Lake Wobegone Exchanges
One of the most frequent questions I've been getting on the health reform speech circuit has been what our expectations are for enforcement activity in the exchanges in Year 1 -- and the answer is just about none.
For the 16 states launching their own exchanges this Fall, much of the focus will be on basic administrative functions involved in getting the millions expected to enroll through the system. For the 27 states where the Federally-Facilitated Exchange will be operating, the answer is really nothing. The Feds are painting a picture of "Lake Wobegone Exchanges", where all of the plans are strong, all of the brokers and agents are good looking, and all of the stakeholders are above average.
Year 1 of the Exchanges was always going to be about getting the "pig through the python" of the enrollment and eligibility process. It was basic fulfillment functions like verifying "clean" enrollments, entering and reconciling new members into plans' systems, and issuing membership cards that tripped up the launch of Medicare Part D in 2006. The rollout of the Exchanges will see the same struggles. But CMS's latest rule points to an enforcement "hall pass" for participating plans in Year 1.
CMS's latest exchange regulation estimated that there will be more than 250,000 agents and brokers registered in the Federal Exchange -- and went on to say it expected to suspend or terminate 2. Not a typo. CMS seems to be saying that their agent oversight role is limited since states have primary responsibility for broker licensing and monitoring -- but still, 2 out of 250,000? Really? CMS further estimated there will be 409 Qualified Health Plans (QHPs) in the Federal exchanges, but only 1 civil money penalty and only 1 plan termination. Talk about a paper tiger.
CMS will not do much but play "whack-a-mole" with anything egregious that comes up in QHPs. There will be little to no unilateral state enforcement in the first couple years of the Exchanges. And there won't be any kind of organized compliance process for plans in the exchanges like we see in MA until at least year two or three. So bottom line: the plans don't have to worry about the hammer coming down in Year One -- unless they kill someone with an administrative screw-up. Lake Wobegone for sure.
Resources
Listen to a three-part podcast series where GHG Executive Chairman, John Gorman discusses the Importance of a Readiness Checklist for the Exchanges for Sales Marketing Enrollment and Risk Adjustment.
Learn how Gorman Health Group's web-hosted modular software solution, Sales Sentinel, makes sales agent training, credentialing, onboarding and ongoing oversight a smooth and seamless process.
When reconciling Plan data to CMS' records, you have to deal with a number of issues. Listen in as Gorman Health Group's Senior Consultant Chris Groves discusses these issues and the importance of reconciling member data.
Choosing a Call Center? Five Must-Ask Questions
This fall promises to be one of the busiest in history for health insurers with the flurry of Health Insurance Exchanges (HIE), Annual Election Period (AEP) and the implementation of the Affordable Care Act (ACA).
Unanswered calls to insurance companies by potential customers will become forfeited opportunities that may never be reclaimed. Many companies will rely on call centers to handle their call overflow, many for the first time. Consider these five questions when selecting a call center:
1. TECHNOLOGY: Does their technology meet your needs?
The complexity of the insurance industry calls for innovative technology solutions: practical solutions that improve the process for agents and customers alike, and proactive solutions that are flexible enough to handle diverse responsibilities in intuitive ways. Can their call center directly connect your callers with agents in the field instantly? Can they track responses at the individual record level? Do they offer dashboards and reporting in real time?
2. TRAINING EXCELLENCE: Are their CSRs well-trained on Medicare and your plan's protocols?
Harper Lee wrote in To Kill a Mockingbird, "We're paying the highest tribute you can pay a man. We trust him to do right. It's that simple." Like Atticus Finch, trust in the training call center agents receive is a key consideration in a partner. After all, they represent your Medicare plan(s), your brand and your relationships. Could your call center partner handle the scrutiny of a CMS audit?
3. AGENT EXPERIENCE: How experienced are their CSRs?
Exerience is critical in the insurance industry. Experienced agents could mean the difference between a successful sales campaign and a failed one. Because AEP is condensed, inexperienced agents shouldn't gain the necessary experience on the fly.
