Potential Changes in Part C Reporting
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. To follow are Part C highlights that merit your attention.
Organization determinations/reconsiderations, Special Needs Plans care management, and enrollments/disenrollments, were updated to include additional data elements, and two new reporting sections were added: Rewards and Incentives Program and Mid-Year Network Changes.
For most data elements with a due date of February 28, the data due date was changed to a couple of different Mondays in February, and the due date for enrollment/disenrollment was changed to the last Monday in August and February. These timing changes are proposed so the reporting load would be more manageable in 2016 than it was in 2015 for the Centers for Medicare & Medicaid Services (CMS)/Health Plan Management System (HPMS), and hopefully it will be more manageable for Plan Sponsors as well.
Two new data elements for Section 6 include the reporting of dismissals for organization determinations and reconsiderations to be more aligned with Part D reporting requirements.
Special Needs Plans (SNPs) will now also report four new pieces of data:
- the enrollee initial health risk assessment (HRA) refusals,
- the annual reassessment refusals
- the HRAs where the SNP was unable to reach new enrollees, and
- the annual reassessments where the SNP was unable to reach enrollees.
Excluded from this reporting are the HRAs that were not done where no refusal is documented and the HRA simply did not happen.
A few new disenrollment data points will now be requested:
- The total number of involuntary disenrollments for failure to pay plan premium in the specified time period.
- Of the total reported in the above, the number of disenrolled individuals who submitted a timely request for reinstatement for good cause.
- Of the total reported in the above, the number of favorable good cause determinations.
- Of the total reported in the above, the number of individuals reinstated.
A new reporting section is proposed for rewards and incentives programs. Plan Sponsors who respond in the affirmative will be required to explain which health-related services and/or activities are included in the program, which rewards enrollees may earn for participation, and how the value of the reward is calculated. They will also need to describe how enrollee participation is tracked, how many enrollees are currently enrolled, and how many rewards have been awarded so far.
Not surprising, CMS' increased oversight over network adequacy is making its way into Part C reporting. The new reporting section, Mid-Year Network Changes, will provide CMS with visibility into how often Plan Sponsors undergo mid-year network changes and how many enrollees are affected by this type of change. CMS states, based on 60-day comments, CMS increased the data elements from 13 to 53. Fun! CMS also states, "Collecting this data will help to inform CMS in determining how broadly to use the new Network Management Module (NMM) in HPMS to verify that plans' networks meet CMS network adequacy standards." If you recall from CMS' 2015 Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast, presenters specifically addressed this module and said Medicare Advantage Organization (MAO)-initiated submissions will not be viewable or evaluated by CMS. However, the NMM also allows for CMS-initiated requests of Health Service Delivery (HSD) tables "in support of various processes," which certainly you can presume will be viewable and evaluated. I don't know about you, but if it is in HPMS, it's viewable to CMS.
For all Plan Sponsors who currently do not have mechanisms for capturing this information, we encourage you to nail down a process. Operational areas may want to get a head start on determining how this information is captured today. CMS is using data now more than ever to determine outliers and to identify candidates for program audits, both of which can lead to enforcement actions. Remember: what they are asking Plan Sponsors to report on are not new requirements — so we anticipate CMS to have little patience for those who demonstrate non-compliance with items agreed to upon initial application.
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Changes for 2015 Part D Reporting Announced by CMS
The Centers for Medicare & Medicaid Services (CMS) recently released an updated version of the Contract Year 2015 Part D Reporting Requirements Technical Specifications.
Sponsors are required to undergo data validation to have some of their Part D data audited annually. Each Part D Sponsor is required to provide necessary data to CMS to support payment, program integrity, program management, and quality improvement activities. Additional reporting requirements are identified in separate guidance documents throughout the year.
REPORT DELETIONS
Long-Term Care (LTC) Utilization -
One notable change for 2015 reporting is the LTC Utilization section will be suspended effective immediately because similar information can be obtained using Prescription Drug Event (PDE) data. Similarly, CMS removed the LTC Utilization reporting section which reports information about the total number of beneficiaries in LTC facilities for whom Part D drugs have been provided because it is provided elsewhere in the Plan's CMS contract.
