calculate & Define Risk Level
In 2016, the Centers for Medicare & Medicaid Services (CMS) will start to transition from utilizing Risk Adjustment Processing System (RAPS) files, to support the Medicare risk adjustment payment, to encounter files. The transition process is gradual, with a weighted percentage being taken for 2016: 10 percent based on the encounter files and 90 percent based on the RAPS files. With this transition, it is critical that health plans ensure that their RAPS files and Encounter files are in sync. Oh- and the vendors are on the hook for this too.
For some, the financial and operational impact of the transition from RAPS files to EDS files for risk adjustment is still a mystery. On October 23, CMS announced further guidance regarding RAPS and EDS Submissions.
There were three key elements:
1). The addition of diagnoses submitted after the risk adjustment deadline for payment year
2). The submission of HIPPS Codes for CAH's
3). The use of default NPIs for atypical providers.
Gorman Health Group (GHG) continues to stress the importance of accurate and timely submission of RAPS and EDS files to CMS. This memo clearly supports our rationale behind this emphasis, and it takes it one step further. Your organization not only needs controls on the front end, it needs quality oversight and standard operating procedures in place to manage the file return elements from CMS.
CMS states that it will not incorporate into the risk score for a payment year additional diagnoses submitted after the risk adjustment deadline. Specifically, after the final risk adjustment submission deadline for a payment year, only diagnoses deletes will be included in a rerun of risk scores for the payment year. Knowing this, there is no time like the present to reevaluate your RAPS and EDS processes. Our new capability will help your plan do this while calculating and defining its current level of risk.
This is a critical time and an imperfect process for health plans and risk baring provider groups, GHG is excited to introduce our new RAPS/EDS Variation Analysis capabilities. Our team of operations and data experts will assess your current processes and data, identifying gaps and discrepancies that need to be addressed in order to ensure compliance and secure accurate payment from CMS through Risk Adjustment operations.
Clients will receive the following critical items upon completion of the analysis:
- Operational Assessment Report - Outline of the processes that the health plan currently has in place for RAPS/EDS file submissions, returns and error resolution, providing areas of opportunity for improvement.
- Variation Analysis Review - Review of findings, outlining instances for potential inaccuracies and risks associated with the health plans current methodology and processes applied to the internal variation analysis.
- Discrepancy Reports - Identifies opportunities to improve completeness and accuracy of each submission to CMS.
- Encounter File Member Analysis - Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the RAPS file member analysis.
- RAPS File Member Analysis - Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the encounter file member analysis.
With this information, a health plan can feel confident that they fully understand the revenue and operational impact of this transition and are able to put processes in place to ensure that there is no loss of revenue or instances of data inequities when transitioning to the Encounter file format.
For more information on our approach and the results, please contact me directly at dweinrieb@ghgadvisors.com.
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Relief for Plans Serving Dual Eligibles?
It seems as though the Centers for Medicare & Medicaid Services (CMS) may be taking a detour in their position on the effect of socio-economic characteristics of a plan's enrollees. Last week, CMS announced plans to release a proposal to change Star Ratings for plans with significant low socio-economic beneficiaries, in a forthcoming request for comment for updates to the program in 2017. CMS stated the agency will release this request for comment by early November.
Although the health industry has voiced their dissatisfaction for quite some time now with the current rating system being applied to dual eligibles, CMS warming to the idea is a bit surprising. Just last month, CMS announced its results from the study, stating that while "research to date has provided scientific evidence that there exists an LIS/Dual/Disability effect for a small subset of the Star Ratings measures, the size of the effect is small in most cases and not consistently negative." This month, the Medicare Payment Advisory Commission (MedPAC) also chose to postpone making recommendations until it saw what action CMS takes.
While this change in position is welcome, it is unclear whether CMS will actually implement a solution. CMS has previously proposed a temporary solution to reduce the weight of seven measures but, after negative feedback, chose not to implement the proposal. It is also unclear whether this change in position comes from new findings CMS has yet to release or whether it changed its position based on the analysis released from the study last month, where the disparities in measures were found to be "insignificant."