4. QUALITY & COMPLIANCE Is a robust quality and compliance program with metrics reporting in place?
Quality and compliance go hand-in-hand. Everyone's accountable to CMS. A good compliance program protects clients, plan members and prospective members alike.
5. ADAPTABILITY: How much flexibility and input is permitted?
Flexibility and adaptability are the bread & butter of a vendor partnership, particularly when responsibilities are outsourced. Will you have access to a support team when needed? Such access ensures seamless support of day-to-day campaign challenges. A high-quality support team is agile, adaptable and attentive to detail. Partnering with an experienced call center helps you stay competitive, provides excellent caller experiences, and helps grow your membership.
Resources
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
Every OEV Call Should Be a Welcome Call
In the world of insurance sales, making the right call during a sales presentation and getting the call right for compliance purposes is critical. Outbound Enrollment Verification calls (OEV) calls are not just for an applicant's protection — they're the insurance industry's version of instant replay!
Verification calls are "welcome calls" with a new member. A verification representative should be on every OEV call. Just because OEV calls are a CMS requirement does not mean verification specialists should just "check the box" and read the questions in a Ben Stein-monotone.
Remember, all plan sponsors are required to conduct OEV calls for enrollments originating from both independent and employed agents/brokers to ensure applicants understand the plan's rules.
Here are some other tips to ensure a plan sponsor makes the most out of every OEV call:
- WRITE YOUR OWN SCRIPT: The OEV call is your first call with a new member following enrollment. It's important to create a natural, personable script to make a favorable first impression. A good OEV script should flow comfortably.
- STAY POSITIVE, WARM AND ENGAGING: Verification calls are often a customer's first point of contact since their enrollment. It's important that OEV agents help to put their company's best foot forward. Verification agents should use a warm tone and shouldn't shy away from emphasizing their company's brand. Use the opportunity to engage the member.
- EMPLOY A COHESIVE PROCESS: Some plans face challenges with OEV calls because their process is disjointed. Instead, work to create internal automation that pushes the calls and letters when necessary, or partner with a vendor that can do it for you.
- CONDUCT OEV CALLS ASAP: Make CMS-mandated OEV calls as soon after the enrollment as possible. (OEV calls must be made to an applicant after the sale; they cannot be made at the point of sale.) Make the call sooner rather than later.
- ARM OEV AGENTS WITH RESOURCES: Plan sponsors should ensure their verification agents have a strong knowledge base of plan details like doctors and hospitals in the network (if applicable), the co-pays for different prescriptions and the maximum out-of-pocket. In short, verification agents should be well-trained and have access to resources.
- IT ALL STARTS AT ENROLLMENT! The enrolling agent can help the OEV process by setting expectations. Our Bloom phone and field agents explain applicants what the OEV process is, when to expect the call and what to expectduring a call. Enrolling agents should stay connected with OEV agents to ensure a healthy level of coordination and cooperation.
Remember, you get only one chance to make a first impression -- and that impression begins with the OEV call!
Resources:
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
To learn how you can put Bloom's Call Center agents to work for you, visit our website.
What Sequestration Could Mean to Medicare Advantage Claims Payment
Last Friday CMS's Medicare Learning Network released some details on how the sequester will impact Medicare fee-for-service. By extension we see some implications for what it means to Medicare Advantage (MA). The CMS notice offered the following:
| To All Health Care Professionals, Providers, and Suppliers: Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program — "Sequestration" The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.
This listserv message is directed at the Medicare FFS program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013. The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare's payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare's reimbursement. Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions. |
Here's what it means for Medicare Advantage:
First, CMS is applying the 2% cut to fee-for-service claims based on dates of service on or after April 1, not dates of payment on or after April 1. Plans that pass the 2% cut on to providers on the same basis as Medicare FFS will be paying at full value for incurred claims with dates of service before April 1, even if paid after that date. However, we expect that CMS will deduct the 2% sequestration from payments to MA plans starting with the April payment. This may cause a short term cash flow issue, with April claim payments for prior months' claims being made at full value, while the April capitation from CMS is at 98% of full value.
