CMS Publishes Revised COVID-19 Guidance

CMS has published additional guidance related to COVID-19 for MA and Part D sponsors, including expanded benefit offerings, telehealth information, Model of Care flexibility and more. This announcement revises and replaces an initial memo released on March 10.

Reach out to us at ghg@ghgadvisors.com with any questions.

by GHG Advisors

On Demand Webinar: Four Trends in Supplemental Benefits for 2021 Success

Supplemental benefits have been a valuable differentiator for Medicare Advantage (MA) plans since the Centers for Medicare and Medicaid Services (CMS) expanded the scope of coverage to certain non-medical supplemental benefits in 2018. Since then, we have seen continued expansion in supplemental benefit adoption and prevalence, which has required MA organizations (MAOs) to become even more creative in plan design to stay competitive.

So, how can you capture and maintain a competitive position in your market? Insights found by a Pareto Intelligence analysis after the MA Annual Enrollment Period (AEP) tell an important story that can influence product pricing and benefit design strategies for 2021. In a recent webinar, Gorman Health Group (GHG) Vice President of Sales and Marketing, Diane Hollie, shared the critical trends in supplemental benefits from the AEP results data that health plans need to know going into 2021 bids. Below is a summary of the key takeaways.

If you did not get a chance to attend the webinar, click here to view the recording.

Trend #1: Supplemental Benefits are Becoming Table Stakes

With the number of $0 HMOs, PPOs, and even HMO-POS plans available in the market—and with many supplemental benefits becoming homogenous across plans—consumers have new expectations about the “standard” offering when sitting at the kitchen table with a Broker.

This is apparent when comparing overall supplemental benefit prevalence between 2019 and 2020. In 2020, only 17% of MA Plans (in the Individual market, including SNP plans) did not offer any supplemental benefits versus 27% in 2019.

Trend #2: The Nationals are Offering Supplemental Benefits at a Higher Rate than Other Plan Types

When reviewing the enrollment data by type of MA plan (e.g., National Plans, Blues Plans, Provider-Sponsored Plans, Regional Plans), it was apparent, in most cases, that the Nationals offered major supplemental benefits, such as the over-the-counter (OTC) and meal benefits, more than other plan types.

One interesting benefit to note is “Transportation Services.” Regional plans, start-ups, and smaller MA plans in the “other” category were on par with the Nationals as far as providing the benefit. This could be attributed to D-SNP plans in this category, but it is certainly a trend to watch going forward.

Trend #3: Supplemental Benefits Can Impact your Member Experience

Given the increase in supplemental benefits offered, health plans should focus even more on member experience. As an example, in the recent Medicare Shopping and Switching Study from Deft Research, inadequate dental coverage was the most prevalent coverage issue mentioned by MA members, followed distantly by poor vision coverage. Therefore, if a plan doesn’t have sufficient dental coverage, member satisfaction may suffer as a result.

But simply offering the benefit is generally not enough to satisfy consumers. When a plan offers supplemental benefits, especially comprehensive dental benefits, communication is critical to managing members’ expectations. This includes:

  • Properly explaining the details of the benefit to ensure that the Medicare consumer doesn’t select the plan with a different understanding of the offering and end up disappointed the first time they attempt to use the benefit.
  • Outlining how to access the benefit once becoming a member or receive the benefit once it becomes available. Typically, supplemental benefits are implemented by outside vendors, which may require members to understand how to use up 6, 7, 8+ different companies to access benefits. This may cause confusion and poor member experience if member education and infrastructure are not properly aligned.

Trend #4 The Availability of Supplemental Benefits Correlates to Higher Enrollment Growth Rates

With data now available from multiple years of plans offering expanded supplemental benefits, we wondered: Does the availability of supplemental benefits impact enrollment? Preliminary results say yes.

For example, plans that offered comprehensive dental, transportation services, and/or meal benefits grew an average of 5% from 2019 to 2020, versus only 2-3% growth for plans that did not offer these benefits. The same goes for the OTC benefit… Plans that offered an OTC benefit grew 7% on average and plans that did not offer OTC actually decreased enrollment by 2%.