Prompt Payment -
CMS removed Prompt Payment to Part D Sponsors and Fraud, Waste, and Abuse (FWA) reporting sections and decreased hour estimates associated with these sections because CMS determined these data are no longer necessary for monitoring through these reporting requirements.
CMS has determined the reporting of these data is no longer necessary for monitoring through FWA reporting requirements. Other methods using data validation processes have replaced the need for this reporting element. Annual Data Validation Audits, informatic analysis of PDE data, and other elements reported elsewhere meet the FWA monitoring goals of CMS.
REPORTING CHANGES
Medication Therapy Management (MTM) -
The addition of a note, reporting of Line Q, "Date(s) of Comprehensive Medicare Reviews (CMRs) with written summary in CMS standardized format," has been reduced to two CMR dates, even if more have been completed. One CMR is required if the member meets eligibility requirements. After analyzing the data, CMS concluded only two dates are needed for monitoring purposes.
CMS provided clarification to Line S, "Qualified Provider who performed the initial CMR," (Physician; Registered Nurse; Licensed Practical Nurse; Nurse Practitioner; Physician's Assistant; Local Pharmacist; LTC Consultant Pharmacist; Plan Sponsor) to provide more descriptive choices.
The Technical Specifications for Part D Reporting document can be viewed in its entirety as posted on the Health Plan Management System (HPMS) Plan Reporting site and on the external CMS website by clicking this link.
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The Impact of CMS Changes on MA & FFM 2016 Agent Readiness
Preparing for the 2016 selling season means implementing a strategy that mitigates compliance risks for your organization and empowers your sales force to meet your enrollment targets. In our recent webinar regarding the impact of the Centers for Medicare & Medicaid Services (CMS) changes on Medicare Advantage (MA) and Federally-Facilitated Marketplace (FFM) 2016 Agent Readiness, I outlined key takeaways your organization needs to enforce in order to protect your health plan from compliance risks while also positioning it for sales success in 2016 and beyond.
1. MA/Part D Compliance and FWA Training for FDRs:
Beginning on January 1, 2016, every organization will need to ensure Compliance and Fraud, Waste, and Abuse (FWA) training requirements for first-tier, downstream, and related entities (FDRs) are fulfilled ONLY through CMS courses found on the Medicare Learning Network (MLN). This includes contracted Field Marketing Organizations (FMOs) and agents/brokers. This means the organization may now require these individuals to take custom training and must have mechanisms in place to accept completion of the CMS training. CMS also explicitly states plans will need to provide accurate reporting of this information.
Ways to fulfill requirement:
Note this requirement does not exempt organizations from ensuring all employees and FDRs are informed on how to report instances of fraud, waste, or abuse and other relevant information as described in Compliance Program requirements.
2. New Features for Health Insurance Marketplace Training
CMS is implementing changes to its process where vendors will be offering training. CMS has approved three vendors as "conditionally approved" (not approved until go-live in late summer 2015). GHG is a conditionally-approved vendor for Health Insurance Marketplace training. The number one takeaway from this is agents still begin and end on the CMS website. They cannot come to any vendor website to take their training; they must go directly to CMS and choose the party they would like to utilize.
Important to note:
- Vendors may use CMS' training or vendor-developed training approved by CMS.
- New! Vendor pricing varies: GHG's pricing is $29 for Individual and/or Small Business Health Options Program (SHOP), while AHIP is $125 for Individual or SHOP and $150 for both.
- Vendors offer Continuing Education (CE) units in 5 or more states (pricing varies by vendor).
For information on the requirements and process for completing Health Insurance Marketplace agent and broker registration and training for plan year 2016, please visit here.
Learn more about GHG Health Insurance Marketplace training at exchangebrokertraining.com.
