This Is the Year to Get It Right
Five consecutive years of very similar audit protocol, continuous partnering with sponsors to identify improvements, and numerous best practice/common conditions memos. Where are you in audit readiness? Did you evaluate the items in the 2016 Readiness Checklist sent in November? I will get back to that! In the meantime, the Centers for Medicare & Medicaid Services (CMS) has started sending audit letters, so we are aware of sponsors and Pharmacy Benefit Managers (PBMs) alike who are prioritizing CMS' requests. Early bird catches the worm, am I right? Presumably these plans have larger enrollment, since they will only be required to provide rejected claims for the one month of January.
Some priorities have not changed: Formulary Administration, Compliance Program Effectiveness, Organization Determinations, Coverage Determinations, Grievances and Appeals, and Model of Care activities are all still part of the base protocol. CMS has committed to releasing pilot protocol to review Medication Therapy Management (MTM) as well as Part C Provider Network Adequacy. Why this additional focus?
- CMS' focus on the reduction of opioid use may be one aspect of piloting the MTM protocol.
- The additional focus on Medicare Advantage (MA) networks is critical. In the past, there was not a requirement to evaluate providers to determine if they were open to new patients or not. If they were contracted and credentialed, then they were used for network adequacy. That does little good for a new member who cannot access that provider.
If you haven't done so, it is time to circle the wagons. CMS is managing a continuous cycle of new audits, audit report finalization, corrective action plan (CAP) review, and validation requests for a variety of sponsors. You cannot change past data, but you can put in place changes that could make improvements for you going forward. Nothing is more important (arguably) than ensuring your Compliance Program is strong. If you have a robust (and documented!) system for auditing and monitoring, you have a greater chance of finding shortfalls before CMS does. Earlier, I mentioned the 2016 Readiness Checklist, which was released on November 20, 2015. This is the sentence that keeps me up at night:
Should you identify areas where your organization needs assistance or is not/will not be in compliance, your organization must report those problems to your Account Manager directly by email in a timely manner.
While this could be viewed as a requirement to notify CMS upon checklist review (which should have been done prior to 1/1), a conservative interpretation would state that at any time, should you identify areas where the organization won't be in compliance, the organization must report to the Account Manager. If you look at it that way, then anything on that checklist pertinent to the program audit areas and identified as non-compliant in your audit period best be indicated as disclosed and not self-identified. Otherwise, CMS might ask why they didn't know about it prior. If you have not received an audit notice yet, do yourself a favor and evaluate your recent disclosures. The list you send to CMS will encompass items from January 1, 2016, through the start of the audit notice.
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CMS audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more >>
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Star Ratings Update: MedPAC Votes to Eliminate Double Bonuses
Star Ratings is already a hot topic in 2016, and we're only one month into the new year. In most recent news, the Medicare Payment Advisory Commission (MedPAC) unanimously voted last month to eliminate the double bonuses associated with Star Ratings, while also virtually unanimously voting to exclude diagnoses collected during in-home assessments from the Medicare Advantage Risk Adjustment model. Although the Centers for Medicare & Medicaid Services (CMS) may opt to take an alternate approach to resolve Risk Adjustment issues within Medicare Advantage, and since CMS can't independently remove double bonuses with amending certain elements of the ACA legislation, this new development is a great reminder of the need to periodically pause and evaluate the value and ROI of programs which remain prominently placed on CMS' radar screen.
When CMS continued their support of in-home assessments in the 2016 Call Letter, we all breathed a collective sigh of relief. And since that announcement, we have seen significant effort by both health plans and vendors to make these assessments even more clinically and socially focused while simultaneously aligning them with Star Ratings measure needs. As a result, any strategic changes made in response to MedPAC's January votes could have a pervasive impact on the care models and operational structure health plans have come to rely on for Star Ratings success. CMS' response to MedPAC's recommendations, along with the plethora of other potential Star Ratings program updates may not only impact health plans and providers, but could also impact a wide array of health services purchased through vendors.