In diving further into OTC, Pareto’s analysis shows that the annualized benefit amount correlates to the amount of enrollment growth for a plan. MA plans with over $300 in annual OTC benefit grew 11%, whereas plans with an annual OTC benefit of up to $200 grew only 3% on average. This demonstrates that certain benefits are more influential for plan choice than others, which can help determine where to place the supplemental benefit dollars.

Watch the Webinar On Demand!

All of these trends are discussed in much deeper detail in GHG’s March 4th webinar titled, “Supplemental Benefits Trends to Address in 2021.” Use the form below to receive access to a recording of the webinar and explore the various data points discussed in this article.

Where Do We Go from Here?

In five years, MA plans will look very different than they do now. The new mindset of the baby boomer who is aging into Medicare will force change; they expect more from a plan and will demand it. Plans will need to improve member experience and address the social determinants of health (SDOH) specific to their population with various supplemental benefits.

This is also the time to reimagine the benefit/plan development process. Waiting to see what other plans are offering and following the leader is no longer sufficient in the long term. Plans must understand what members want/need and how to offer it effectively. There is also an opportunity to introduce benefits into the market that will help lower costs, increase Star ratings, and retain members over time, but this means effective change using strong data analysis with a clinical and quality lens in product and benefit strategy today.

For help with plan development, product strategy and benefit design, and more, get in touch with GHG’s Sales & Marketing team.

by GHG Advisors

CMS Announces COVID-19 Mailbox for MA Plans

In case you missed it, CMS announced a COVID-19 mailbox for Medicare Advantage plans to submit policy and benefit related questions. View it here: https://ma-covid19-policybenefits.lmi.org/covid19mailbox

GHG’s experts are also here to answer any of your Coronavirus-related questions—don’t hesitate to reach out for support.

by GHG Advisors

Dramatic Changes to the Telehealth Benefit Due to COVID-19

Over the last week, the Centers for Medicare and Medicaid Services (CMS) has released several documents providing guidance and relief to healthcare organizations amidst the COVID-19 pandemic. First, CMS broadened access and greatly relaxed regulations around telehealth services for Medicare beneficiaries. Through this expansion, Medicare can temporarily pay providers for telehealth visits for Medicare beneficiaries across the entire country.

Shortly after this announcement, CMS released two telehealth toolkits to help healthcare organizations navigate the expanded benefit: the General Provider Telehealth Tool Kit and the End Stage Renal Disease (ESRD) Provider Telehealth Tool Kit. According to CMS, “each toolkit contains electronic links to reliable sources of information on telehealth and telemedicine, which will reduce the amount of time providers spend searching for answers and increase their time with patients. Many of these links will help providers learn about the general concept of telehealth, choose telemedicine vendors, initiate a telemedicine program, monitor patients remotely, and develop documentation tools. Additionally, the information contained within each toolkit will also outline temporary virtual services that could be used to treat patients during this specific period of time.”

What Does Expanded Telehealth
Benefits Mean for Medicare Advantage Plans?

With the government and CMS directing
healthcare providers to deliver only essential and emergency care to patients,
those looking for non-essential services are suddenly unable to access the care
they need.

With the expansion of telemedicine, Medicare
beneficiaries are now able to receive various services through telehealth,
including common office visits, mental health counseling, and preventive health
screenings.

Since Medicare beneficiaries are at a higher risk for COVID-19 (i.e., coronavirus disease), telehealth allows them to visit their doctor from the comfort of their home, instead of going to a doctor’s office or hospital and putting themselves or someone else at risk. Patients will now be able to visit with providers using a wider range of communication tools, including telephones that have audio and video capabilities, making it easier for beneficiaries and doctors to connect without a face-to-face encounter.

This change also broadens telehealth flexibility without regard to the diagnosis of the beneficiary or the coverage they have. The expansion is effective for all Medicare beneficiaries, not just those with Medicare Advantage (MA) that may already have a telehealth benefit within their plan. It is available to all Medicare beneficiaries whether they have no coverage in addition to Medicare, a Prescription Drug plan, a Medicare Supplement plan, or an MA plan. Note that CMS has requested that MA plans communicate the specific policies and procedures on how to manage the flexibilities with relaxed telehealth regulations to both members and providers.