3. Plan Benefit Training Is Important (but doesn't have to be long!)
The point of plan benefit training is not to communicate every detail of your benefits but to provide key information, such as:
- basic company information,
- plan types,
- service areas,
- premiums and deductibles,
- any changes from benefits last year,
- network restrictions and/or changes,
- highlights of drug benefits,
- description of value-added benefits,
- anything that makes you stand out from competitors, and
- most importantly, how and where to get more detailed information
Remember, every interaction your sales agents have with prospective enrollees should be viewed as a golden opportunity to educate the public about your organization. Ensure your staff is effectively trained to make every member touch count.
4. Licensure
CMS does not specify how or how often the organization checks licensure − just that they ensure the agent is licensed. GHG recommends the organization use primary-source verification through the state Department of Insurance (DOI) or National Insurance Producer Registry (NIPR). At a minimum, the organization should check annually and upon any expiration date. Quarterly checks are slightly more robust, and monthly checks the most rigorous.
5. OIG/GSA (Exclusion) Checks
Like compliance and FWA training, this is a compliance requirement that applies to all delegates (and employees) — not just agents. Every agent representing your plan needs to be checked against the federal exclusion lists every month. Plans need to work with their Compliance Department to ensure this requirement is met.
Whether you operate strictly in the MA market or are participating in the Health Insurance Marketplace, thorough and streamlined agent/broker training positions your plan to make the most of every opportunity and minimize compliance risks. Focus on better agents, not just more agents, to best serve your plan and your beneficiaries.
Need help? GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained but contracted, licensed, and appointed per CMS requirements. Sales Sentinel™ can also assist your organization with administrative onboarding functions such as form collection and writing code assignment.
If you have questions, please contact me directly at afleming@ghgadvisors.com.
Resources
Gorman Health Group is one of three conditionally approved for exchange marketplace training, is accepted by all carriers in federal exchange states and provides CE credits available in most states. To learn more visit exchangebrokertraining.com >>
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Best Practices and Common Conditions of Audit Preparation
As we wait for the 2014 Part C and Part D Program Annual Audit and Enforcement Report to be released, we contemplate the activity that our client partners have experienced during CMS audits, in remediation of identified conditions, and preparation for future activities.
This year started a new audit cycle. It has also been a year filled with plan sponsor confusion and frustration over published audit protocol that did not appear to be fully vetted before release to the industry. We received a number of clarifying questions regarding the protocol instructions and data layouts before CMS' summer Oversight and Enforcement conference, and we continue to advise clients — whether they are undergoing a CMS audit or not — to reach out to CMS for clarification in writing. Protocol aside, there is much you can do to perfect the things you have control over — when you can't change the data of the past. With that, and using CMS nomenclature, I bring you some best practices and common conditions of audit preparation that we have garnered over the years.
Best Practices
- Audit participants know their self-identified and disclosed data very well.
- All documentation is perfectly organized when presenting tracers in easily accessible folders, reachable by one click.
- Information Technology and Support staff tests telephone and web connectivity in every conference room. Contact names of multiple IT staff are posted in each webinar room, with one professional outside the conference door at all times.
- Debrief meetings occur every evening with the full plan audit team and CEO. CEO also kept well informed during the day throughout the audit.
- Audit participants are honest and forthcoming with reviewers.
Common Conditions
- Organization is not audit-ready in light of annual protocol release.
- Organization is not fully prepared in light of best practices/common conditions memos to demonstrate thorough evaluation of same.
- Tasks completed but documentation is not in place to substantiate it.
- Webinar participants designate drivers and speakers ahead of time, but do not designate note-takers, runners, or a master of the mute button.
- Organization does not leverage opportunities to outreach to Compliance or CMS for clarification of guidance.
If you have been holding your breath patiently waiting for an audit notice, don't worry, there's still time. The best practices above help your audit run smoothly, efficiently, and help demonstrate a connectedness of a well-oiled machine of a Compliance Department. These folks are generally the ones tasked with the housekeeping and logistics of planning, as well as documentation uploads, leadership summaries and let's not forget their day-to-day work.