Many health plans (and their vendors) have leveraged risk assessment work streams to hardwire carefully-planned and strategically-prioritized clinical care and care planning activities into in-home assessment workflows in order to seamlessly impact Star Ratings and achieve multi-faceted return on investment (ROI). In addition, the data collected during risk assessments is often stored in centralized data warehouses and used throughout the health plan as a foundation for population health, care management, and consumer experience strategies. And if that wasn't enough, because members often value the relationship with, and advice received from, the clinician they allow into their home, any changes to in-home assessments introduce a host of new risks relative to self-care and disease management, member satisfaction, and consumer experience.
As we await guidance from CMS regarding their response to MedPAC's recommendations and regardless of how CMS ultimately responds to both issues, this is a great time for leadership to study and thoughtfully consider a number of decisions which could result from either the elimination of double bonuses or changes to CMS' treatment of in-home risk assessments:
- What is the downstream Star Ratings impact of any benefits proposed for reduction or elimination?
- How have quality, medical management, pharmacy, Star Ratings measure gap closure, member retention, and other strategic priorities been hardwired into in-home risk assessments?
- What is the secondary ROI from in-home risk assessments on Star Ratings measures, health outcomes, medical loss ratio (MLR), member satisfaction, and member retention?
- Are current work streams adequate to support strong 2016 performance on new Star Ratings measures under consideration for addition to the Star Ratings program?
- How is each department using the data collected during in-home risk assessments?
- How well positioned is the provider network to serve the care planning and care management needs of members currently receiving in-home assessments?
- What types of alternative workflows and tactics will be used in the event diagnoses obtained from in-home assessments are not allowed for risk adjustment purposes?
Because time is of the essence in our industry, strategic planning and change management never ends. As John Gorman has said for years, it will be the most adaptable plans which will both survive and thrive through the tumultuous industry evolution.
In-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created white paper.
Gorman Health Group (GHG) can help you adapt your Star Ratings approach to account for these potential changes and streamline your Star Ratings strategy to influence health outcomes while remaining compliant with CMS regulations. For additional questions and inquiries about how GHG can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
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Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.
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Breaking the Incompatibility Barrier — Four Keys to Merging Operational Productivity and Compliance
Can compliance and efficiency co-exist in Operations? Is there a "right" balance between the two, or could it be more of an intertwining of the two? If you have been in Operations long enough, you have been told you have to increase efficiency, reduce staff, and improve handle time or auto-adjudication rates. What you probably have not been told is to be more compliant, except maybe by the Compliance Department. Widgets in, widgets out, is the name of the game.
It's a lot of plates to keep in the air, trying to balance more with less, and now we add in compliance. What if compliance and productivity cannot only co-exist but can cause a department to thrive? Here are the four critical keys to an intertwined compliant, productive Operations team.
- Don't Ignore the Human Factor — Productivity and compliance are both reliant on employees. All the best tools, reporting, and systems can be in place, but if well-trained and engaged employees aren't on the team, we won't have well-run productive and compliant processes and teams. Employee engagement, like member engagement, is critical to success.
- Know the "Why" behind an Action — We need to change compliance from an obstacle to be circumvented to a process to be embraced. We do that by showing the relevance to the process — the "Why." Have you asked your team what the critical Centers for Medicare & Medicaid Services (CMS) requirements are for the activities they perform? Does the Claims staff know the time frames for processing a claim or the requirement for a clear and understandable denial reason? Even more important, do they know why those requirements are in place and how they impact the beneficiary?
- Have the Right Tools — Do you know how many manual work-arounds your team completes on a given day? How many member communications must be manually completed? How much manual research is needed to adjudicate a claim? Does your management know? IT changes are costly and take time, but we must get things on "the list." That's why a current prioritized list of enhancements is needed. Make sure to document the productivity and compliance loss due to the work-arounds. Include team member's input — their voice is important to understanding the true issues. Spearhead the top critical needs on the earliest IT release possible.