What Does Expanded Telehealth
Benefits Mean for Providers?

Beyond the benefit to members, an
increased emphasis on telehealth for non-essential visits will reduce the
strain on the healthcare system overall, ensuring that doctor offices, urgent
care centers, and Emergency Departments are available to treat the most urgent
cases while reducing the risk of healthy beneficiaries contracting coronavirus
disease by unnecessarily visiting a healthcare facility in person.

The expansion of the telehealth benefit
will allow providers the opportunity to see more Medicare patients for non-essential—but
still important—services, such as diabetes control, a patient not feeling well
and is not sure what to do, prescription refill, and depression or anxiety
brought on by isolation.

Conclusion

Although telehealth has many benefits,
it is not without its complications. Providers were generally not prepared for
the onboarding of a telehealth platform, the expense, the change to the
structure of current practice operations, and the rapid timeline in which telehealth
needs to be implement in order to effectively manage the most vulnerable
members. Many of the specifics will require providers to quickly adapt (e.g., the
requirement that telehealth calls be initiated by the Medicare patient; the different
CPT and HCPCS codes).

As we look to the future beyond current COVID-19 flexibilities, in a recent proposed rule, CMS has also included the ability for plans to use telehealth services for certain specialties in order to expand their footprint into counties where they may not otherwise have been able to meet the network adequacy requirements. The success plans demonstrate in their ability to effectively care for and manage members remotely during this crisis may further support the expansion of relaxed adequacy requirements beyond those in the current proposed rule.

If you still have questions on how to navigate the expanded telehealth benefit, consider attending our upcoming virtual open forum on Thursday, March 26th, where the healthcare experts at GHG and analytics leaders at Pareto Intelligence will answer all of your specific questions across a variety of topics, including Marketing, Star Ratings, Risk Adjustment, Compliance, Network Adequacy and Development, Telehealth and Analytics.

by GHG Advisors

In Light of COVID-19, Overcommunication is Necessary

Since COVID-19, otherwise known as coronavirus disease, surfaced in China at the end of last year, consumers have been bombarded with media coverage and corporate communications about the spread of the pandemic, the necessary precautions, the state of the global economy, and changes to operations, most of which has been less than positive.

In particular throughout this news cycle, the various health organizations, such as the Centers of Disease Control and Prevention (CDC) and World Health Organization (WHO), have continued to emphasize that older adults and people with preexisting conditions are at a higher risk for serious COVID-19 illness. Many of those people have Medicare.

Because of this, Medicare beneficiaries are understandably confused and scared. There is an unfortunate amount of false information being distributed, and every news organization has their “spin” on the coronavirus disease. How do they know what is real? Where can they go for reliable and accurate information? This uncertainty is compounded by being stuck in isolation, which can lead to or worsen depression. Medicare beneficiaries are extremely vulnerable right now, and they need a voice of reason, a source of truthful and factual information to calm their fears. As a health plan, you can be that voice.

What should be communicated to members?

Health plans have access to a wealth of knowledge about COVID-19 that can and should be shared with beneficiaries. If you haven’t already, you can be helping members understand:

  • What is coronavirus disease and the seriousness of the virus to the Medicare population 
  • The symptoms of the coronavirus
  • What to do if the beneficiary believes they have the virus
  • What actions to take to prevent the beneficiary from contracting the virus
  • How to stay healthy both physically and mentally
  • Any changes in benefits during this time, such as:
    • Telehealth Benefit: What is it and what can it be used for? Who should the beneficiary call for a telehealth visit? Are there copays when using the telehealth benefit?
    • Prescription Drug Benefits: Are there any changes to copays or refill amounts?
    • Access: What happens if someone is not at home and needs to see a doctor?

How should a health plan communicate to members?  

