Countdown to Final Submit
Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit. Here are a few of the things we learned this year along the way.
- CMS has not updated their Part D readme file to include the FDR chart noted in 3.1.1C. It seems a bit redundant to the information entered in the Part D Data section of HPMS, but to each his or her own. CMS provides no template for that chart so we can imagine either it is overlooked upon initial submission by the applicant, or it is submitted in varied forms.
- Despite making reference to an additional webinar to be held after the second user call, no webinar was scheduled nor was any announcement made to correct that statement. However, CMS staff demonstrated timely responsiveness to posed questions both directly sent to application contacts as well as through the DMAO mailbox.
- With an industry push for quality (read: limited) network establishment, applicants can expect a high level of scrutiny on exception requests. If providers are available in a service area, CMS has stated that applicants should not even submit an exception request, so put those pencils down and step up contracting efforts.
You have until 8:00 PM Eastern Time tonight to submit your application. There should be a good sense of what potential deficiencies exist, so maintain the momentum to fill those gaps. Embrace the reality that CMS may certainly identify additional gaps in the submission. Ensure that your team has time built into your implementation plan to address any additional deficiencies.
Resources
We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Contact us today to ensure a smooth, compliant process.
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
In 2015 a Slap on the Wrist Can Be the Kiss of Death
It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government. 2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS). It's already on a pace for 2015 to be the toughest year ever in enforcement actions against Medicare Advantage plans. And generally speaking, the regulatory bar is rising faster than anyone imagined. Consider:
- So far in 2015 CMS has issued significant new Medicare Advantage and Part D regulations, and this year's Advance Notice for 2016 rates and rules for Medicare and Part D health plans is the most anticipated I can remember in more than 20 years.
- 2015 is the toughest year in benchmark payment rates thanks to the approximately $200 billion in cuts from the Affordable Care Act.
- 2015's technical corrections for Star Ratings are almost bewildering in their complexity in raising the clinical bar. Indeed, in 2014, an election year, CMS famously told Medicare Advantage plans below 3 Stars for 3 consecutive years that a stay of execution was granted. In the fall, many of those low performers were quietly shown the door and were non-renewed. In 2015, however, the agency is handing out live ammunition to its firing squad. Now an intermediate sanction freezing marketing and enrollment automatically knocks the plan down to 2.5 Stars, often meaning loss of millions in bonus payments and rebate dollars. In competitive markets now, the first plan sanctioned is the first hunk of roadkill.
- The HHS Office of Inspector General, the guys with the badges and guns in Medicare, have made data validation audits for Medicare Advantage risk adjustment one of its top priorities in its 2015 workplan. And the President's budget includes over a half-billion dollars in recoveries from these RADV audits.
- But nowhere is there better evidence that the paper tiger is growing its claws back than in CMS' track record in enforcement actions against MA plans. In January, the agency levied the highest monthly toll of civil monetary penalties ever -- and if it keeps up the pace, 2015 will be nastiest enforcement environment in Medicare history.
*January 2015
Granted, CMPs don't typically amount to much, usually no more than a couple hundred grand, rarely 7 figures plus. But the damage is actually far greater, when considering damage in the local and national press; the chatter factor among beneficiaries; lost membership, and damage to the Star Rating and the relationship with CMS, which for many plans is or is becoming its biggest customer. A slap on the wrist is now the kiss of death in this environment.
Last week, my colleague conducted a webinar on the "Top 10 Things Killing Your MA Plan." CMS' top infractions, in order, are coverage determinations and grievances, and formulary administration, or performance of your pharmacy benefits management vendor. Those findings are driven by these 10 root causes:
Now is the time to ensure your compliance function and Medicare operations have the right tools, processes and people to be successful in the toughest environment we've ever seen in government health programs. In 2015, Gorman Health Group launched its latest product, CaseIQ™ , providing a new way to ensure your Appeals & Grievance cases come to a timely and compliant resolution. The tool not only captures all the data points needed to categorize, work and report coverage disputes and complaints; it also guides users through the appropriate processing of each case, minimizing the risk of non-compliance due to user error. Built and governed by GHG Medicare compliance subject matter experts, CaseIQ™ aims to keep our clients out of CMS' audit crosshairs. Learn more in our recent press release.
In addition, in the Common Conditions, Improvement Strategies, and Best Practices memo based on 2013 program audit results, CMS outlined areas where plans have been consistently non-compliant and described best practices to address failings. Ongoing monitoring is at the heart of non-compliance. Our solution, the Online Monitoring Tool(OMT™), is a highly flexible oversight tool and dash boarding software that brings together key metrics, documents, and tasks for ongoing monitoring and auditing, which results in the Organization being audit ready. This integrated solution also streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.