Resources
The Centers for Medicare & Medicaid Services (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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Medicare at 50: Past, Present & Future
Since its inception on July 30,1965, millions of elderly and disabled Americans have been able to obtain medical care through Medicare. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number has dropped to a staggering 2 percent.
The accomplishments for Medicare have been noteworthy.
These include increased access to health insurance coverage and healthcare, decreased disparities in access by race leading to desegregation of hospital staff and facilities, as well as payment and delivery system reforms such as prospective payment, capitation, and shared savings — all of which have been adopted by private payers. Karen Davis from Johns Hopkins and former President of the Commonwealth Fund noted the success of Medicare's insurance Marketplace which offers beneficiaries a choice of traditional Medicare and Medicare Advantage plans with a 4-5 Star program that is driving plans and enrollment to higher quality. Medicare spending per capita has grown more slowly than overall health spending per capita and is currently at historically low rates.
The challenges are many.
Disjointed coverage (Parts A, B, D) is confusing to beneficiaries and results in high administrative costs and overpayments. Out-of-pocket costs for premiums, cost-sharing, and uncovered services remain high, and Medicare has no out-of-pocket maximum. Medicare does not cover long-term care services or home- and community-based services. Provider payment still remains largely fee-for-service, resulting in incentives for volume and provider not patient-centered care.
The Future
The future involves many different directions. The first is moving from an acute care model to a program that can effectively care for beneficiaries with complex chronic conditions. Provider payment reform needs to move to value-based payment that rewards efficiency and quality. The focus needs to shift to patient-centered care rather than provider-centric care. Care coordination and team care needs to be a focus. Program fragmentation and high out-of-pocket costs, particularly for high service users, needs to be addressed.
As Charles Darwin pointed out, evolution isn't about being the biggest or the smartest, but the most adaptable. Government programs have become the biggest opportunity for payers. Rates will be positive especially in Medicare Advantage, but the compliance environment will be brutal throughout the rest of the Obama administration. Star Ratings and the member experience are now driving the market — 30 plus states are now using some form of Star Ratings for performance-based payment, many states have adopted quality ratings for Medicaid managed care plans, but there is no national standard….yet, and the Health Insurance Marketplace will begin publishing quality ratings in 2016.
What have we learned?
John Gorman, Founder and Executive Chairman at Gorman Health Group, recently provided lessons learned in the 19 years we have partnered with health plans operating in Medicare, Medicaid and now the Health Insurance Marketplaces. He discusses the current industry environment and what's important moving forward. Read more >>
About 81M will be enrolled in Medicare by 2030. Is your organization prepared?
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Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our 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 >>
GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Contact us to learn more >>
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2016 Marketing Guidelines: Evolve or Pay
There were several significant changes released in the 2016 Medicare Advantage & Part D Medicare Marketing Guidelines (MMGs), all of which communicate the same consistent message from the Centers for Medicare & Medicaid Services (CMS), the focus is on the beneficiary.
Possibly one of the more surprising trends was that with the focus on improving the beneficiary experience, CMS has actually also provided significant leeway in the way that Organizations are permitted to fulfill the requirements. However, with the leeway provided, CMS reminds us that "If CMS finds the Plan/Part D Sponsor failed to comply with applicable rules and guidance, CMS may take compliance action, including intermediate sanctions and civil money penalties." In other words, "Evolve or Pay".
In our recent webinar, Nilsa Lennig, GHG's Vice President of Sales & Marketing Services and I, discussed the new guidelines and what is required of plans to do moving forward.
Below are the top three revisions released in the 2016 MMGs that we believe will have the most significant impact on Organizations:
1. CMS revises current guidance to allow Organizations the option of providing the pharmacy/provider directory to new or renewing enrollees OR a separate notice to alert enrollees where they can find the pharmacy/provider directory online and how they can request a hard copy. In addition, in keeping with the information released in the 2016 Call Letter, CMS includes language requiring Organizations to contact providers monthly to obtain updates to provider information. Once updates from providers are received, Organizations must update the online provider directories in real time.