Until we see whether CMS changes its position on dual eligibles, plans falling below three stars for three years under the current rating system will still face termination, regardless of the number of dual eligible enrollees enrolled in the plan, if they cannot improve their performance to at least three stars.
Stay tuned.
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2015-2016 CMS Program Audit Protocols Update
It's Christmas in October (and Hanukkah, too) if you've been waiting for the revised 2015-2016 Program Audit process and protocols. Let's get right down to it!
You'll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?
Overall Process
- If the Sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in an audit report. After the third failed attempt, the Centers for Medicare & Medicaid Services (CMS) will classify this as an Invalid Data Submission, or IDS. There is NO reason a universe should be submitted late. Some of our Sponsor partners have required additional time for certain submissions, and they requested that time from CMS and got it. Nothing should irk senior leadership more than a universe being submitted a few minutes late, especially considering data issues in program audits directly impact Star Ratings.
- CMS Account Managers will be playing a greater role in the validation of pre-audit issue summaries, which are made up of disclosed and self-identified issues. CMS also clarifies if CMS identified an issue during the course of routine monitoring and brought it to the Sponsor's attention, it would be classified as a self-identified issue. There are specific timing issues CMS will consider in determining whether an issue is corrected or uncorrected. It is best practice for Compliance departments to incorporate a log similar to what CMS has provided in the management of disclosed and self-identified issues.
CPE
- Reduction of employee interviews, with addition of interview(s) of those responsible for managing accountability for FDR oversight. Not a surprise seeing as this has been a consistent finding for CMS throughout 2015 and previous years. Sponsors should coordinate and start mock interviews now with those who are responsible. CMS is seeing gaps in FDR oversight compliance whether or not you have three FDRs or three dozen.
- By the numbers:
- Tracer templates narrowed down from 2 to 1;
- Tracer samples increasing from 5 to 6, all to be conducted in week 2, so Compliance staff can participate in week 1 activities;
- There are 3 options for providing supporting documentation for tracers: embed into your Tracer, upload via SFTP, or have it immediately available onsite.
- CMS has incorporated a documentation request list to help them review the effectiveness of a compliance program. These documents will need to be submitted along with the 5 universes for this audit area. CMS has also provided a template for the Sponsor to demonstrate organizational structure and governance. This template includes a number of questions and data requests, and should help auditors compare apples to apples.
CDAG and ODAG
- Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) universe time periods will be determined by the Sponsor's enrollment size. In addition to numerous data layout clarifications and updates, CMS also details which universes may be combined with others to determine effectuation and notification scores.
- As previously announced in 2016, Part C and Part D grievances should be submitted based on date of resolution notification. They include a reminder not to include Complaints Tracking Module (CTM) cases in grievance universes. (Who is still including CTM cases in grievance universes? Please call us, whoever you are, and let us help!)
Formulary Administration (FA) and Special Needs Plan Model of Care (SNP-MOC)
- Thankfully, there were no significant changes noted in the core processes for these audit areas. Plans will note CMS has added the Cardholder ID to the SNP Enrollees (SNPE) record layout, and, more importantly, they request separate record layouts be submitted for each unique MOC rather than per contract.
Pilot Protocols
CMS commits to releasing the pilot protocols for Medication Therapy Management (MTM) and Provider Network Adequacy later this year.
- They describe one of their objectives for the MTM review to "initiate enforcement actions and/or identify possible performance measures for sponsors to implement." Technically, CMS can refer a Sponsor for enforcement action for any aspect of the audit. Why highlight it in MTM? Get busy making sure your program is in order.
- No surprises in network adequacy — CMS has emphasized they will be evaluating networks for adequacy by also evaluating whether or not participating providers' practices are open to treat enrollees. Some of our partner clients have already started their own internal evaluations to ensure this important beneficiary protection is met.
This year's audit season was a whirlwind of many things. For Sponsors and auditors alike, it's fair to say the industry struggled with the earlier-published protocol. Now that this document set has been released for 2015 and 2016, this should allow some breathing room for all to start implementing changes in tools, reports, and monitoring efforts. Unfortunately, that breathing room overlaps the upcoming holiday season, so perseverance is key! There is truly no rest for the weary.