- Provide Measurable Results of Success and Failure — How do you and your teams know when you are successful or when you failed? Do your reports show both your production and compliance goals? Typically, Operations has lots of reports, but how are they aligned — with commercial or Medicaid metrics or the unique Medicare metrics? Is this shared with your team?
In the Medicare world, Operations can't be a balancing act — it's all about intertwined compliance and productive Operations teams. At Gorman Health Group, we know how important it is to link compliance and productivity. For actionable advice on this topic and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas.
During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
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Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Risk Adjustment: Proposed Changes & New Regulations
At Gorman Health Group (GHG), we pride ourselves on having our fingers on the pulse of what continues to be a complex and volatile government programs environment. Whether it is fact or fiction, our clients and our peers look to us to interpret and filter through the official announcements, the breaking news, the propaganda, and the hype.
Being accountable for GHG's Risk Adjustment division keeps me and our team of consultants quite busy, and just when other departments get to breathe for the holidays, we are inevitably fielding questions and providing "home stretch" support to clients as they prepare for the final submission of risk adjustment data. (In case you missed it, CMS published this memo outlining extended deadlines for data submission.) See full memo here.
If you live in the risk adjustment world, you know this critical business function never really takes a holiday. The Centers Medicare & Medicaid Services (CMS) calendar for data collection and submissions leaves little room for vacations, especially knowing risk scores recalibrate annually and the work to ensure complete and accurate diagnostic data for Medicare Advantage (MA) beneficiaries requires a watchful eye at all times. The reality is, either your hair is on fire, or you just sent the guy in the cube next to you out to refill your propane tank.
Whether we are in the trenches with our clients, or supporting them from afar, GHG is always keeping an eye on what is coming next. So, while you were collecting charts and checking them twice, and making sure your In-Home Assessment vendors were sending information to your Case Management department, here is what has been coming across the wire…don't worry, we have been keeping tabs on all of the critical activity in the risk adjustment space:
October 28, 2015: CMS announces proposed changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017 which would apply "improved predictive ratios" for full benefit and partial benefit dual-eligible beneficiaries.
November 4, 2015: CMS admits to having underpaid dual-eligible health plans and, in turn, overpays for beneficiaries with low medical costs, sparking concern not only about inequities in payment, but the potential for adverse selection.
December 2, 2015: CMS released an early preview of 2017 MA Ratebook Growth Rates, signaling a hopeful bump in MA plan payments due to a 3.1% increase in traditional Medicare spending in 2017. This is one variable in the equation. Risk adjustment calculation changes and other policy changes will complete the puzzle. More to come on February 22 when CMS releases the Advance Notice for 2017. Stay tuned.
http://www.modernhealthcare.com/article/20151202/NEWS/312029999
December 28: CMS released a Request for Information outlining the expansion of Medicare's Recovery Audit Program in an effort to identify instances where Medicare is overpaying.
http://www.modernhealthcare.com/article/20151228/NEWS/151229937
January 14, 2016: The Medicare Payment Advisory Commission (MedPAC) voted to pass recommendations which would change how MA plans are potentially paid, potentially saving CMS $5 billion and revealing its position on In-Home Assessments and Star Ratings Quality Bonus Payments.
http://www.modernhealthcare.com/article/20160114/NEWS/160119925
January 22, 2016: This one has a bit of a political spin to it, but we thought it was worth reporting. AHIP released a funded analysis conducted by Avalere Health, finding the risk adjustment model used by CMS "lowballs" the cost of treating chronic conditions such as depression, osteoarthritis, chronic pain, and rheumatoid arthritis by millions, and, in some cases, billions of dollars.
http://www.modernhealthcare.com/article/20160122/NEWS/160129948
Just like our consulting services and our analytics solutions, we assessed the current state of the Medicare risk adjustment industry, collected our findings, and delivered meaningful, actionable information which will keep our clients and readers informed and prepared for what lies ahead in 2017.
A more in-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created whitepaper.
For additional questions and inquiries about how GHG can support your organization's risk adjustment programs, please contact me directly at dweinrieb@ghgadvisors.com.
