Man writing regulatory rules

2021 Medicare Advantage Readiness Checklist

Every year, CMS releases an annual Readiness Checklist in an effort to remind Medicare Advantage (MA) Plan Sponsors of key contractual responsibilities in the upcoming plan year. The Readiness Checklist is not only a great reminder for existing Sponsors, but is also an excellent guide for plans that are new to the MA market.

This year, the Checklist released on October 2nd includes an assortment of existing and changed requirements to help you and CMS determine if you are ready for health plan operations in 2021.  

CMS expects that Sponsors are utilizing the Checklist for the upcoming contract year. However, the agency also conducts a teleconference with Sponsors to understand any potential challenges and obtain feedback about a plan’s process improvements to mitigate any risks or gaps in meeting obligations. CMS requires plans to report any requirements where they are at risk or where technical assistance is needed. 

Sponsors should carefully review the Checklist for regulatory changes and updates that may have occurred since the previous year. Remember, this Checklist is intended as a summary of critical requirements and it includes references for plans to locate any guidelines that they may need to understand the guidance. Plans should review all Checklist references including Health Plan Management System (HPMS) memos, Final Rules, and the Call Letter for the detailed interpretation of these CMS requirements.

A few examples of focus areas that may be new or expanded upon in 2021 include:

Systems, Data, & Connectivity: Prescriber Real Time Benefit Tool (RTBT) – Part D Sponsors
Contracting, Subcontractor Provisions, and Oversight: MAOs Offering Dual Eligible Special Needs Plans (DSNPs)
Enrollment/Disenrollment: Timing of Annual Enrollment Period (AEP) and Electronic Enrollment Mechanisms (Excluding MMPs)
  • Plans that may have implemented changes to their temporarily absent policies due to the public health emergency (PHE), allowing out-of-area members to remain enrolled, ends on 12/31/2020 or at the end of the public health emergency, whichever is earlier. These members will automatically be disenrolled on 1/1/2021 if they are still absent from the service area or 6 months after the individual left the service area, whichever is later. 
  • Plan Sponsors' ability to accept enrollment on electronic devices or secure internet websites must follow CMS enrollment guidance, including submitting materials and web pages related to enrollment for approval prior to use and complying with CMS data security policies. Sponsors are also ultimately responsible for handling of sensitive beneficiary information including when it is processed by first tier, downstream and related entities (FDRs) and must report security and/or privacy breaches timely.
Grievances, Initial Coverage/Organization Decisions, and Appeals: Continuation of Benefits While an Appeal is Pending
  • This requirement is only for applicable integrated plans.
Where Do We Go from Here?

Outside of program audits and data reporting, the Readiness Checklist is a valuable tool in CMS’ oversight arsenal. Is your MA Plan ready for 2021? GHG conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. Contact GHG Advisors today to learn how we can help you be best prepared.

CMS' Proposed Addendum to Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

On July 7, 2020, the Centers for Medicare and Medicaid Services (CMS) distributed a draft addendum to address changes to Unified Appeal and Grievance processing for Integrated D-SNPs in the Parts C and D Enrollee Grievances, Organization/Coverage, Determinations, and Appeals Guidance. CMS notes that rules implementing unified grievances and appeals apply only to fully integrated dual eligible special needs plans (FIDE SNPs) and highly integrated dual eligible special needs plans (HIDE SNPs) referred to as "applicable integrated plans." CMS included a list of states that may meet these requirements, but plans should contact CMS if they believe they may meet the integration criteria in the regulations. CMS requested comments on the proposed changes by August 7, 2020.

The addendum is a supplement to the current MA and Part D Appeal and Grievance guidance, and each addendum section aligns to the same section in the chapter. Noteworthy changes are summarized below. 

Section 10.1.a-10.6.a Introduction 

CMS added terms, applicable integrated plans, integrated organization determination and integrated reconsideration, and guidance that Medicaid requirements must be considered before finding a request invalid for dismissals. Also added were plan responsibilities for providing the enrollee the opportunity to present evidence and ensuring that no punitive action is taken against providers requesting or supporting integrated organization determination and integrated reconsideration. Finally, CMS added requirements to ensure that all comments, documents, and records are considered before making a determination and that applicable integrated plans must review Medicaid information as part of its monitoring procedures and updates to state Quality strategy. 

Section 30.a-30.3.1a Integrated Grievances 

CMS added that these must be reviewed by someone with appropriate clinical expertise if reviewing a denial of expedited resolution of integrated appeals or reviewing grievances regarding clinical issues. In addition, CMS clarified plan responsibilities for non-Part D and excluded drugs that may be available under Medicaid coverage. They added that integrated grievances can be filed at any time, so there are no timely filing limits. Plans must still meet the requirements for QIO and IRE reviews of termination of services from providers and hospital discharges, as well as for Medicaid-covered benefits. Plans must also comply with any state Medicaid quality of care requirements. 

Section 40.1a-40.12a Part C Integrated Organization Determinations 

CMS clarified who may request an initial determination, which includes providers that have not waived the ability to seek payment from the enrollee or are providing treatment to the enrollee. CMS stated that the provider may, after notifying the enrollee, request a standard or expedited pre-service request. Integrated organization determinations must be reviewed by a physician or other appropriate healthcare professional with knowledge of Medicare and Medicaid coverage criteria before the applicable integrated plan issues the integrated organization determination. 

Payment requests may be expedited and are not to be treated differently than non-payment requests for expedited integrated determinations. Plans should apply the same process to assess a request to expedite a payment as they to do assess requests to expedite non-payment cases. In addition, CMS included instructions on notification requirements for payment denials where there is no member liability, indicating that plans must send the enrollee a notice of the denial that includes that there is no member liability. 

Section 50.1a-50.10.a Level 1 Integrated Appeal 

If the provider requests that the benefits continue while the integrated appeal is pending, the provider must obtain the written consent of the enrollee to request the integrated appeal. In addition, plans must accept verbal requests for expedited and standard appeals and upon request, and integrated plans must provide the enrollee's complete case file free of charge and in advance of making the integrated reconsideration decision. Expedited Extensions may only occur if the enrollee requests the extension, or the extension is justified and in the enrollee’s interest, and there is need for additional information and a “reasonable likelihood that receipt of such information would lead to approval of the request, if received.” For denials of expedited appeals, the enrollee must be notified within 2 days of the denial.  They may be notified verbally, but written notice must be provided within 2 days of the verbal notice. Denial Notices must be sent and include language that the case was forwarded to the Part C IRE. 

Other Key Updates 

CMS also added in a new section 50.13 Continuing Benefits While an Integrated Reconsideration Is Pending, which applies to cases where an enrollee, their representative, or their provider is appealing an applicable integrated plan’s decision to reduce, terminate, or suspend previously authorized Medicare Part C or Medicaid covered services or items. This section should be carefully reviewed as it includes information on the timeframe for making these requests and the requirements to note when a plan must continue to provide service and when they are not financially responsible for services. 

Section 90.a Effectuation includes information about timelines for reversal effectuation and requires that the disputed services are authorized or provided promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination. 


Plans should carefully review the addendum and provide comments to CMS by the deadline of August 7th, while making changes to plan policy as needed. 

Still feeling unsure about the potential updates? GHG assists plans in 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.