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In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Let us help you create a culture of compliance. Contact us today to get started >>
If your organization is interested in a mock audit utilizing the latest protocols. We can help! The Online Monitoring Tool™ is our compliance software designed to help organizations operating in Medicare, Medicaid and the Health Insurance Marketplace track the compliance of their operations. Learn more >>
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10 Millon People Expected to Have Marketplace Coverage in 2016
The 2016 Health Insurance Marketplace open enrollment is right around the corner, opening on November 1, 2015. With premium rate increases well above 10% for 2016, it's no surprise the 2016 enrollment projections for the Marketplace are estimated to increase by less than a million from the total current 2015 enrollment, bringing the total individuals enrolled by the end of 2016 to 10 million.
In the most recent press release from the U.S. Department of Health and Human Services (HHS) on October 15, 2015, HHS is aiming to enroll more than one out of every four individuals eligible for Marketplace insurance. It's great news that more individuals will be enrolled, but 10 million is a rather conservative target set by HHS and significantly lower than the January 2015 Congressional Budget Office (COB) estimate of 21 million individuals. HHS anticipated the migration from employer-sponsored coverage to the Marketplace would be much more significant. Companies are still choosing to work with insurance companies directly to purchase health insurance as opposed to purchasing insurance through the Small Business Options Program (SHOP) or sending employees to the Marketplace to purchase health insurance on their own. This is contributing to the slower enrollment increase.
Starting in 2016, the definition of a small group employer will be increased to include companies having 51-100 employees. The enrollment increase we will see in 2016 will be due, in part, to this change. In previous years, these companies were classified as large groups and not subject to the Affordable Care Act (ACA) regulations. By changing the definition of a small group, it now requires companies having 51-100 employees to abide by the ACA regulations and will increase Marketplace enrollment. The annual tax penalty for not having health insurance will also be a driver for increased membership in 2016. The penalty for not having health insurance has been gradually increasing each year. The uninsured are becoming more aware of the tax penalty which will be applied to their annual income tax filing if they cannot provide proof of insurance coverage. For 2016, the penalty is $695 per person, or 2.5% of yearly income, whichever is greater. For each child under the age of 18, the penalty is $347.50. If 2.5% of your yearly income is greater, then the penalty will be capped at no more than the national average premium for a bronze plan. If your penalty is based on the per person/per child method, then the maximum penalty for a family is capped at $2,085. As the penalties start to increase, the more people with be inclined to purchase health insurance coverage.
For health plans, this means consumers are not just looking towards the Marketplace as the only channel to purchase health insurance. Health plans still need to be actively working with their sales brokers and potentially exploring new channels of enrollment, such as a private exchange. Redefining internal operations to support the changes implemented by the ACA should be the biggest focus for health plans right now. With the growing trend of members enrolling into a Qualified Health Plan (QHP), health plans need to be looking at transforming internal operations to support a more value-based outcome approach. This approach is driven by the company, provider, and membership knowledge acquired from internal data analytics.
The top three areas health plans should be focusing on are:
- Transitioning from a fee-for-service model to a value-based model
- Data management and analytics
- Risk adjustment operations
Ensuring all Americans have affordable healthcare is the core reasoning behind the ACA. The three areas listed above are starting points to help health plans keep the cost of healthcare down while ensuring individuals are offered affordable insurance with quality benefits.
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Considering Network Expansion? The Role Network Adequacy, Risk Adjustment, and Star Ratings Play
The leaves are changing colors, pumpkins are out on every front stoop, and the brisk weather signifies fall is in full swing. It also means we are in the midst of application season for health plans wanting to expand their geographic footprint. The Centers for Medicare & Medicaid Services (CMS) has put provider networks front and center under the bright spotlight, and Medicare Advantage (MA) plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's network adequacy and accessibility is a cornerstone of any new initiative.
In today's marketplace, it is no longer acceptable to meet the bare minimum health service delivery (HSD) requirements. Consumers, and CMS, are demanding plans be able to offer choices including quality and cost efficiency. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentive and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.
Additionally, the belt is tightening with day-to-day network management, and plans must reach out to their providers on a monthly basis to confirm demographics and availability of their providers to ensure the information is updated in real-time with online directories and close the loop between the providers submitted on the HSD tables versus those in the directory. We will also delve into network adequacy becoming part of the overall audit protocol pilot for 2015.