The operational implications that come along with the changes around network updates and provider directories are huge. While Organizations will have to work through the specifics of these new processes, the cost savings of not having to automatically send printed directories is a clear win for the industry.
2. CMS modifies current guidance to require submission of all agent/broker websites that mention specific products. While this change may be operationally burdensome, we actually view this as a positive. Clearly, this is a revision that has to do with risk areas that have been identified in the industry - anyone who has overseen or reviewed agent/broker websites can attest to that! With the CMS requirement in black and white, we believe that CMS has actually made it easier for Organizations to oversee agent/broker websites in order to ensure Compliance.
3. CMS now specifically states that submission and approval of mobile applications (app) for marketing to prospective enrollees is required. From our perspective, this revision indicates again that CMS has become aware of an area of industry risk. In order to implement this requirement it will be important that Organizations get ahead of this trend and a) ensure that agent/broker/FMO contract language is strong related to which delegates are permitted to develop an app to market plan products and b) ensure that there is a process in place around internal compliance review and submission to CMS of mobile applications.
Conclusions?
- CMS continues method of applying Compliance Actions, as well as Civil Money Penalties
- CMS Continues to have a laser focus on beneficiary protections
- CMS has provided significant flexibility to fulfill certain key requirements — take advantage!
If you have questions or need clarifications regarding any of the information listed above, contact us here and a team member will bee in contact with you shortly.
Resources
Read our recent case study regarding a mid-sized managed care health plan who struggled with appeals, grievances, and Complaint Tracking Module cases (CTMs) to see what their challenges were and how they overcame them. Download now >>
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At the Intersection of Exhausted and Impossible
Today, most employees and employers in all organizations struggle to do more with less…not just health plans.
Information flow and the necessity to respond quickly to change have totally transformed existing jobs in the last ten years. There is little opportunity to spend days considering the implications of data and information received. The necessity of implementing new programs to meet the Centers for Medicare & Medicaid Services (CMS) requirements strains the resources of health plan organizations and departments even further and may contribute to lapses in compliance and, therefore, regulatory risk. A daily to-do list for the Part D team routinely includes:
- Rejected claims review
- Formulary maintenance
- Adjudication issues resolution
- Intra-departmental calls to assist with resolution of grievances and Complaints Tracking Module cases (CTMs)
- Transition fill and notice monitoring
- B versus D medication resolutions
- Intra-departmental and other organization meetings
- Compliance communications and directives
- Personnel issue resolution
- Clinical pharmacy activities
- Part D Star Ratings monitoring and report reviews
- Case management activities
- CMS-required reporting
- Enrollment and eligibility issue resolution
- Prescription drug event (PDE) reconciliation
- AND the never diminishing email inbox
The list goes on and on. A thorough review of all department functions either utilizing internal human resource assistance or external experts can provide recommendations for the right size staffing, resource delineation, and recommendations for new products or tools for the Pharmacy/Part D Department. The review should include the following questions: What is the right mix of pharmacists, pharmacy technicians, and business analysts? How many hours or full-time employee (FTE) segments should be dedicated to the various tasks? Will additional training and refining of work processes help to alleviate some of the burden? Is there a software solution that will streamline some of the manual processes currently in place?
With the insufficient amount of true subject matter experts in the industry, we know recruiting is difficult and time consuming. If interim staffing is what you need, Gorman Health Group (GHG) can enhance your team with our own, providing knowledgeable, effective assistance and an eye for detail from processors and analysts with decades of experience. Our pharmacy consultants come fully trained and prepared to provide short-term or long-term support and create a business case for additional resources, training, and tools. We offer strategic and operational leadership experts when, and where you need it.
Interested in more information? Contact us today.
