Double Your Value: Three Critical Ways CMS Audit Readiness and the Member Experience Program Intersect
What do the Centers for Medicare & Medicaid Services (CMS) program audits and member experience programs have in common? At their core, both activities are looking out for and protecting Medicare health plan members. CMS, in their oversight role, is responsible for ensuring Medicare Advantage (MA) and Prescription Drug Plan (PDP) members receive all the rights and benefits of original Medicare as well as the additional services agreed to in contracts with MA plans and PDPs. Operations has to own compliance with CMS as well as how operational functions touch and impact our members' experiences. "The cornerstone of an effective member experience is cross-functional alignment, placing the member at the center of the health plan's initiatives and core business functions" says Carrie Barker-Settles, Gorman Health Group's (GHG's) Director of Sales & Marketing Services. In days of shrinking payments, plans need to be even more efficient as they provide services to their Medicare members but without cutting corners that result in non-compliance or driving members away from our plans. We can each make a difference in the areas of compliance and member experience efficiently as the goals are so aligned.
Here are three critical ways you can increase your member experience program's operational components and drive audit readiness.
- Denials in Claims Payment and Appeals: One of the most negative things a member will experience with his or her insurance is having something be denied that he or she thought would be covered. This is reality with any health plan, but how a denial is handled can make things so much worse. Claims denials often include standard templated denial reason codes. Appeal upholds may be more customized, but not always. It is important to review member denial language in claims and appeals to make sure the language is clear and understandable to your members. Are they able to understand the next steps they should take if they disagree with the decision? This is a common audit finding and a big driver of dissatisfaction.
- Claims and Appeals Development: Another action that should occur prior to denial of services is to completely develop the claims and appeals prior to the decision. Many plans experience trouble obtaining additional information from their contracted providers. When this occurs, what is the process to escalate that lack of response? Establishing a systematic process to obtain needed information to correctly determine approval or denial of service is critical to appropriate management, member satisfaction, and compliance.
- Appeals and Grievances: Root cause analysis on your appeals and grievances and then taking action on what is identified is an important step to close out cases. Often only provider information is tracked and trended, or overall appeals and grievances reports are provided to the Quality Committee. Programs need to ask how complaint information is being used to improve the plan. A plan can enhance a member's experience through analysis of what happened and what can be done to prevent that from happening again. CMS expects to see thorough and complete investigations and resolutions when complaints are received, as do we all when we submit a complaint. Root cause analysis and follow-through will not only benefit all your members but support your need to demonstrate quality complaint processing to CMS.
Just as compliance is everyone's job, so, too, is ensuring members have the most positive experience possible every time they interact with a plan. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says it best, "I'm often asked what is the cost of non-compliance, or how much is the fine if we don't do X-Y-Z? A final rule was released on September 6, 2016, which adjusts maximum civil monetary penalty (CMP) amounts allowed for all agencies within the Department of Health and Human Services (HHS). This, along with CMS' recent memo on the 2017 CMP methodology, should demonstrate to the industry that the agency is prioritizing this aspect of enforcement for good reason. Denials, appeals, and access to care should be under constant evaluation by Operations and Compliance in order to identify opportunities for improvement." She goes on to say, "Audit readiness aside, ask yourself if you are truly beneficiary ready."
When we in Operations expect CMS compliance to be managed by the Compliance area or member experience to be managed by the Sales & Marketing area, we do ourselves a disservice and lose out on some of our most valuable benefits to our health plan. Implementing these steps will change the dynamics of our department by making our teams more member centric, promoting ownership, and making a live CMS audit easier.
GHG's Operational Performance practice area consultants have been in your shoes. We have faced the multiple priorities and pressures to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department or improving your support of member engagement, we can help.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can 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 about how we can help you >>
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An "October Surprise" in Medicare Advantage Star Ratings
Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year's includes an "October Surprise:" a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought bonuses and rebates.
Roughly 370 MA plans are currently scored under the Star Ratings system, which we all know by now is graded on a curve. Plans above 4 Stars get substantial bonus payments and bid rebates from CMS and above 5 Stars can market and sell their products year-round. In this sense, plans below 4 Stars are circling the toilet bowl as there is only so long they can compete against the better benefits of 4+ Star plans. The Star Ratings for 2017 will likely knock many 4+ Star plans off their pedestals. Here's why: for 2017, for the first time, 188 new plans could be scored under Star Ratings.
- 64 of the 188 are Medicare-Medicaid Plans (MMPs), which CMS announced in June will be moved into their own separate Star Ratings program this fall. This is a bit of bad news for most MA plans, since their inclusion in the MA Star Ratings program would likely have helped fill the lowest end of the curve.