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Whether you rely on multiple vendors or a largely internal team, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>
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Sales 2017 Readiness — Are You Maximizing Your Sales Potential Today?
Here we go again, planning for the upcoming selling season. Every year it seems to approach more quickly than the year before. Are you ready? If the answer is no, or you are not sure, here are a few critical items to consider as you create your 2017 Annual Election Period (AEP) strategy:
- Market Analysis — What worked during AEP 2016? This is the time to reflect on strategies which helped and/or hindered your success from the previous year. While it's fresh in your mind, create a market analysis to review all the components of your sales process. From material distribution to product design, it's important to understand what components of your strategy worked and what needs to be adjusted.
- Channel Mix — Do you have the right mix of agents to represent your plan? It's important to evaluate the effectiveness of both your internal and external sales forces. The industry is moving toward a more diverse distribution channel. The need for internal and external field agents, coupled with telesales, helps maximize your footprint and reach all corners of your market.
- Seminar Plan Development — Did the materials you provided keep your agents compliant during their presentations? CMS secret shoppers are out in full force, and having the right tools for your agents will be imperative to high Star Ratings. In addition, baby boomers are also forcing us to rethink how we present products to Medicare beneficiaries. With the growth of internet shopping, online enrollment presentation opportunities must be included as a part of your strategy.
- Marketing — Did your direct mail make the phones ring, or did your marketing miss the mark? How you implement your marketing strategy impacts lead flow, brand awareness, and enrollment. Successful marketing programs deploy a multi-touch communication strategy which blends education, lead generation, and conversation tactics to maximize new member acquisition.
- Sales Training — Was your sales force ready to sell your plan? Sales training is a critical part of plan and agent success. Create a curriculum which encompasses sales and product training, time management, Medicare basics, and compliance. Don't forget to teach them about member retention―it's hard enough to acquire new members, so you also need to know how to retain them. Enable your agents to start the season with all the knowledge needed to make that sale and keep that new member on the books.
With the narrowed time frame for AEP, your sales strategy must continually change to adjust to the Medicare climate. What worked last year may not work this year. Don't delay, the time is now―start planning for your success today!
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Network Adequacy Top of Mind for CMS
The Centers for Medicare & Medicaid Services (CMS) continues to reinforce its focus on health plan provider networks with several recent announcements.
The release of the new Network Management Module (NMM) within the Health Plan Management System (HPMS) is the tool CMS will utilize for monitoring network adequacy. The NMM functionality allows both CMS and organizations to evaluate health services delivery (HSD) provider and facility networks separate from the annual application process. The NMM employs the same evaluation criteria and calculations currently used by the automated network review portion of the Medicare Advantage (MA) initial and Service Area Expansion (SAE) application process. Please note organizations can access the NMM functionality to submit their network tables for an "organization-initiated" automated review. Results generated for an "organization-initiated" review will only be available to your organization and not be viewable by CMS. Our subject matter experts at GHG are able to assist plans in utilizing this new functionality as part of an overall network audit and maintenance policy plans should adopt to continually assess how their network, as its largest asset, meets the goals of the organization.
Additionally, CMS released the Draft 2017 Letter to Issuers in the Federally-facilitated Marketplace (FFM) on December 23, 2015, and is proposing new policies on network adequacy and monitoring to provide more transparency and detail to be Qualified Health Plans (QHPs) in an FFM to fulfill the requirements to provide reasonable provider access to their members. Plans have the ability to review the draft letter and provide comments back to CMS by January 17, 2016. We have provided a link to the full draft letter, and, as with MA plans, Gorman Health Group (GHG) has the ability to manage your network adequacy reports and audit for all QHPs.
Lastly, on January 13, 2016, CMS provided training on the summary of changes to the 2017 MA applications. One of the key points addressed is the SAE application will require HSD Tables for the entire Medicare Advantage Organization (MAO) network at the contract level, not just the counties the application is proposing to expand into with the SAE request. The change comes as CMS has indicated plans should have tighter control on their existing provider networks to ensure adequacy is met over the life of the contract.