As important as the content of your message is, the method by which you deliver it is also important. Members need this critical information to exist in a place where they can easily access and understand it. Some suggestions include:

  • Your Website: Dedicate a section of your website/member website and/or build a landing page to address all of the communications topics listed above. Continue to fill those pages with daily content to update members. (For example, an FAQ section or Q&A from your medical director would be very meaningful.) This will help you become the source of truth.
  • Mail: Send a letter to all members explaining the expanded benefits granted by CMS, including any changes to current benefits for members, and then direct them to your website/landing page for the most up-to-date information.
  • Nurse Line: If not already done, consider adding plan-specific scripting for potential member questions. This can include the availability of after-hours support, the potential risks for contracting the virus, what members should do if they have a fever, where members can go for testing or if symptomatic, and prescription drug access.
  • Email: Email helps you communicate quickly and efficiently. Members should receive updates at least weekly during this time to reinforce that you are there for them, reiterate benefit changes, and share other critical updates. Always direct them to your website/landing page for the most up-to-date information.
  • Social Media: Facebook should be updated frequently with helpful lifestyle tips, such as how to get food delivered, senior hours at stores, and other information that might be beneficial. Use your most effective social media platforms to educate your members and nonmembers about the virus, as well as the expanded telehealth benefits available. Direct them to your website/landing page for the most up-to-date information.
  • Health Plan App: Use this as an additional channel for the latest facts and information, and direct members to your website/landing page for the most up-to-date information.
  • SEO: Optimize your website/landing page for search in order to bring members and nonmembers to your site. It’s important for truthful and factual information to be at the top of search results to drown out false claims and “spin.” Plus, you might also pick up a couple new members during the process!
  • Customer Service: Give your representatives the tools they need to be successful. They will be getting many calls and should have strong communication guidance to deal with the multitude of member questions. Consider a special task force of customer service members/clinical providers to be available to answer members’ complicated questions.
  • Public Relations: Seek out interview opportunities on the radio, TV and in print to help disseminate truthful and factual information to members and nonmembers alike.
  • Webinar: For a more creative approach, a webinar on coronavirus disease and how your health plan is working to support members allows you to get as close as possible to a “face-to-face” interaction while members are quarantined and staying in their homes.
  • Care Management: Conduct additional outreach to members who are the most vulnerable due to multiple comorbidities or high-risk illnesses such as heart disease, lung diseases and diabetes.

How often should a health plan communicate?

During this time, overcommunicating is actually a great idea. Adding web content daily is not too much. Sending weekly emails or emails as soon as you have significant information to share is not too much. Adding daily updates to Facebook is not too much, especially when Facebook content can be fun and informative (and many need a little fun right now). People want to know that their health plan is there to support them, and being in constant communication with helpful, truthful, and factual information is one way you can show that.

Who else should health plans be sending communications?

Members should be your highest priority, as they are the most vulnerable right now. But keep in mind the other audiences impacted by COVID-19 who also need to be hearing from you:

  • Providers: Providers need your full support in standing up a telehealth benefit and understanding how to properly bill it. Multiple methods and communications should be utilized to partner with providers on telehealth.
  • Brokers: In many situations, your brokers are your voice, and you want them to be educated on what is happening. Broker emails, portal communications, and webinars are all strong methods of communication to keep them informed and up to date on the latest developments. Plus, they should be made aware of how and when you are communicating to members.
  • Outreach Partners: Ensure State Health Insurance Assistance Programs (SHIP) and other organizations are aware of benefit changes and the lines of communications available to your members.
  • Caregivers: Many people are caring for their parents who have complex needs and are very vulnerable during this unprecedented time. Providing guidance on what they should do and how to monitor those in their care will help eliminate uncertainty and ensure both themselves and their loved ones remain safe and healthy.

Above All Else, Choose the Right Tone

Over the last several weeks, health plans have been wondering who, what, how, and how often in relation to their marketing and communications activities. Above all else, keep in mind the sensitivity of this conversation. Be clear, simple, and genuine. Do not condescend or demand. The right tone should be empathetic, understanding, and helpful, so that members feel less uncertain, confused, and scared.