In an upcoming white paper, Gorman Health Group's (GHG's) Senior Vice President, Regan Pennypacker, will provide compliance insight on the draft application. A key network component in the draft is that plans will be required to submit their HSD tables for their entire network, not just the counties the plan is proposing to enter with the service area expansion request. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely.
Given that applications will be due in a few short months, GHG is here to help. We have a long history of providing direct contracting assistance for plans, the ability to run multiple network adequacy and availability scenarios, and prepare your plan's HSD tables for submission. We also have the bench strength to help you develop a true network strategy taking into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work together and build strategic network operations to support your plan goals.
Important key dates for application submission:
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GHG can assist your organization in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Let's get started. Contact us today
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MA-VBID Request for Applications Released
The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications for the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, which is an opportunity for MA plans to offer supplemental benefits or reduced cost sharing to enrollees with CMS-specified chronic conditions, focused on the services that are of highest clinical value to them. Applications are due by January 8, 2016.
CMS will tentatively select plans by April 2016. The application document repeats most of the information CMS released in the original announcement and webinar. However, the application will be submitted via a web portal which will be released in the near future. The process is much like the MA contract application process. CMS does provide information about the questions which will appear in the template.
Applicants will be required to present narrative explanations about their proposed interventions. First, there is the general overview of the proposed interventions describing the overall approach and understanding. This section must convey specific enough information tracking to details about interventions in later sections of the template. It will act to set the stage of an application.
Next, applicants must describe each separate VBID intervention. This will include each combination of plan and enrollee group so every target population is described with repetitive plan information and interventions. CMS describes the target population according to the eight qualifying diseases/conditions listed in the VBID demonstration.
Applicants must list specific benefits for each target population. CMS lists the various combinations of benefits:
- Reduction or Elimination of Cost Sharing (not conditional)
- Reduction or Elimination of Cost Sharing for High Value Provider
- Reduction or Elimination of Cost Sharing Conditioned on Participation
- Supplemental Non-Covered Benefits
CMS asks for "clear descriptions" in each of the four options and provides a number of elements applicants must discuss in their narratives.
While applicants must upload actuarial and financial documentation in this template, there are no specifications about the types of information for which CMS will ask. Notably, there is a statement that such information may not be required.
Health plans must also discuss their compliance history extending to January 1, 2010. Finally, an official of the applicant must certify their applications, their understanding about the conditions including marketing limitations, and bid requirements.
Data analysis is the key first step to identifying target populations and subsequent benefits which will become the focus of the demonstration. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations. Contact us to learn more >>
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Download a copy of the recording from the October 5 webinar titled "Medicare Advantage Value-Based Insurance Design Model (MA-VBID)", hosted by John Gorman.
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
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Data Revolution: The Need for Accurate Data to Drive Quality Analytics
The Affordable Care Act (ACA) made a tremendous impact on the healthcare industry. What was once a free-flowing commercial market with very low requirements and data interaction has now transformed—it has morphed into a highly-regulated market heavily dependent on data to deliver quality outcomes for members and to remain financially sound. The processes set forth in the ACA mirror existing Medicare processes with adjustments in order to make the processes work for the Commercial population.
With the introduction of the ACA, data has had a staggering increase of importance and has become an integral part of the healthcare industry. The need to have refined data management processes to ensure data integrity and quality analytics is at an all-time high. Achieving this should be at the forefront of health plans' minds. Daily, health plans rely on the accuracy of their data for analytics which drive business decisions related to such things as rate setting, risk score calculations, federal and state data submission, and population health management. All too many health plans "assume" the information they are receiving from their membership, claims, and provider platforms into their data warehouse is accurate. This assumption is based on the fact these systems are considered to be "the source of truth." This terminology leads to false reassurance that just because it's the truth, it also means it's accurate. Always trust, but verify the data utilized. Inoperability between systems and software is a huge issue which increases your risk of losing data during transmission of information. Refined data management process and data governance are the links needed to bridge the data gaps.