Resources
Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Don't chase data points. Spend your time on the things that will impact your audit results when a CMS audit comes — and it always does. Visit our website to learn more >>
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CMS 2015 Oversight and Enforcement Conference - Compliance Edition
The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward
Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be a part of: pessimists, optimists, or realists. In order to maximize your success, you best classify yourself in the realist bucket — quick.
One thing that did not change over last year is CMS' overall assessment of improvement. Mr. Mulcahy confirmed CMS has still not seen the improvement they had hoped to see after years of issuing best practices and common conditions information to the industry. Go back to last year's video archives, and you will find he said the same thing last year. According to CMS, sponsors are still surprised by audit activities and findings and unaware of their level of compliance.
Many best practices to combat this type of situation in your organization were discussed during the conference. For example, one organization pulls universes using CMS' data layouts on a monthly basis. Another organization stressed the need to not only focus on the short term in corrective action plans (CAPs) but also consider the long-term solutions required for long-term success—that includes a deep-dive into processes and continuous training. Once-a-year specialized training will no longer cut it, especially in the areas of Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) where CMS notes sponsors, at times, seem unaware of their compliance.
Some things that are changing are the audit protocol instructions and data layouts currently on the Program Audits site. CMS confirmed there are a number of issues requiring clarification or correction in the protocol — we anticipated this. They hope to release updated protocols by the end of this month, but if a plan is subject to audit in the meantime, they will receive the updates. In terms of audit support, CMS' Jennifer Smith confirmed there is still a plan for CMS to release a chapter on audit activities. Once released, this should be a great help to plan sponsors. CMS also provided detail pertaining to the Medication Therapy Management (MTM) and Provider Network Adequacy audit pilots, scheduled to be released in late summer or early fall.
We are continuously making adjustments to processes to ensure alignment with CMS activity, and we hope our clients and all plan sponsors are doing the same. The Medicare Parts C and D Oversight and Enforcement Group (MOEG) confirmed that, if any sponsor receives a civil money penalty (CMP) or sanction, they will be expected to engage an independent auditor to validate corrections. CMS confirmed 93% of plans audited in 2013 received some sort of CMP, and at the recent GHG Forum in April, I shared the majority of enforcement actions since 2014 have indeed been related to CDAG and ODAG. Talk about a risk! It really is time to look inward, be a realist, captain your ship, and adjust those sails.
If you have questions pertaining to the audit protocol, CMS advises you to forward any questions to part_c_part_d_audit@cms.hhs.gov. If you have questions regarding the conference, or have questions on how we can assist, please feel free to contact me directly at rpennypacker@ghgadvisors.com.
Resources:
Register now for a new webinar on improving quality ratings and member retention efforts, as well as prominent compliance and service issues plaguing the industry on Friday, June 26 from 1-2 pm ET.
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Medicaid Rule Imposes New Standards for Beneficiary Access
Per the announcement by CMS on Tuesday, the proposed Medicaid rule would require plans to implement an 85% medical loss ratio (MLR). Implementing an MLR for Medicaid would bring the programs in line with the private health insurance market and Medicare Advantage. However, as mentioned by GHG's Sunmi Janicek, it would not be without challenges. The compliance costs for Medicaid plans with the increase in diligence needed in identifying & documenting costs incurrent to improve quality could be high. Additionally, the CMS proposed rule would impose new standards for beneficiary access and availability to the MCOs provider network.
As with our Medicare Advantage clients, GHG can assist plans by doing a deep dive into their MLR cost drivers, such as poor-performing providers within their participating network, while balancing the requirements for a robust, accessible provider network for beneficiaries. Once we have identified the key cost drivers, we can work with plans to do the following:
- Develop forward looking budget assumptions for benefit premiums, project clinical utilization and provider reimbursement budgets
- Develop clinical & financial performance metrics designed to bring performance in line with expectations
- Develop strategies around how to best impact provider practice patterns, access, treatments, referrals and coordination of care
- Design network modifications based on clinical & financial performance
- Develop performance based payments for provider reimbursements benchmarked to clinical & financial outcomes metrics
Reaching these goals will require the formation of great partnerships between the plan and providers. Plans will want to reach out to provider partners that share their same goals and incentives and secure strong leadership and physician champions to lead the charge. We know the transformation will not be easy. The shift from fee-for-service to value based reimbursement, facing the social services, behavioral health needs of the population, and developing the analytical capabilities to support these changes are challenges that Medicaid managed care plans will face under the proposed rule.