If you still have questions on how to communicate with members and providers, consider attending our upcoming virtual open forum on Thursday, March 26th, where the healthcare experts at GHG and analytics leaders at Pareto Intelligence will answer all of your specific questions across a variety of topics, including Marketing, Star Ratings, Risk Adjustment, Compliance, Network Adequacy and Development, Telehealth and Analytics.

by GHG Advisors

Remote Work in Challenging Times—Steps to Survive and Thrive

For many professionals, like those of us at Gorman Health Group (GHG), we were working from home (i.e., remotely) before the words “Coronavirus” or “COVID-19” were ever spoken. Prior to social distancing and “shelter in place” orders, 43% of US employees worked remotely at least some of the time. Surveys are currently underway to determine how COVID-19 will impact this statistic.

The reality is that mandatory work-from-home (WFH) policies are needed and necessary in this crisis. Although this change was not at all disruptive to the way GHG works, we understand that, for many others, this is new territory, and you may be faced with challenges you weren’t prepared to overcome. (Like arguing with a cat who insists on sitting directly on your keyboard.)

Drawing on our many years of experience in the
WFH space, the advisors at GHG wanted to provide some advice for working remote
effectively:

Confirm you have adequate technology and connectivity.

  • This includes your laptop, charger, mouse, and keyboard.
  • Contact your IT department to ensure you have what you need to securely connect to servers and systems.
  • Utilize videoconferencing whenever possible. As humans, we need to feel connected—consider daily standups with your team or even virtual “coffee breaks” to bridge the gap created by social distancing.
  • Contact your internet service provider. Many companies are offering price breaks during this time for increased bandwidth.

Stick to your schedule.

  • Most of us have regular working hours. Whether that’s an 8-, 10-, or 12-hour day, continuing your regular hours and sticking to your usual schedule will help maintain a sense of normalcy.
  • Most people recommend getting ready and dressing for the day you would have had if you went into the office. While you likely can work in your “comfies” all day, research shows that you are more productive if you’re dressed and ready for the day, rather than lounging in your “lazy” clothes. Ultimately, it’s all based on your preference. However you feel most effective, stick to that!
    • If you participate in video meetings, continuing to represent your “professional self” is the way to go.

Dedicate a workspace.

  • If you have an office, that’s ideal. Your workspace should be as separate as possible from the places dedicated to other activities, like eating or sleeping.
    • Research shows that a delineation between workspace and living space helps you get into the right mindset, maintain focus, and stay motivated while working. If you try to work in the place where you live and play, you’re more likely to get distracted.
      • This also helps you disconnect when the day is over by leaving your work in that space.
  • If a separate office is not possible, consider an area in your bedroom, dining room or kitchen that is sectioned off from the main purpose of the room.
  • Let the family know that during work hours, that’s your space. Set ground rules.

Ensure you are being productive.

  • Limit distractions such as television, barking dogs, or children by wearing noise-canceling headphones.
  • Update your to-do list every morning and set time limits for each task when appropriate.
    • Like a financial budget where we allocate money to specific activities, you should do the same with your time using a detailed schedule. This will help keep you on task and progressing towards your goals.
  • If you manage employees, take extra time to meet with them virtually. Create an agenda that includes updates from each team member, so they can contribute. Employees need to feel valued, not disconnected, and regular video or conference calls help accomplish that.

Keep your scheduled breaks.

  • Don’t skip your morning coffee, whether you get a cup from your kitchen or the local drive thru coffee shop.
  • Take a scheduled lunch break, and enjoy a healthy, home-prepared meal. Consider a brief home workout to get your body physically moving.
    • Consider using any extra time for evening meal prep.
  • Take an afternoon break. Go for a brisk walk with the kids and/or the dog.

Find new ways to take advantage of commute time.

  • Take an online exercise class.
  • Do yoga, meditate, dance.
  • Read! Tackle that book you’ve been wanting to read but couldn’t find the time.