When speaking about data and data management, the immediate correlation is to think of it as an IT department responsibility. With the growing regulations and oversight from the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) around data, it has now also become a business responsibility. Long gone are the days when a business area could simply submit a change request and not be a part of the IT functions to implement the change. It is a critical piece now to have the business department working side by side with the IT department to ensure the changes or updates being implemented are accurate and within the regulations set forth by the regulators. As we all know, CMS and HHS can have last-minute changes and hard deadlines to which health plans must adhere. Knowing that working to meet these deadlines can be strenuous to achieve and realizing the IT infrastructure within your organization is increasingly complex, the business needs to be working with IT daily to notify them of any changes related to their work. Such items would include changes to the deadline, format, or field requirements, to name a few. It is a much more agile process than ever before. Having a business area who understands the technical components and effort needed to complete a desired change along with the required regulations leads to a much more successful engagement between IT and business.
There was a release on October 6, 2015, from HHS regarding rules to advance electronic health records with added simplicity and flexibility. HHS recognizes there is a need to make health information available quickly and easily to those who need it, as noted by the comment from Karen B. DeSalvo, M.D., M.P.H., M.Sc., national coordinator for health IT. She stated, "This rule is a key step forward in our work with the private sector to realize the shared goal of making actionable electronic health information available when and where it matters most to transform care and improve health for the individual, community and larger population. It will bring us closer to a world in which health care providers and consumers can readily, safely and securely exchange electronic health information." This is a huge advancement for HHS. Health plans need to establish and perfect their data infrastructure now so, as advancements occur within other areas of the industry, they are able to receive and store information utilized for analytics.
Here are some important questions to ask yourself when it comes to your organization:
- Does your organization have a solid data management process in place to account for CMS and HHS requirements which could withstand an audit?
- Has a clear understanding been established on the inoperabilities existing within the company and established ways to remedy any issues which may occur?
- Has data governance been established?
- Are integrated analytics established throughout the areas highly focused on member and provider engagement to support risk adjustment and Star Ratings?
- Is your organization able to analyze population health management information easily and effectively on a consistent basis?
If you answered "no" to any of these questions, you will want to evaluate your current structure to identify areas of opportunity. The data within your organization provides the knowledge you need to understand your organization, members you serve, and maintain your financial solvency. Clean data to drive quality analytics is something every health plan wants. You need to ensure you have the right processes in place to manage the data within your organization effectively to set yourself apart from your competitors.
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Healthcare Trends: ICD-10, Mergers, Part B Premiums & MA-VBID
ICD-10
We are into our third week of ICD-10, and so far, reviews of implementation woes have been mixed. Some reports tout a smooth rollout process, with few problems — at least from the side of payers and clearinghouses. However, providers have noted several issues they are encountering from the transition, such as not being able to complete referrals, long wait times with insurance company calls, and possible delays in payment.
Merger Updates
Both the House and Senate held hearings on the pending health insurer mergers, with light grilling of the executives and less than anticipated contention during the Senate hearing. There is a suggestion that the less than rigorous questioning of the executives meant a "win" for the CEOs. Only Senators Franken and Blumenthal seemed to show any serious concern over the consumer impact of the mergers. However, it is important to note that until the DOJ weighs in on the matter, the status of these mergers is still unclear, and the questions posed during both hearings were just the tip of the iceberg. These insurance giants will face much more scrutiny within the near future, with a careful analysis and rigorous review of potential market impacts from the deals.
HHS' Updated Shutdown Plan
HHS finally released its most updated contingency staffing plan, likely preparing for the possibility of a government shutdown in December. HHS estimates that 51% of staff would be on furlough. CMS would continue large portions of Affordable Care Act (ACA) activities, and the Medicare program will largely continue without disruption. CMS fraud and abuse activities will be curtailed, and fewer recertification and initial surveys for Medicare and Medicaid providers would be completed. The 2016 Contingency Staffing Plan is available here: http://www.hhs.gov/about/budget/fy-2016-hhs-contingency-staffing-plan/index.html
Reconciliation
The House of Representatives has moved forward with its reconciliation package that would repeal major provisions of the ACA — including the individual and employer mandate, Cadillac tax, medical device tax, IPAB — effectively dismantling the law. The package would also deny funding to Planned Parenthood. It is still unclear whether the Senate will vote on this legislation, and it is all but guaranteed to be vetoed by President Obama.