Second, the 2% is applied after all other calculations. For instance, assume the Medicare allowable rate for a service is $100, and the service is subject to the Part B coinsurance of 20%. Payment to the provider would normally be $80, with the beneficiary paying the other $20. With the sequestration, it's $78.40 to the provider. But, since the coinsurance is calculated before applying the 2% cut, the beneficiary still owes $20. The original fee schedules still apply: the 2% comes off the payment, not the calculation of the payment.
We're not sure yet how this will affect how MA plans pay claims. For instance, if a plan covers office visits at 100% of Medicare allowable, less a $10 copay, and if they determine that their contracts allow them to pass the sequestration through to providers, does this mean that they would pay $78.40 instead of $80 for the Part B benefit, plus $10 (the $20 coinsurance minus the $10 copay)? That's a total of $88.40, versus $90 the plan would have paid prior to the sequestration, a reduction of 1.78%. But the plan's capitation is being cut by 2%. So revenue gets a bigger hit than claim payments.
If this is an accurate example, calculating this is going to be a nightmare for MA plans' claim systems. They will have to be able to calculate the Medicare Part A or B payment, net of the Part A and B deductibles and coinsurance, and subtract 2%. Then they'll have to add back the full value of the deductibles and coinsurance, and subtract the plan's copayments.
But it gets worse. If plans will only be able to apply the 2% against what Medicare would have paid, they will need deductible accumulators for the Part B annual deductible, and the per benefit period deductible for Part A. And they will need to calculate the different copayments for regular hospital days and lifetime reserve days. Presumably there is no way to know if someone has used up the lifetime reserve, since that would require access to claim data from periods when beneficiaries are covered by FFS Medicare or other MA plans.
It is a little simpler for capitation payments. For plans that capitate providers based on a percent of premium, the 2% cut will just flow through to the capitated provider group. Plans that pay a specified fixed capitation per member month will probably have to eat the reduction. But either way, the capitated delegated provider group will need to follow the Medicare FFS logic if they apply the 2% reduction to their provider payments. So the same complications remain; they just move downstream from the plan to the capitated provider entity. We think this is something that health plans need to address immediately with their capitated providers, to ensure that the capitated entities are prepared to administer the 2% sequestration accurately -- and within the next month.
It's only a matter of time before the complications of sequestration and Congressional inaction reach the point that no one in Medicare Advantage can administer it. That time may come next month if the President and Congress can't come to agreement to avoid a government shutdown on March 27, and if CMS keeps most of its draconian 45-Day Notice proposal in place when final MA rates, and the final terms of the 2014 Call Letter, are announced on April 1.
Resources
Listen in as Gorman Health Group Senior Vice President Bill MacBain shares an update on the sequester, what GHG thinks is likely to happen next, and the potential impact on Medicare Advantage.
Gorman Health Group Senior Vice President Bill MacBain explains the logic behind the proposed rate change, and shares a brief analysis of the impact in this regulatory summary.
Click here to review GHG's comments in response to the Advance Rate Notice, submitted to CMS on March 1, 2013
Gorman Health Group Senior Vice President Jean LeMasurier summarizes the 2014 CMS Draft Call Letter.
Exchanges: Sales Agent Certification
CMS has released a notice seeking comments on their plans for training and certifying sales agents who could enroll persons into the federally facilitated exchanges. To be exact, the notice is about collection of data about the sales agents who are trained and certified for selling coverage offered by qualified health plans on the exchange. It just so happens that the vehicle for doing the collection is the training and certification program that is mandated by the law and the final regulations published last March. So, CMS does not want comments about the requirement to be trained and certified but they do want comments about what information is collected and maintained about individual sales agents.