At GHG, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan. Please reach out if we can provide guidance regarding the rules and regulations for all government-sponsored health plan networks.
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GHG's multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
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Top Tips for Star Ratings Success in 2016
Amidst our rapidly-changing industry landscape, the Star Ratings program essentially serves as a "Medicare Advantage stress test," measuring a plan's ability to master the operational complexities encountered while improving the quality of care and general health status of Medicare beneficiaries through member-pleasing experiences. At any given time, there are multiple Star Ratings cycles in play. For example: operational teams and providers have now shifted their focus to services impacting 2018 Star Ratings, Quality and Pharmacy teams are beginning to finalize Healthcare Effectiveness Data and Information Set (HEDIS®) and Prescription Drug Event (PDE) data for 2017 Star Ratings, and the Star Ratings team is feverishly working to optimize performance across both the 2017 and 2018 Star Ratings cycles.
As we've said before, there is no rest for the weary within Star Ratings, and 2016 will likely be no different. But January is a time for new beginnings and fresh starts, so we want to provide you with a few helpful tips to start off the New Year strong:
Monitor and Manage Execution Risk
As John described in his blog this week, we are watching a slew of significant industry issues this year. Some of these issues will directly impact Star Ratings workflows (such as potential new measures, potential program changes to account for dual eligibles/low-income subsidy (LIS) members, and the evolution of Medication Therapy Management (MTM), some will directly impact Star Ratings strategy (such as mergers, drug pricing, provider networks, and care delivery), while others will have an indirect impact on Star Ratings. The Star Ratings impact of these issues and risks, combined with the impact of internal and local risks and issues, will continue to evolve and may change unpredictably throughout the year. It's important for health plan leaders to understand the Star Ratings impact associated with these, and other, types of issues so risks can be routinely evaluated and mitigated where possible. Just as importantly, monitor and evaluate your internal execution risks so mitigation strategies can be deployed when staffing challenges, organizational changes, or administrative processes are not functioning as designed. Make sure your Star Ratings reporting, monitoring, and oversight processes spotlight these risks so leadership is aware of key risks and can adjust the sails as needed if the winds change during the year.
Align Your 2016 Star Ratings Work Plan with Your Strategic Plan.
Health plans are updating their strategic plans more frequently, and often more significantly, than in the past to account for the nature, extent, and speed of industry changes. It is not uncommon for staff to invest time, effort, and resources in selected areas only to later discover there were other, more critical, areas which could have yielded a higher return on investment (ROI) from Star Ratings-related investments. Star Ratings success amidst a changing industry will test a plan's flexibility, agility, and leadership. With that in mind:
- Ensure your 2016 Star Ratings work plan aligns with your organization's strategic plan and captures activities needed to mitigate the impact of strategic adjustments.
- When planning for strategic change, engage Star Ratings leaders to ensure leadership is prepared for, and can mitigate the impact of, such strategic change on Star Ratings. As changes are made, help department leaders understand the full scope of change and its impact on Star Ratings and deploy well-planned tactics to mitigate Stars Ratings risk as changes are implemented.
- Align Star Ratings strategies and tactics with population health, quality improvement, and care management workstreams, and cross-leverage member interventions to simultaneously achieve cross-functional purposes.
- Evaluate the impact of your delegates and vendors on your Star Ratings strategic goals and deploy targeted efforts where improvement is needed.
Run Star Ratings as a Strategic Program
A health plan's Star Rating ultimately reflects the effectiveness with which the entire organization (and its first-tier, downstream, and related entities) and its provider/pharmacy networks work together to improve quality of care and the health status of Medicare beneficiaries in ways which meet members' expectations. As Star Ratings expand into long-standing, multi-faceted new clinical areas, health plans may discover a need for increased collaboration among internal teams and with providers. With this in mind, it is important plans run Star Ratings as a strategic program with dedicated leadership, well-documented workflows, and carefully-crafted leadership support to best ensure the plan hits the ever-important 4-Star threshold.