Part B Premiums
The 2015 Medicare Trustees Report estimates that Part B premiums will increase by 52% next year, from $104.90 to $159.30. Although beneficiaries purchasing Part B through Social Security deductions will be shielded from this increase, due to a likely no cost of living adjustment (COLA) in 2016, the remaining 30% will face a significant rate hike. This is because a "hold harmless" provision shields Social Security recipients from Part B premium increases which outweigh the Social Security COLAs. However, this means the 30% not qualifying under the hold-harmless provision will be on the hook for the entire increase in 2016.
Medicare Advantage Value-Based Insurance Design Model
The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications (RFA) for the Medicare Advantage Value-Based Insurance Design model. Applications are due on January 8, 2016. Interested organizations should begin conducting in-depth data analyses now in order propose a benefit plan in the RFA.
Resources
Download a copy of the recording from the October 5 webinar titled "Medicare Advantage Value-Based Insurance Design Model (MA-VBID)", hosted by John Gorman.
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
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The 2016 Star Ratings: Finding Calm in the Chaos
All great changes are preceded by chaos, and the Centers for Medicare & Medicaid Services (CMS) release last week of the 2016 Star Ratings certainly introduced a great deal of chaos for Star Ratings teams throughout the industry. With approximately 5% of additional reimbursement tied to ≥4-Star performance, health plan leaders are either taking a deep breath this week (if they earned ≥4 Stars and qualified for Quality Bonus Payments) or doing their best to quell the inevitable panic if the 4th Star eluded them.
CMS continues to leverage Star Ratings to support improvements in member perceptions and longer-term, sustainable improvements in health plan performance and health outcomes. CMS continues to make rapid, continuous changes among measures, cut points, and program criteria. The speed and extent of change reinforces the need for a seasoned, dedicated Star Ratings leadership team which embraces and manages Star Ratings as a holistic, silo-busting program. It's vital for health plans to simultaneously excel not only in their clinical and pharmacy quality functions but also in every other health plan function. This includes everything from care coordination, network operations, member experience, risk adjustment, appeals and grievances, and compliance, to claims and encounter data and analytics, marketing, and every other department in the organization.
As we adapt to the first Star Ratings cycle with no predetermined thresholds, it's clear there is very little low-hanging fruit left in the Star Ratings program. It's time for us to climb the tree.
With budget season upon us, it is an ideal time to evaluate Star Ratings strategies and work plans to ensure 2017 investments are wisely made. Now that the 2016 Star Ratings are out, take an objective look at your Star Ratings programs to ask:
- Are we investing adequately in the areas where we need the most Star Ratings lift?
- Will our Star Ratings initiatives achieve our goals?
- Are we conducting the right interventions, with the right members, at the right time?
- Are we adequately integrating medication management and behavioral health into our Star Ratings programs?
- Are we adequately coordinating provider and member engagement activities?
- Are our provider contracts and pay-for-quality programs designed adequately to sustain success in the new Star Ratings environment?
If your plan achieved 4 Stars this year, this is no time to rest. The 178 plans at 3 or 3.5 Stars in 2016 are working hard to achieve 4 Stars this year, and with CMS' bell curve, this means some of the current 4-Star plans will drop in 2017. And don't forget — there are another 188 Medicare Advantage plans not rated in 2016. This huge group of plans will impact the bell curve as they receive their first ratings.
If your plan missed a 4-Star Rating this year, now is not the time to panic. There is still time to influence your 2017 Star Ratings, particularly since the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Health Outcomes Survey (HOS) surveys will not be fielded until early 2017. But since time is definitely of the essence, it is important to invest time and resources wisely into the areas with the greatest opportunity for short-term improvements.
We can help. Gorman Health Group understands the complexities and nuances of the Star Ratings program and measures. We know how to design programs, initiatives, and tactics to improve Star Ratings performance. From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.
With time waning to influence the 2017 Star Ratings, find calm amidst the chaos and prepare for the great changes to come.
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