In the process of telling us what they want to collect, CMS is also letting us know something about the training and certification program. First, they expect that approximately 250,000 agents will take the FFE training and certification program. They note that this excludes all states where a state operated exchange will function. If agents (approx. 240,500) are allowed to sell QHP coverage in state operated exchanges, the states need to develop and offer their own certification program. CMS also notes that captive agents (approx. 110,500) are expected to enroll persons through their QHP. This means any training for these sales agents must be conducted by the health plan and must follow required enrollment processes through the exchange.
CMS will collect basic identifying information such as name, location, and state license as the agent accesses the system. There is no paper process so agents without electronic access need not apply. After providing basic information, the agent will take the training course and complete the exam to be certified. CMS expects the agent to spend 4.75 hours to complete training and testing in the first year allowing for re-taking and re-testing for those who fail to complete it in the first try. For succeeding years, the expected time requirement falls to 3.25 hours. During this process, CMS can identify particular issues about the test such as time required or troublesome questions and concepts. In addition, CMS will know the individual test taker's training history and their relative success. There is no prohibition on retakes or how often an agent can re-take the training and test. Agents who are certified though the process will be listed on the FFE website so that interested persons can contact them for information and assistance.
CMS notes that they will use collected data for oversight and monitoring. CMS will take follow-up actions whenever they identify questionable activity. Also, from time to time, CMS will ask agents to make their records available for oversight and compliance purposes but does not make clear what records are involved in these requests or actions will occur. Finally, agents will be required to sign an agreement that allows all of this to occur plus documents their commitment to periodically updating information.
Access to the portal will begin around July 1. There is no indication of a fee for taking the training and CMS does provide an outline of the training program that covers the basic components of exchange operations and eligibility determinations.
No doubt there will be questions since any data collection efforts with federal implications for the agent call big brother into question. Clearly, sales agents will have concerns about another body getting complaints about their sales activity and CMS will counter that it has over 25 years of experience with sales agent mischief dealing with vulnerable populations in the Medicare Advantage program.
Click here for information on how to submit comments on this notice.
Click here for a description of the data collection program and some of the processes that will be used to train, certify and collect information.
Resources
Senior Vice President for Public Policy, Jean LeMasurier, summarizes the February 7, 2013 notice from CMS regarding Agency Information Collection Activity.
Download a podcast on the key components of OEV calls and get advice on how to handle rapid disenrollment — and other common challenges.
Learn how Gorman Health Group certifies, trains and manages sales agents with our Sales Sentinel software.
250,000 Agents in the Federal Exchanges???
In a Federal Register notice out yesterday CMS officials are projecting 254,095 health insurance agents and brokers will sign up to sell the "metal plans" in the new federal health insurance exchange (HIX) system. Quarter. Million. Agents. OMG. And the scary part: they face a fraction of the regulatory requirements Medicare sales agents do.
"Federally facilitated exchanges" will operate in some two dozen states next year -- largely in Red States with a significant presence of independent brokers, such as Florida, Texas and Arizona. The final regs on the Federal exchange issued last May included a surprise provision allowing agents to sell exchange products to eligible individuals -- designed to get more enrollment into the program faster through this huge distribution channel.
CMS plans to collect information about producers through a registration process, and by verifying a producer's licensure status and issuer appointments. Once the agents get through the registration process, they will be able to get any required training and take any required exams on the CMS Learning Management System site.
In addition to using the producer data to run the exchange training process, "CMS will use the collected data for oversight and monitoring of agent/brokers." Exchange agents would probably have to register with the system annually, and getting through the entire process could take each agent an average of 4.7 hours, CMS estimated.
Here at Gorman Health Group, we certify, train and manage over 30,000 agents selling Medicare products. And I can tell you that less than 5 hours' training and a bare-bones certification process means there are going to be plenty of sleezeballs selling the "metal plans" to the chronically uninsured. And that will only serve to confuse and exploit huge numbers of them, diminish support for health reform, and bring complaints down upon sponsors. We need a tougher system than CMS outlines here to ensure these vulnerable Americans don't fall prey to predatory salespeople.