- The 124 that are left still represent enough mathematical volume that their performance will shift the bell curve. Most will likely earn an overall rating of 3 or 3.5 stars, which will cause rating dilution for those at 4+ Stars. If those plans have the same level of performance as the previous year, they will likely dip below 4 Stars. This is a looming disaster for those companies because they've already booked the bonus money and predicated their benefit designs and 2017 campaigns on receiving the rebate.
- Regarding the 6 "dead men walking" plans below 3 Stars for 3+ years and slated for termination: a "hospital improvement" bill, which passed the House and is still in the Senate, includes a provision to delay CMS' authority to terminate MA contracts based on poor Star Ratings for 3 years. It's possible these 6 plans may continue to fill the very lowest end of the Star Ratings bell curve, thus helping other low-performing plans by padding the lowest end of the bell curve.
Many plans are going to get a nasty shock when they dig into CMS' latest news. It's another stark reminder Star Ratings management is a constant campaign, and plans cannot afford to get comfortable when it comes to their quality performance.
Resources
CMS recently notified plans of the first preview period for the 2017 initial Star Ratings data. It is critical for plans to begin the annual re-evaluation of Star Ratings performance now to pinpoint new problem areas, implement tactical actions, and identify improvement opportunities to raise ratings. Read full analysis >>
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Keep the End in Mind as 2017 Readiness Approaches
According to Author Stephen Covey, in his book The Seven Habits of Highly Effective People, you should "begin with the end in mind." This means to start with a clear understanding of your destination so you know where you're going and understanding where you are now so the steps you take are always in the right direction.
Many department leaders have said, "I wasn't trained to be a compliance manager. I was just a good individual contributor managing my practice area, and someone asked me to take on this role." A powerful first step in becoming successful in a new role is to understand your organization's "End in Mind," which is usually described in the mission statement.
As Medicare Part D plan sponsors approach the 2017 Readiness season, this advice would be well taken. The Centers for Medicare & Medicaid Services (CMS) has intensified its program audit schedule, making it much more likely for a plan to receive the dreaded audit notice from CMS in 2017. Working from the point of view your plan will be one of those receiving an audit notice next year, you should approach the 2017 Readiness process as compliance audit preparation. In other words, the end in mind requires a critical review of the processes downstream from the Readiness Attestation.
Are your policies current with the latest regulatory requirements and guidance? Do your procedures match the actual processes in place? Can you demonstrate you comply with your stated processes? This is the approach CMS will take in a Compliance Program Audit. By attesting to the end point in the Readiness Checklist, you are in effect stating the processes on which the end is predicated are also functional and compliant.
Since most plan sponsors rely on first-tier, downstream, and related entities (FDRs) to help meet the operational and compliance requirements, it is also time to evaluate their performance. An FDR audit for delegation oversight is a critical part of the compliance plan for all plan sponsors. Any delegated function performed by an FDR is ultimately the responsibility of the plan sponsor. In the event of an audit, one of the greatest risks to a plan sponsor is from its FDRs. Since the Pharmacy Benefit Manager (PBM) is usually the largest, most impactful FDR, close attention should be paid particularly to regulatory changes that have been made in 2016 and need to be implemented in 2017.
Strategies that will ultimately improve the Compliance Readiness for 2017:
- PBM delegation oversight audits
- Mock program compliance audits
- Targeted audits (coverage determinations, formulary administration)
- Operational gap assessments
- Benefit administration testing
These represent key methodologies that can be used to discover deficiencies in functionality which translate to audit deficiencies Gorman Health Group can assist plan sponsors with as we approach the 2017 plan year.
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 about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
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How to Efficiently Conduct an Audit
Audits from regulatory bodies swarm around an organization like bees. And like a bee, upon first sight we do not think of the value they bring, but instead we first think of the sting that is to come.
A key aspect of an effective compliance program is to ensure there is an effective system for routine auditing and monitoring along with a system to identify compliance risks. You've established what you believe to be a solid audit plan for the year, but other things just seem to get in the way. First, you're tasked with researching the requirements for a new plan type. Then you have a fire to put out with a delegate. One of your staff gets a job offer she can't pass up, and before you know it, your audit schedule for the year is derailed. You'll get to them, right? Let's just hope you don't receive an audit letter in the meantime. With every passing Monday you hold your breath, all the while wondering how much time it will be before the inevitable occurs.