Resources
CaseIQ™, GHG's latest solution, offers built-in reports that allow for tracking of past performance, current backlog as well as trends, and is designed to assist the caseworker to a complete and compliant resolution in Part C (MA) appeals, Part D appeals, and Part C and Part D grievances. Learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Getting Ready for the Bid Season
Since the CMS Medicare Advantage January enrollment numbers did not include the last three days of the Annual Election Period (AEP), it is important to utilize the February enrollment file to get the full picture of AEP results. At GHG, we like to develop the reporting in January for directional results and get an idea of where the landscape may be heading for the year ahead. Plus, looking at your marketplace at the beginning of each year is very important to the product/plan/benefit process that is now upon us.
Last week, my colleague, Diane Hollie, and I spoke at a conference solely geared toward the upcoming bid process. We spoke about the types of analyses an organization should be looking at and we had great discussions about the data and types of data to be viewed/analyzed. One thing was very evident - Marketing, Sales, and Product Development staff that have the data of the marketplace need to be a part of the bid process.
The bid process needs to be a team approach, with one clear leader, and include representatives that are accountable for profits and losses (P&Ls). For example, some of the team members that should be included are Sales/Marketing, Finance/Actuary, Network, Pharmacy, Medical and Health Management, and Compliance.
At the beginning of the bid process, it is important to level-set the team on the marketplace. Some of the analyses we typically present include:
- Service area demographics
- Medicare penetration
- Current membership analysis
- Enrollment trend analysis
- Results of the last AEP — who are/were the winners and losers this AEP and why?
- Product analysis
- Benefit analysis
It is important to dig into the data to understand the story being told. Remember to ask - what part in the story do you play? Are you a protagonist with a diminishing role, are you the antagonist shaking up the market, or are you just happy to stay alive in the story? Whatever role you play, it is important to understand the part, own it, and have your plot development for the next AEP and beyond.
Check back next month as we look at the AEP results and see what's happening in the marketplace on a national level.
Resources
GHG will provide a complete benefit design and strategy analysis that will take into account organizational strengths in operations and medical management that includes a thorough examination of your intended market and a feasibility analysis. Visit our website to learn more >>
Smart benefit design is a dynamic process that begins with an examination of intended markets with consideration given to strengths in member retention and medical management, and is executed with specific enrollment and financial targets in mind. Visit our website to learn how GHG can help >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Medicare Secondary Payer (MSP) is all about the money.
Money going out as a result of paying claims as primary payer when it's possible you should be paying as secondary payer. CMS reduces plan payments for members with MSP, shown on the Monthly Membership Report (MMR) as an MSP adjustment (reduction).
Money coming in results when research and outreach attempts validate paying as secondary payer; transactions are submitted to change or delete the occurrence records in Electronic Correspondence Referral System (ECRS). The recovery results are shown as favorable MSP adjustments (increase) in your Monthly Membership Report (MMR) payment. Claims recovery also produces additional revenue.
Medicare Secondary Payer shifts the burden from Medicare to commercial insurance companies. The burden is shifted to both employer plans (Group Health Plans) as well property and casualty insurers (Non-Group Health Plans). For Medicare Advantage plans, MSP is when an employer group sponsored health plan pays primary over the Medicare Advantage plan.
MSP validation is not a one and done process. Information can change, be inaccurate or out of date. Outreach validation requires diligence and persistence. ECRS submissions need to be monitored for non-responses and records under development. Other coverage information and system flags need to be updated for claims reprocessing and recoveries from other insurers for claims that were paid as primary in error.
GHG's MSP Reconciliation Team has delivered exceptional outcomes for our clients by recouping millions of dollars in MSP recoveries — much more than our clients expected! Each time we're able to obtain a positive validation and submit a correction to ECRS it means money for the client. That's a satisfying feeling!
Resources
When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Kaiser Family Foundation & CCF Release 50-State Survey on Medicaid and CHIP
It's time again for the release of the annual 50-state survey on Medicaid and CHIP enrollment, eligibility, cost-sharing and renewal policies conducted by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families.
It's clear that the Affordable Care Act (ACA) has broadened Medicaid's base of coverage for the low-income population and fast tracked state efforts to move from obsolete, paper-based enrollment processes to a more modernized enrollment experience.
Highlights of the key findings include:
• Overall, states have made significant progress in offering Online Medicaid applications in all states, except Tennessee, and the majority of states accept Medicaid applications by phone. States also have instituted policies that rely on electronic data sources and minimize the paperwork process to verify information of applicants.