Resources
Senior Vice President for Public Policy, Jean LeMasurier, summarizes the February 7, 2013 notice from CMS regarding Agency Information Collection Activity.
Download a podcast on the key components of OEV calls and get advice on how to handle rapid disenrollment -- and other common challenges.
Learn how Gorman Health Group certifies, trains and manages sales agents with our Sales Sentinel tool.
FFE — Notice of Intent to Apply
Things should be starting up in the next few weeks for health plans interested in offering products in the FFE. Given the lack of specificity in the final exchange regulation and CMS' pursuit of state help, potential applicants will be in a constant scramble to see who's on first between the states and CMS. So, there is a need for tactical observation and quick analysis to determine their ability to meet each new twist as it is announced. It is a moving target of regulation that does not lead to a sense of certainty for any health plan that they can or will apply.
Preliminary CMS timelines call for submission of a notice of intent (NOI) to apply sometime in February. CMS relies on the NOI to begin to set up their automated systems for actual applications that will be received beginning in April. While CMS does not use the NOI to determine their need for resources, a large response could do just that. Also, the NOI is not binding, starting with a fairly incomplete set of requirements means that applicants can only estimate their willingness to follow through with an application and merely send one in to check the startup box in the process.
CMS has also let it be known that there is no timeline for states to decide if they want to be a regulator in the FFE. Some state legislators in FFE states are being pressed for more state regulatory action by their constituent health plans. So, it is likely that some health plans will not know which regulations will be applied as they make a decision to complete the application.
No doubt, CMS is looking for the lowest common denominator that will relieve their worry over resources as well as the concerns of potential applicants. However, potential applicants need to know ASAP if the FFE requires building new structures and operations or not when state rules are determined sufficient. While submitting an NOI is a no-brainer, the expense of actually making the application under these uncertain circumstances has real budgetary meaning for some health plans and may staunch some of the willingness to complete the application.
The preliminary FFE timeline looks like this.
February — March
- Health Plans submit Notice of Intent to apply
- FFE Health Plan Application released
April — May -
- CMS begins review of applications
- CMS releases benefit module
- CMS tests consumer application
June — July — CMS Call Center goes live
- CMS conducts all application reviews
- CMS reviews all benefit proposals
August — September
- CMS completes all health plan FFE agreements
- CMS readies each FFE for enrollment operations
October
- Open Enrollment begins
November - December
- Open Enrollment continues
January 2014
- Open Enrollment continues
- QHPs begin coverage period for enrollees
March 2014
- Open Enrollment Ends
Resources
Gorman Health Group Senior Vice President of Public Policy Jean LeMasurier offers a summary of the latest guidance on the state partnership exchange, released on January 3, 2013 from HHS.
Download Jean LeMasurier's whitepaper on Insurance Exchanges in the ACA.
Listen to a discussion focused on the lessons learned from MA and Part D when it comes to product strategy in the Exchanges.
Read Gorman Health Group Chairman, John Gorman's, blog titled "Exchange Activity Kicks into High Gear".
2013 Will be a Very Busy Regulatory Year
CMS is planning to issue a lot of regulations in 2013 that will impact Medicare Advantage (MA) and Prescription Drug Plans (PDPs) as well as plans that will be offered in the individual and small group market Exchanges.
The Medicare Advantage and Part D Advance Notice of Payment Rates and Call Letter will be issued in mid-February and the Final Rate Notice and Call Letter will be released the first week in April 2013. These documents provide critical rate and policy information for MA and PDP plan designs, benefits and cost structures as well as for overall compliance for plan year 2014.
CMS will issue a proposed rule on how they will implement the Medicare Advantage Medical Loss Ratio (MLR) Requirements which takes effect in 2014. The ACA requires MA plans to meet a minimum loss ratio of 85 percent or remit the difference to CMS.