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Every Star Ratings work plan is unique, and the opportunities to improve performance are similarly unique. With this in mind, it can often be helpful to conduct an objective evaluation of your program. Gorman Health Group's team of experts can help you review key infrastructure and workflows to identify opportunities to improve your Star Ratings performance.
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New Hospice Policies Could Mean Big Changes for MA
Medicare's hospice care is garnering much attention and starting the evolution process this year. The Centers for Medicare & Medicaid Services (CMS) issued several new regulations changing hospice payments, and these regulations come with big implications for Medicare Advantage (MA) plans as well.
Last month, the Senate Committee released a policy options paper, discussing solutions for managing chronic illness. In the paper, the Committee proposed that MA plans be required to offer the hospice benefit currently provided under Medicare Part A. Such a change would mean changes to the MA payment system in order to include hospice reimbursement. It would also come with the inclusion of additional measures under the Star Ratings system.
These proposals have been floated around throughout the years, however, with the inclusion of the new end of life talks and the evaluation of the Care Choices Model, this proposal has more teeth and may become reality in the next several years.
Medicare will now also pay for Advance Care Planning talks. Most Medicare beneficiaries and their families state they would like to be involved in end of life planning, yet these talks are often avoided because of the sensitivity of the subject, prognostic uncertainty, and, most importantly, lack of training or pathways for physicians to facilitate these talks. A small number of beneficiaries currently have advanced care directives. This year is an important test for this new payment in assessing whether the talks will have an effect on the care patients choose to receive and whether this will result in more frequent and earlier hospice admission.
Although these payments are small, this is a great opportunity for plans to lead more physicians to discuss end of life care and put plans at an advantage if approached correctly. More patients electing hospice care could lead to better patient quality and experience. Hospice care is more person-centered and tends to improve outcomes such as pain and satisfaction. At the same time, although plans would lose the patient's premium from the shift to hospice, they would also shift the bad claims experience due to the highly expensive end of life palliative treatments and unnecessary hospital care. However, due to the sensitive nature of the discussions, plans should establish a careful framework in their approach in order to contain patient satisfaction and quality.
This year also marks the launch of the Medicare Care Choices Model (MCCM) from CMS. The five-year model allows some hospice-eligible patients to access hospice care without having to forego curative treatments, the way the system is currently set up, and allows for providers to receive payment for this care. The program has some significant limitations: hospice providers will only receive $400 per month or $200 per month for those enrolled for less than 15 days. This means in order to be financially appealing, patients will receive much lower benefits than normally received through hospice treatment. However, it may set up a basis for continued advanced care discussions and lead to more patients electing full hospice care. Despite the low payment, however, the model received significant provider interest and will see a high level of participation.
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At Gorman Health Group, we would be happy to work with your organization to develop beneficiary outreach and/or other programs to address the growing need for this kind of program, which, if applied properly would benefit both the beneficiary and the help plan. Contact us to learn more >>
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Health Insurance Marketplace — What's Contributing to the 2016 Enrollment Growth?
On December 22, 2015, the Centers for Medicare & Medicaid Services (CMS) released a snapshot report of the Health Insurance Marketplace Open Enrollment, capturing Marketplace enrollment from the beginning of Open Enrollment (November 1) through December 19 (Week 7 of Open Enrollment) for consumers who signed up for health coverage through the Healthcare.gov platform. Not accounting for the millions more selecting plans through State-based Marketplaces (SBMs):
- More than 8.2 million consumers signed up for healthcare coverage — 28% more than enrollment a year prior.
- Approximately 29% (about 2.4 million) are new consumers, while 71% are consumers renewing coverage.
- New consumers are over one-third higher than the number of new consumers who signed up by the deadline for January 1 coverage last year.
- More than 4 million people made plan selections between December 13 and December 19, which represents almost 50% of the cumulative Open Enrollment plan selections through December 19, 2015.