• States still have continued transition work to do under the ACA , such as improving information systems, implementing improved renewal processes and improving coordination between Medicaid and the Marketplaces.
• Reflecting the low incomes of parents and adults in Medicaid, as of Jan. 1, 30 states charge premiums or enrollment fees and 27 states charge cost-sharing for children. No states charge premiums for parents or adults newly eligible under the ACA in traditional Medicaid, but most charge nominal cost-sharing for both adult groups.
• The long-standing gap in coverage for adults has been eliminated in the 28 states that expanded Medicaid but persists in the 23 non-expansion states where parents are covered at a median eligibility of 45% of the federal poverty level and non-disabled adults without dependent children remain ineligible.
The policy environment continues to rapidly change on a weekly basis, making it difficult to capture a complete picture of certain developing processes such as renewals, verification using data sources, and account transfers between coverage sources. Even so, this 2015 survey creates a new baseline for measuring ongoing progress and improvements in Medicaid and CHIP in future years as states continue to revolutionize their programs.
Resources
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
2016 CMS Applications: Highlights and Basics
This week's CMS industry training on applications was quite informative, and contained many audience questions that you will want to hear. The recording is already available to registrants for those who missed it. There was way too much information for me to summarize, so I have included here a few highlights from the call and some basics that are easily overlooked.
Highlights
All new Part D applicants (MA-PD and PDP) who do not have a Part D contract with CMS that has been in effect for one year prior to application submission, must use a contracted first tier, downstream, or related entity (FDR) that has one year experience in the last two years performing functions in support of another Part D contract. Also, new PDP applicants must have two continuous years' experience offering health insurance immediately prior to submitting the application or five continuous years actively managing prescription drug benefits. CMS confirmed that the applicant can use the experience of a parent or subsidiary of its parent to comply with these requirements.
CMS also highlighted that applicants must validate their home infusion (HI) and long term care (LTC) pharmacies prior to submission. They must have valid NPIs. If you upload invalid information, the application will be considered deficient. This reminder is certainly a result of last year's CMS exercise of calling HI pharmacies directly to ask them about the services they perform. Based on the tone of yesterday's call, there is low tolerance for applicants that do not verify this information. They further mentioned that applicants must make sure their ITU file matches ITU reference file. "Even if the spelling is wrong, please use the wrong spelling." You will need to listen to the entire call recording to catch all the information provided, but the slides are a good start.
Nail down the basics.
- It may seem trivial, but make sure you have the right contact name in the Part C Application Contact and Part D Application contact fields. Earlier last year when CMS sent their first round of deficiency notices, only the application contacts received the emails at the plan — no one else. With only one week to address deficiencies or gaps after that first notice is received, it is imperative that the right contact is in place and that they are aware that they need to monitor notices from CMS quite closely.
- Cross-walk documents using pdf page numbers. CMS has quite a bit of information to review so point them directly to the requirement in your document, be it the Quality Improvement Plan or the PBM contract.
- CMS stresses to follow instructions and use the new templates for the Part D application; do not use anything from previous years. Also, do not submit such a thin application that is indicative that it is simply a placeholder for more time.
Make sure your effective dates are in line with the application requirements.
· Consider your licensure and contract effective and end dates. For example, your state license or certificate of authority needs to be in effect to cover the entire 2016 plan year. If yours expires mid-year, you can expect a deficiency unless you upload documentation showing the certificate covers the entire plan year, or other documentation such as proof of payment for the renewal.
· If you have a subcontract of an FDR that you must upload to CMS based on the fact they are performing a key Part D function, ensure that the effective date is appropriate. For example, one key Part D function is enrollment processing. Enrollment functions must be in place and operational during the AEP. Therefore, ensure that the effective date of a contract is in line with the time frame for which they will begin working with Part D beneficiaries on your behalf. (Remember: if delegating this or other key Part D functions to a parent organization, that executed subcontract must be uploaded. As mentioned in last week's call, the Part C agreements are not required this year for upload. )
In a couple days, I'll post some interesting things that our team has encountered along the way that may help shed light on the application documentation. For example: is there an upload missing from the Part D readme file? There sure is. Is there something in the PDF application that doesn't quite match HPMS? A couple things, actually. If you have questions, by all means follow CMS' instructions for questions! However, if you find anything that doesn't quite make sense that you'd like to share, we'd love to hear from you.