CMS is also planning to issue a proposed rule in September 2013 on "Policy and Technical Changes to the MA and PDP Programs for Contract Year 2015".
CMS also plans to finalize a number of regulations that implement provisions in the Affordable Care Act (ACA). These include:
• Insurance Market Rate Review
• Essential Health Benefits, Actuarial Value, and Accreditation
• Eligibility, Appeals and Other Provisions under the ACA
• Certain Preventive Services under the ACA
• Wellness Programs
• Notice of Benefit and Payment Parameters
• Minimum Essential Coverage Exemptions
• Nondiscrimination
Resources:
To learn more about how Gorman Health Group can help with Medicare Advantage Regulations visit our website.
To learn more about how Gorman Health Group can help with Part D Regulations visit our website.
To learn more about how Gorman Health Group can help with Compliance, visit out website.
Download Jean LeMasurier's summary on three new proposed regulations implementing provisions in the Affordable Care Act.
The Claws Will Come Out at CMS in 2013
Health plans and other stakeholders in Medicare Advantage and Part D can be assured of one thing by President Obama's reelection: that the claws will come out at the Centers for Medicare and Medicaid Services (CMS) in his second term.
Having worked a number of years at the agency I can tell you there is a natural tendency among career regulators to be emboldened in a President's second term. With legacy in mind they know that a Democratic White House won't push back much on a more aggressive posture with the private sector. And frankly many of those regulators have scores to settle with some of the companies in their portfolio that go back even pre-Obama. Now's their chance.
But CMS on the warpath in the next four years is driven by many more factors this time around, like the fact that the agency would like to be in business with many fewer than the almost 2,000 plan options available in Medicare Advantage. The career staff feels there's an embarrassment of riches in MA/Part D, to the point that it confuses beneficiaries. Therefore, a priority in the second term will be to simplify the program by systematically hunting down and eliminating inferior species.
Second, CMS made it very clear that it would begin targeting Medicare Advantage and Part D plans with lower than 3-Star ratings for three or more years in 2013. Low-Stars plans also get the "Scarlet Letter" of a low-quality indicator on Medicare.gov, and this past AEP marked the first time CMS actually sent letters to enrollees of sub-3 Star plans encouraging them to take a look at higher-ranked plans in their market. If you've been below 3 Stars the last several years you now have a target on your back.
Third, budget pressures and cuts to CMS's administrative funding in the last couple years meant that CMS shifted more of its traditional oversight functions to the plans themselves. This year, through routine site visits and remote data monitoring, CMS will find that many of those functions have been neglected and the agency will make some examples. This is particularly true of the renewed focus by CMS on delegation oversight -- how a plan monitors its vendors like its pharmacy benefit manager and affiliated provider groups. They'll also pay much more attention to "compliance effectiveness" -- whether the plan's internal compliance program is actually a living, breathing function that roots out issues before they become problems for beneficiaries.
Fourth, there were a number of new audit protocols for 2013 announced by CMS in last year's call letter, such as expanded use of private contractors overseeing program integrity in Medicare Advantage and Part D, renewed emphasis on remote monitoring of sales and enrollment "red flags", and intense focus on Complaint Tracking Module cases where beneficiaries are howling about poor performance.
Finally, 2013 will be the year that the long-dreaded Risk Adjustment Data Validation (RADV) audits will begin in earnest. CMS, its program integrity vendors, and the law enforcement branch of HHS, the Office of Inspector General (OIG), will undertake dozens of audits of health plans' diagnostic data submitted for risk adjustment in the coming two years. Yesterday OIG said the $124 billion MA program is the focus of very few investigations from fraud-hunters—a conclusion that comes on the heels of several RADV audits alleging hundreds of millions of dollars of questionable payments in the program. Last year HHS officials published the results of years-long investigations into four MA plans, and concluded that the plans had received nearly $600 million more than they should have in 2007 by inflating diagnostic data. All four companies denied the allegations, but OIG is continuing with probes of several other of the 175 plans participating in MA.