Sometimes an extra set of hands is all that's needed to get your audit activities back on track, but you do not have the budget for another full-time employee. Think of the following member-impactful audits that can be accomplished while you handle other responsibilities:
- Part C and Part D Grievances and Appeals
- Member Enrollment and Disenrollment
- Marketing
- Coordination of Benefits
All audit plans should include not only aspects included in CMS' protocol but also include audits of other self-identified areas of risk. Any operations that touch member service or payment might be considered higher risk on your assessment. Are they? And are you able to accomplish them all with the resources you have? Does your staff have the right skillset for the audits? From a CMS Q&A:
The safeguarding of beneficiary rights and protections is arguably the most important responsibility of a sponsor. Demonstrating you have the resources to detect, correct, and prevent occurrences of non-compliance is a struggle when a department lacks things like the time, resources, or skill to perform certain audits. Contact us for ideas on how we can partner with you to efficiently conduct some of your audits, providing you with some much needed assistance.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. 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 about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Lessons on the Audit Front
The regulatory scrutiny continues. The Centers for Medicare & Medicaid Services (CMS) 2016 Compliance and Program Audits are in full swing, and it is readily apparent plan sponsors must be "audit ready." CMS' intent to hold plan sponsors accountable to comply with Medicare standards and ensuring beneficiary protection is evident. Plan sponsors must be ready to take the test.
It all starts with the data…make sure you get it right! The invalid data submission (IDS) was a condition added to the 2016 scoring methodology. CMS has emphasized the need for plan sponsors to validate all data submission before they are uploaded. The "Three Strike Rule" applies. If the sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in the audit report. After the third failed attempt, or if an accurate universe cannot be produced in fewer than three attempts due to missing or unavailable data, an IDS may be cited.
Speaking of audit scoring methodology, confusion appears to remain regarding the audit scoring method. Samples are no longer given a pass/fail score with a specified passing score of 95%. Issues are now identified as conditions. One condition may apply to multiple samples. CMS will evaluate the condition by the potential impact on the beneficiary as either an observation, Corrective Action Required (CAR), or Immediate Corrective Action Required (ICAR). The audit score is generated based on the number of non-compliant conditions discovered; the maximum audit score is unlimited.
Thus far in 2016, the most common conditions cited by CMS are ones we have seen before. Plan sponsors' failure to properly administer its CMS-approved formulary, usually due to a coding error by the Pharmacy Benefit Manager (PBM), remains a risk area. It is critical for plan sponsors to have an adequate oversight monitoring program to identify and remediate issues expeditiously.
Coverage Determinations, Appeals, and Grievances (CDAG) continue to be a low performer in 2016 CMS Program Audits. It is important for plan sponsors to connect the dots with end-to-end case preparation, and remember — nothing is off-limits. CMS can open any can of worms that is identified as a risk. Coverage determination notification letters remain a targeted area. Plan sponsors must have the necessary quality checks and/or oversight to ensure notification letters are specific to the enrollee's case, accurate, and provide the information needed to approve coverage in the case of a denial. This is a recurrent finding from prior years which CMS has cited in Best Practice Memos, so there is a low tolerance for inadequate denial letters.
New to the 2016 audit cycle is the Medication Therapy Management (MTM) Program Pilot Audit, which is conducted virtually in the second week. Despite the fact results of this pilot are not included in the plan sponsor's final report, CMS is not taking this audit casually. "The goal of this audit is to evaluate the implementation of the plan sponsor's adherence to its CMS-approved MTM Program," said a subject matter expert on our Pharmacy Solutions team. Be sure you are ready to tell the case story. "CMS has been particularly interested in looking at the continuity of care across plan years for members who received a Comprehensive Medication Review (CMR) in the previous year. This is one area which appears to be especially disconnected if plans may have had multiple MTM vendors or changed PBMs," continued Miller. "Coordination of information flow, especially for enrollee's year-over-year tracking, is essential." Plan sponsors that incorporate strategies for a ready state for CMS audit will be more successful. The conduction of an MTM Program mock audit is an effective way to identify shortfalls and issues in your data collection, accuracy, and overall readiness — before you are presented with a CMS audit engagement letter.
Another challenge noted in the 2016 audit front is, despite CMS process enhancements, auditor inconsistency. This presents a challenge in what a plan sponsor can expect. In order to be prepared for a program audit, plan sponsors should prepare by exceeding CMS' expectations, not just meeting them.