Resources
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. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow up questions. Visit our website to learn how GHG can help >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
How to Maintain the Accuracy & Consistency of Data through an Entire Life Cycle
It doesn't matter whether you call it the Annual Election Period (AEP), Open Enrollment Period or Fall Open Enrollment; it's that busy time of the year when beneficiaries are on the move. Now that the dust has settled, it's time to take a thorough look at your member data. Your members are your revenue. Accurate member data and continuous maintenance will yield the maximum, most accurate level of revenue to your organization.
While Plans strive to have correct data in their systems right from the start, it doesn't always work out that way. The result is inconsistencies in data and the need for an "AEP Reconciliation". That's the process of identifying a discrepancy, correcting it and not only making it right, but keeping it right. Reconciliation is about maintaining and assuring the accuracy and consistency of data from the start and over its entire life cycle.
Member data is the heart of an organization and the driver for many processes. It's critically important that this data is correct in all of your organization's systems. All systems need to be in sync, CMS to Plan, Plan system to Plan system, Plan system to PBM — it's a continuous circle of checks and balances.
Accurate data not only helps create that important first contact experience with your member but keeps you connected to your member. Correct member data reinforces your organizations credibility and promotes a feeling of value to your member.
Data Reconciliation Tips
- Member Demographic Information — Maintain and update any changes to names, DOB, addresses (permanent, billing, personal representatives, POA's), telephone numbers, email addresses.
- Enrollment Spans— Verify that the Plan/PBP/LIS is correct in all spans within the enrollment — not just the current span.
- Payment Method — Validate that the correct payment method is set up (SSA, Direct, RRB, EFT, etc.)
- Special Status — Update special status or status flags in the appropriate systems to ensure proper claims payment and plan payment. (i.e. ESRD, Hospice, MSP, Medicaid, Institutional etc.)
- Optional Supplemental Benefits — If your enrollee elects supplemental benefits, verify the Part C premium change was submitted to CMS.
- CMS Reports — Work monthly CMS reports promptly and completely. (List of CMS reports is available in PCUG v8.3, Table K-1 All Transmissions Overview)
- Plan Discrepancy Reports — Compare data within your own plan systems and with your PBM. Create discrepancy reports and work them daily or weekly.
Don't forget about Medicare Secondary Payer (MSP) Reconciliation!
Now is the best time to tackle all that MSP information you've received. Many plans get overwhelmed with MSP data, especially at this time of the year, and find it difficult to perform the time consuming outreach and research that's necessary to obtain validation results.
This simple process carries a powerful financial punch — efforts here can yield big results! GHG can assist with MSP Reconciliation. We have experienced analysts that can research, perform outreach and reconcile your MSP data.
Start the year off right - with clean, accurate data.
GHG's Consultants and Reconciliation Analysts have the expertise, knowledge and experience for all your reconciliation projects.
Resources
To hear more information on reconciliation, including detailed evaluations of the MMR & MOR reports, come hear GHG's expert, Jennifer Young explain the Fundamental of Membership Accounting & Reconciliation, January 26-27th at the Medicare Advantage Membership Accounting & Reconciliation Conference, Sanibel Harbour Marriott Resort & Spa, Ft. Myers, FL.
Let GHG check the box in each and every operational area of your organization. Our team of veteran experts can assist in AEP preparation, transmitting of timely and accurate membership information, recommending staff levels and utilization, and maintaining and improving all enrollment processes. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
Operational Assessment — time for a “Check-Up"
It's time for an operational assessment.
Here's why….
An operational assessment is an opportunity to review your day to day operations to ensure processes are accurate, running efficiently and most importantly, compliant. Over time employees tend to reinvent the wheel - they stray from the documented processes and before you know it, the way it's being done is now the accepted "norm". If management isn't close to the work being performed or not working with a "sleeves rolled up" attitude, then you may be unaware of exactly what's going on in your operational areas. You may believe the staff is doing "this" but they're actually doing "that".
Here's another reason .…
You don't know what you don't know.
GHG's Operational Assessment starts with a period of discovery through observation and interviews. We get people talking. Individuals will have a chance to demonstrate and explain their role and tasks within the operational area. It's through this review and discovery phase we uncover the good, the bad, and the ugly. Typically, an operational assessment will consist of reviewing processes, policies & procedures, production reports and performance metrics, training materials, and systems.
The only thing you have to fear….
Organizations shouldn't fear finding gaps or process failures — they should fear not finding them. Assessments are meant to identify problems, make best practices corrections, and implement changes for excellence; there are no blame games.
Don't delay….
There's no time like the present for an operational assessment. The benefits of improved operational performance can be compelling, including better performance, efficiencies, and increased revenue.
Achieving excellence is a process. Begin the journey with a Gorman Health Group Operational Assessment and we will guide you on the road to excellence.