This is also about setting the tone with health plans before the launch of the Affordable Care Act's health insurance exchanges this fall. CMS knows most of the plans that participate in Medicare Advantage and Part D will also jump into the exchange, and bloodying some noses in 2013 lets them all know who's calling the shots as we sail into what promises to be a chaotic launch of health reform. Remember the messy launch of the Medicare drug benefit in 2006? The launch of the exchanges and the complexity of the subsidies will make Part D pale in comparison...and CMS wants its private sector partners to be walking on eggshells.
Smart executive teams will commit themselves to a doctrine of "lean and clean" and a culture of compliance in the President's second term.
Resources:
For more infomration on how Gorman Health Group can help with Part D requirements, visit our website.
For information on how Gorman Health Group can help support your goals with Medicare Advantage, visit our website.
To find out how Gorman Health Group can help you develop a Star Ratings action plan, visit our website.
Federally Facilitated Exchanges — Getting States to Help Out
The fog has cleared. CMS sees the size of the FFE Mountain and is beginning to put its plans in place to get health plans certified to participate in the FFE by August 2013. While the partnership states have clearly indicated their intention to play a role in reviewing federal requirements for FFE applicants, other states' governors have cited a myriad of reasons for not having an exchange. At this point, CMS has a few issues to sort through before they can give directions to applicants.
Each state must communicate to CMS their level of cooperation in conducting reviews of applications and oversight of health plans in the FFE. All of this activity must be accomplished at warp speed to make sure that everyone is on the same page in terms of their roles and responsibilities in getting plans on the FFE.
For the seven partnership states, the decision is clear. Each state has provided information in their blueprint application about areas they will oversee. While this is a major step, CMS and each partnership state will need to mutually agree how state requirements comport with FFE requirements. Where they do not, states must understand federal criteria and conduct reviews accordingly in the application process. An MOU will certify the process in each state.
Currently, twenty-four other states that have chosen not to partner with CMS will follow different routes as the FFE becomes operational. CMS extended the timeline to February 15 to encourage more of these states to become a partnership state. To give them an idea of what partnership means, CMS published descriptions of the roles the states can play in a partnership.
At the same time, CMS has made numerous entreaties to these states about roles that they can play in the FFE oversight process (see pp14-16). Consequently, CMS must plumb each non-partner state to determine their interest. This means that leadership in the state regulatory agencies must determine the degree to which they should become a cog in the federal regulatory system.
For some, providing no support is fundamental political theater that demonstrates state independence and requires the federal government to incur full costs along with responsibility for failure. Notably, any of these passive states can still receive payments to provide licensure and solvency as well as any other information that will assist the FFE.
For FFE states willing to coordinate, the CMS task is to evaluate state requirements to determine equivalency to FFE requirements and agree on methods for oversight with each state in whatever limited number of areas equivalency can be established, as well as how information can be continuously shared to support FFE oversight activities.
The dance steps needed for mating state regulatory structures with the federal government in each of the 24 non-partner states are substantial. Getting state/federal agreement to mutually oversee health plans in any limited area requires bureaucratic grease, especially in a compacted timeline. To work with states and make the path as clear and uncomplicated as possible, CMS is making a framework to do this with added definitions and analytic tools. The goal: to be ready in three months for the first applicants.
Notwithstanding resolving equivalency of requirements in states that wish to hold off federal takeover in even a small way, the mating process will also bog down in negotiations around added resources, costs incurred and payment for state services. CMS needs to ensure that these issues do not become obstacles that upend the August 2013 timeline. CMS will need to re-consider using any state's regulatory structure when it becomes clear this engagement process has overwhelmed the goal in that state.
Resources:
Download Jean LeMasurier's whitepaper on Insurance Exchanges in the ACA.
Read Steve Balcerzak's previous blog post on the FFE draft application for qualified health plans.