So what is contributing to the positive enrollment growth in the 2016 Health Insurance Marketplace?
While it is normal to see higher consumer demands during the weeks leading up to the January 1 effective coverage deadline, there are some other factors which may be contributing to the enrollment trends.
- Automatic renewal process — As part of the Federally-facilitated Marketplace (FFM) auto-enrollment process, generally, if consumers do nothing, they will be auto-enrolled in the same plan with the same premium tax credit and other financial assistance, if applicable, as the prior plan year. This provides consumers with a simple, familiar process to renew their coverage.
- Broker guidance and training— CMS is providing more guidance and instructional tips to brokers on how to engage consumers and simplify the consumer enrollment experience. This can been seen in:
- the numerous broker training sessions CMS hosted going into Open Enrollment,
- CMS provided enrollment tools such as the "Marketplace Application Checklist" brokers can use to help consumers prepare to complete their applications on Healthcare.gov,
- a new "For Agents and Brokers" link has been added at Healthcare.gov, making it easier for agents and brokers to get to the Agents and Brokers Resources webpage (http://go.cms.gov/CCIIOAB),
- and consumer research shared with brokers showing what drives consumers to take action.
- Customer awareness — The first Health Insurance Marketplace Open Enrollment period was longer than in future years in order to give consumers a chance to understand their options and make a selection (in addition to allowing further opportunity to beneficiaries impacted by hiccups in FFM enrollment functionality to complete enrollment). As we enter the 2016 plan year, enrollment processes and functionality are not only tighter, renewing beneficiaries are now more familiar with how to research coverage options and avenues in which they can enroll.
With Open Enrollment coming closer to the end, extremely high traffic is anticipated on Healthcare.gov specifically on the January 15 cut-off date.
CMS will continue to release snapshot reports for the Healthcare.gov platform throughout Open Enrollment. It is anticipated more detailed reports which look at plan selections across the FFM and SBM will be released by the Department of Health and Human Services (HHS) later in the Open Enrollment period.
For more Open Enrollment Trends:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-22.html
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Gorman Health Group's annual training can help you prepare. As a CMS approved training vendor, we offer robust training on an easy-to-use platform at an unbelievably low price. Visit our website to learn more >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Top Five Operational Resolutions for 2016
Did you know only 8% of people who make New Year's Resolutions achieve them? There are many reasons why resolutions are not accomplished. They may have been too aggressive or priorities changed. Sometimes it's because the goal is too vague or there are far too many and a person is unable to focus on them all.
When it comes to achieving resolutions, there are two keys to success: be specific and stay positive.
Here are our top five operational resolutions to consider for 2016:
- Re-evaluate your controls against current guidance. Are the standards still the same? Is your evaluation process adequate to ensure compliance?
- Fix your highest volume workaround. Every department has them. Some prevent rework, some are due to obsolete systems, some were set up for ease of users, but workarounds are hard to monitor, hard to explain in an audit, and are a risk with staff turnover. Fix it so you have one less thing to sidetrack processes.
- Set up redundancy in processes. We have all been in a place where a single individual knows a process. Your single source of success can easily turn into a single source of failure if that staff person wins the lottery and decides to travel the world.
- Evaluate and improve the highest priority item requiring rework. One client had a high volume of Medicare Secondary Payer (MSP) records which would be closed and then show up again every few months. The rework and premium loss and recovery were a continuous cycle. After evaluating the records, a root cause was identified, which was within the plan's control, and resulted in less MSP churn.
- Celebrate more successes. Does your staff know their compliance rates? Do they know if they are improving month over month? Do they know the compliance issue they reported resulted in better ongoing compliance and prevented harm to members? Celebrating successes not only ensures staff sees the part they play in the big picture but reinforces the requirements.
Gorman Health Group has experienced consultants who can assess and review the operational areas of your organization. We can review current processes and look for efficiencies to improve outcomes and better compliance. Make a resolution to improve your organization's operational areas — we can help make it happen in 2016.
For more information, please contact me directly at jbillman@ghgadvisors.com.
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