Resources
Let GHG check the box in each and every operational area of your organization. Our team of veteran experts can assist in AEP preparation, transmitting of timely and accurate membership information, recommending staff levels and utilization, and maintaining and improving all enrollment processes. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
Private label health plans - a tool for increase market capture and improved patient outcomes
Private label health plans or co-branded health plans are joint efforts between like minded health plans and provider organizations interested in enhancing market share, achieving improved patient outcomes, minimizing duplication of services and achieving financial accountability. In its purest form, a private label health plan combines the strengths of the participating providers such as reputation, innovative practice patterns, trusted referral patterns and coordination of care techniques with those of the participating health plan such as benefit design, network design, contract administration and other insurance plan core competencies.
Most often, a private label enterprise has as its core characteristics, a value based limited network in which the participating providers agree to, and adhere to, mutually designed clinical and financial performance targets which are intended to optimize patient outcomes and financial performance targets ultimately leading to increased provider and health plan profitability. Benefit plans are customized to maximize in network access, member engagement and minimize out of network referrals. The insurance partner, in addition to providing the basic insurance administrative and medical management insurance functions, contributes by offering access to data and technology often unavailable to providers otherwise.
Private label health plans are a potentially attractive option for health plans that are already working with Accountable Care Organizations , (ACO's) and large Integrated Health Systems, (IDS) who control all, or a majority of, the resources necessary to achieve continuity of care ranging from primary care to end of life care.
Large self insured Employers that labor under legacy self insured insurance programs for their retiree populations are potential customers for private customized private label benefit plans and value based networks because they offer the Employer greater control over benefit offerings, defined employee or retiree contribution and medical cost.
At the Gorman Health Group we have a history of supporting Medicare and Medicaid Health Plans and Provider organizations on innovative approaches to network development, healthcare pricing and model of care development, as well as working with ACO's on achieving improved financial performance and member engagement.
Resources
Need our help? Interested in starting a dialogue on Private label plan development, value based network formation or optimization of ACO performance? Take the first step and call us at 202-364-8283 and ask for me directly or one of our senior subject matter experts or contact us via the GHG website. We are here to help.
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
2016 CMS Application Season Begins
Yesterday CMS released the 2016 Part D application, and this afternoon the 2016 Medicare Advantage (MA) application was released. Despite the applications' release dates, potential and current Plan Sponsors should be well under way in the preparation of the upload that is due on February 18th. Aspects of the application that require significant lead time to accomplish include the establishment of an adequate network and the acquisition of the required state licensure.
If you haven't done so already, register for the industry user calls; these are scheduled to be recorded and available on the MSCG website a few days after each call. Today's industry training was delivered by CMS' Arianne Spaccarelli, Paul Foster, Nisha Sherry, Melissa Cooley and Greg Buglio. They provided an incredible amount of detail regarding the Part C application process, Special Needs Plans (SNP) proposals, and automated application training. It is worth listening to the recording, but here are some highlights:
Past performance will be considered — 14 month look-back. This was provided as a reminder in the past but this is in the regulation. See 422.502(b)(1-2) for the detail; boiled down, if during the past 14 months the MA organization fails to comply with the requirements of the Part C program under any current or prior contract, or in absence of 14 months of performance history, CMS may deny the application. You might be wondering if this is also outlined in the Part D regulations. It certainly is; in 423.503(b)(1-2) CMS also outlines the same for Part D organizations.
A major change that appeared in the draft 2016 MA application and made it to the final version was the deletion of the upload requirements for provider contract templates, executed administrative contracts/LOAs, and their respective crosswalks to regulations. This change reduces the burden to applicants in the short term. CMS stressed that attestations are still required to comply with these requirements and CMS may request that documentation at any time. (From our perspective, it is highly recommended that applicants consider incorporating the CMS-developed model contract amendment for MA administrative and management contracts, and for first tier or downstream entity provider contracts. You can find that on the MA applications site. Plans who do not use the model amendment may find themselves missing the spirit of the requirement if they do not include the exact required language. Worst case scenario? CMS comes a-calling, and picks apart your contracts. Why risk it? )
As in past years, there is an order to completing the steps of the application, and those steps have been outlined in the training. A number of inexcusable reasons for requesting an extension were described in delightful detail. They include trying to upload your provider and facility tables at the last minute, forgetting to hit the Final Submit button, or simply being unaware of your service area needs for your application. Listen to the call — they just aren't having it!
Keep track of the GHG blog where I will provide some additional lessons learned from past applications, quirky issues that applicants often face, as well as important things to remember. Don't go it alone if you can help it; many hands make light work with this type of project.
Resources
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. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>