Remember that this is a trying time for
everyone. While working remote may come easy to some, for others, it will be a
significant challenge, and we need to be considerate of that. No matter how you
organize your day, it’s important to find moments that you can embrace. An
early morning coffee on the porch while the sun is rising. Extra time in the
shower or tub. The chance to write a letter to a loved one, service member, or local
nursing home or extended care facility. Above all, be patient and be kind.

And if you just can’t get the cat off your
keyboard, try putting a cardboard box next to your computer. That’ll keep them
entertained until everything is back to normal!

This is a time of great uncertainty, and the healthcare industry is at the forefront of a global battle against COVID-19. If you have any coronavirus disease-related questions, consider attending our upcoming virtual open forum on Thursday, March 26th, where the healthcare experts at GHG and analytics leaders at Pareto Intelligence will answer all of your specific questions across a variety of topics, including Marketing, Star Ratings, Risk Adjustment, Compliance, Network Adequacy and Development, Telehealth and Analytics.

by GHG Advisors

CMS Shares Key Information Surrounding MA Organizations & COVID-19

On March 10, 2020, CMS issued key information via HPMS memo on the responsibilities and flexibilities afforded to Medicare Advantage organizations and Part D sponsors related to disasters and emergencies resulting from COVID-19.

A declaration by the Governor of a State is one of the triggering events for the special requirements related to Part A\B and supplemental Part C benefit access.  Under 42 CFR 422.100(m) the requirements are in effect until the end of the date identified in the state declaration or for 30 days if no end date is identified.  To date, declarations have been made in at least 8 states.  We urge you to follow www.nga.org/coronovirus for specific information related to your state(s) of plan operation.

When the special requirements are in effect, the requirements for MAOs are:

  1. Cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities subject to § 422.204(b)(3), which requires that facilities that furnish covered A/B benefits have participation agreements with Medicare.
  2. Waive, in full, requirements for gatekeeper referrals where applicable.
  3. Provide the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.
  4. Make changes that benefit the enrollee effective immediately without the 30-day notification requirement at § 422.111(d)(3). Such changes could include reductions in cost-sharing and waiving prior authorizations.

We urge you to review the HPMS memo here. and follow https://www.nga.org/coronavirus/ for specific information related to your state(s) of plan operation.

Contact a GHG expert today with any questions or if you need assistance.

by GHG Advisors

Feeling the Madness! The 2020 CMS Program Audit Cycle Begins

This March, sports will not be the only excitement—health
plans are gearing up to receive audit notices as we enter the second year of
the four-year Program Audit Cycle. The ball is in your court… Your team’s
readiness depends on review of the current audit protocols and practice,
practice, practice. Are you performing “mock” auditing to identify risks?

The Centers for Medicare and Medicaid
Services (CMS) started the current audit cycle in 2019 with a number of audit changes
and process improvements to assist plans, including:

  • Removal
    of Audit Element Review    : Suspension of the review of Call Logs and the
    Website audit element from the Formulary and Benefit Administration protocol, as
    well as removal of the Enrollment Verification audit element from the Special
    Needs Plans Model of Care (SNP MOC) protocol.
  • Streamlining
    Information    : Release of the Program Process Overview document with the
    Program Audit Validation and Close Out guidance, along with a Program Audit
    Frequently Asked Questions (FAQs) on the CMS program audit website.
  • Compliance
    Program Effectiveness (CPE) Protocol Changes:     Includes
    suspension of the CPE self-assessment questionnaire and several changes to the
    CPE universes.

CMS is continually seeking “…to improve
audits by soliciting sponsor feedback,” and recently opened for comment on the
proposed changes for 2020. Some notable changes include reductions in audit
elements and protocols, such as:

  • Removal of Part D Coverage Determinations, Appeals, and Grievances (CDAG) Table 9 (Standard Independent Review Entity [IRE] Auto-Forwarded Coverage Determinations and Redeterminations [SIRE]) and Table 10 (Expedited IRE Auto-Forwarded Coverage Determinations and Redeterminations [EIRE]), as well as removing Table 16 Call Logs.
  • Reducing timeliness CDAG sample size from 75 to 65 and increasing Grievances from 10 samples to 20, likely to compensate for the removal of Table 16 Call Logs.
  • Edits to the CDAG universe requirements, including updating the notification requirements to coincide with Parts C and D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance Section 10.5.3 and adding exclusion language throughout the remaining tables.
  • Removal of ODAG Table 14 Call Logs and reducing timeliness samples from 65 to 60 cases and Clinical Decision-Making from 40 to 35, while also increasing Grievance samples from 10 to 20.