GHG is here to help navigate you through the steps.
Please reach out if we can assist you with any of the following:
- MLR Analysis
- Provider Integration strategies
- Reimbursement strategies
- Risk Assumption strategies
- Network Adequacy compliance
Resources
Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement.As states begin to increase oversight activities and implement more robust compliance and fraud waste and abuse practices, our expertise in compliance program development will be an asset to any organization. Contact us today >>
Medical Loss Ratio Concern in CMS Proposed Medicaid Rule
The much anticipated Medicaid regulation from the Centers for Medicare & Medicaid Services (CMS) has been released, which aims at helping align regulations for managed care plans, creating a dynamic shift in how the Medicaid business will be handled moving forward.
One example of the new change is the proposed implementation of the 85% minimum Medical Loss Ratio (MLR) for the Medicaid program. This is to ensure adequate funds are being spent on coverage for Medicaid members appropriately. MLR thresholds are currently being used by the private health insurance plans, as well as, Medicare Advantage plans for projections of future medical costs and covered services. This could pose a problem for Medicaid Managed Care Organizations (MCOs). While Medicaid MCOs don't have the high sales and marketing costs of individual commercial plans, since sales are handled by the states, compliance costs could be high, making the 85% figure a cause for concern. "Medicaid MCOs will have to be diligent in identifying and documenting costs incurred to improve quality, to drive up their MLRs, said my colleague, Bill MacBain, Senior Vice President of Strategy.
With the soaring number of newly enrolled members joining Medicaid, Avalere estimated that by the end of this year, 73% of Medicaid members will be receiving some type of service through a managed care plan. The regulation aims to look at delivering a structured approach to supporting delivery systems, enhancing health outcomes and most importantly, improving the beneficiary experiences. These new regulations seeks to align CMS' Medicaid regulations to reflect today's changes in delivery systems, increase measures in managing care coordination, and promote quality of care using analytic data to oversee Medicaid managed care.
Additional proposed changes include:
1. Appeals and Grievances — The proposed rule makes a few updates to the appeals and grievances process to align to MA plans. For example, the rule seeks to shorten the time frame that Managed Care Organizations (MCOs) and Prepaid Inpatient Health Plan (PIHPs) have to make a decision about a standard appeal from 45 days to 30 days, same as MA plans. The expedited appeal time frame would be shortened from three days to 72 hours, also same as MA.
2. Beneficiary Protections — Under current regulations, coordination and continuity of care focus on primary and acute medical care. The proposed rules aim to reduce coordination issues beneficiaries with chronic and complex conditions face. The proposed rule also seeks to align enrollment practices between Medicaid fee-for-service (FFS), Medicaid managed care, and Marketplace coverage.
3. Network Adequacy Requirement - The rule would impose new standards to ensure beneficiaries have adequate provider networks and ensure beneficiaries are receiving accurate network information.
4. Medicaid Managed Care Quality Rating System (QRS) — Align with existing MA and Marketplace rating systems. Standardize quality metrics among states and plans.
5. Long-term Care - As expected, the rule also includes a section on managed Medicaid long-term care. The proposed rule could include beneficiary protections, provisions to ensure access to care and enrollee choice and control, and designation of an ombudsman to offer independent oversight.
The proposed rule will be posted in the Federal Register on June 1. The deadline to submit comments is July 27.
Resources
Gorman Health Group is dedicated to assisting Medicaid managed care organizations, as well as states with developing models of care, maximize member engagement. Visit out website to learn how we can help with your Medicaid needs >>
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