The industry anxiously awaits the
distribution of the updates, as the current audit protocols are set to expire
April 30, 2020.

GHG assists plans with implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

by GHG Advisors

5 Key Takeaways for Product Leaders from the Advance Notice

The news is out and one thing is clear: CMS is proposing significant changes across all focus areas for Medicare Advantage (MA) plans in the 2021 Advance Notice and 2021/2022 Proposed Rule. On top of that, CMS has announced that there will be no draft or final call letter this year. Instead, items typically released in the call letter will be provided through a combination of rulemaking (in the case of policy) and HPMS memos providing process instructions and other guidance.

With bid submissions on the horizon, these announcements must be
top of mind for MA plans. Below are the key takeaways for product strategy
leaders to prepare for 2021:

  1. In 2021, Medicare beneficiaries with ESRD will be able to enroll in MA plans. Also, organ acquisition costs for kidney transplants will be excluded from MA benchmarks, except for PACE organizations. Plans will need to account for this in the development of 2021 bids. In addition, plans will need to change enrollment forms, enrollment scripts and other materials that reference ESRD eligibility for 2021.
  2. In 2021, MA Part D (MAPD) and Prescription Drug Plans (PDPs) will be able to offer a second tier for specialty drugs with lower beneficiary cost sharing. This change allows plans to negotiate better deals with manufacturers in exchange for placing their drugs on the preferred tier. Plans will need to work closely with their Pharmacy Benefit Managers (PBMs) to understand if this will be offered and the types of drugs that will be on the list. Plans who extend this to their members have the opportunity to utilize it as a retention opportunity for current membership, as well as a sales opportunity.
  3. Plans will have more flexibility to include telehealth providers in certain specialty areas (e.g., psychiatry, neurology, and cardiology) and will be allowed a 10% reduction in the number of beneficiaries required to meet time and distance standards. This is especially important for rural areas. Plans that were not able to enter counties because of network issues in the past may want to revisit this for 2021.
  4. CMS is clarifying and codifying its previous guidance on supplemental benefits. For Special Supplemental Benefits for the Chronically Ill (SSBCI), there is a minor clarification to expand the chronic conditions for which SSBCI may be offered. Hopefully, CMS will release this guidance soon.
  5. CMS is not a fan of D-SNP look alike for many reasons. For plans where either the bid or actual enrollment exceeds 80% of members entitled to medical assistance, CMS proposes to not enter or non-renew the plan’s contract. (Where threshold exceeds 80%, members could be transitioned to a D-SNP offered by the organization.) If you don’t currently have a D-SNP, this could be a loss of membership. Plans who compete against these D-SNP look alike plans may see an increase in membership this year.

With the February enrollment data officially released, look out for another article next week on the results of the Annual Enrollment Period (AEP). And, join us on March 4th for an exclusive webinar on the Supplemental Benefits Trends to Address in 2021. In that webinar, Diane Hollie will highlight what we are seeing in the market that may influence your benefit and product decisions for 2021. Click here to register.

If you need help navigating the product and benefit design
implications of CMS’ recently released policies, contact Diane Hollie at dhollie@ghgadvisors.com.

by GHG Advisors

CMS Releases New Notice of Denial of Medical Coverage

On February 19, 2020, CMS released a new OMB-approved Notice of Denial of Medical Coverage (NDMC), also known as the Integrated Denial Notice (IDN), for Medicare Advantage plan use. While CMS encourages plans to begin using the new form as soon as possible, it must be implemented by April 1, 2020. The form and instructions can be found here.

Contact Tina Bailey with any questions.

by GHG Advisors