Resources
Our highly structured mock CMS audit services are designed to replicate the latest CMS audit processes. Our team of industry veterans is ready to help your organization practice and learn the new CMS audit protocols; new universes and many more data fields, interviews via a webinar, and of course the CMS protocol documents. Visit our website to learn more about our CMS Mock Audit services >>
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Complaints — Make Sure They Are the Gift that Keeps on Giving
Have you ever received a gift you knew had value, but you just weren't sure how to use it to its full potential? Complaints are very much like that. We need to change our view of complaints and consider them to be gifts from our members that need to be opened and cared for as the important pieces of information they are. Complaints are something we all wish would never be needed, but every health plan receives them. Our members have needs, and sometimes those needs don't appear to our members to be met. In those instances, if we are lucky, the health plan receives the complaint. If we are not lucky, our members' neighbors, acquaintances, doctors, or even worse — regulators and congressional representatives' — receive the complaint.
Regan Pennypacker, Gorman Health Group's (GHG's) Senior Vice President of our Compliance Solutions Practice says it best, "Complaints, grievances, expressions of dissatisfaction — these are a part of life in the course of running any government program. The processes are in place to provide an avenue for your membership to speak openly about their dissatisfaction and provide you an opportunity to take that data, analyze for trends, and, if possible, make changes in an effort to improve quality."
Here are four components for making the most of that opportunity:
- Train staff to hear complaints. There is a delicate balance in Customer Service to identify complaints. Some Customer Service staff members are so focused on fixing the immediate issue, they don't recognize the additional complaint concerns. An example of this is a member calling to change his or her primary care physician (PCP) because things are "not working out with this provider." It is easy and beneficial to help the member change to a new PCP, but what is the underlying issue that needs to be explored? If the health plan doesn't know what is going on, there is no way to resolve the matter for this caller or other members. Having staff trained to recognize when a complaint is presented is the first key step to successful complaint management.
- Correct categorization of complaints. This is an often discussed topic as it is a high audit risk and a frequent audit finding. A complaint is identified, but what type of complaint is it? Customer Service is often the first to talk to members about their concerns. Sometimes the call is an inquiry or an educational opportunity or a misunderstanding that can, with the right information, satisfy a member. Other times the call is regarding a complaint that is an appeal, grievance, coverage determination or organization determination, or a combination of several types of complaints. Ensuring knowledgeable staff and clear support tools are in place to correctly categorize those complaints allows members' concerns to be heard and addressed and appropriate due process to occur. If a member calls to complain about wanting but not being able to get a specific medication, that will most likely fall under a coverage determination or appeal if it was previously denied by the plan. Obtaining all the details will allow for a thorough and correct determination. What if it is a provider who was not willing to discuss any other formulary options, even if the member explained the drug makes the member sick? Possibly there is a quality of care grievance that needs to be explored; carefully categorizing a complaint is the next critical step in processing complaints.
- Empowered, knowledgeable staff who can thoroughly investigate the complaint. Regan summarized this well, "Skilled, knowledgeable, empowered grievance and appeal coordinators are key drivers in plan satisfaction. Yes, the complaints will still come in, but what are you doing about them? How are those addressing grievances empowered to turn that interaction into a positive customer experience?" Some of my greatest product loyalty has been developed when I called to complain about an issue, and the company representative listened, investigated, and resolved the issue. It wasn't always resolved in the manner I wanted, but I knew I was heard and that what could be done was done. People processing complaints have to understand the importance of a complaint reported to the plan and be empowered to manage that complaint in the highest customer-focused manner.
- Tracking, trending, and root cause analysis. Often times there is a disconnect between all the information gained from complaints and ways to make that information useable to improve processes and quality. Most plans track their complaints and report them to the Quality Committee. Some plans analyze the information searching for trends that can be managed and processes that can be improved. They look at the root cause of the issue that caused the complaint to see what can be done differently going forward. They evaluate the data to see who else might be impacted and proactively work to remediate the situation. They truly see the value of the gift provided to them to improve their organization.
Complaints are like constructive criticism: hard to hear sometimes, but they can make a big difference going forward. Just as it takes a strong person to adapt to constructive criticism, it takes a change in culture to value complaints as an opportunity to change and improve. Finding the worth in your members' complaints will make your plan a stronger, more customer-focused organization. Does your organization leverage the complaint gifts you receive and make them count? If not, you are losing a key opportunity on a gift you already have and just don't know fully how to use.
At GHG, our consultants have worked in the weeds. We understand the processes and pain points health plan staff face on a daily basis. We are here to help you as you evaluate your program and adapt to an ever-changing environment. I would welcome the opportunity to talk to you about how we can assist your organization as you strive towards more compliant and efficient operations.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can 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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Meeting CMS Halfway: The 2016 Audit and Enforcement Conference
On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements, upcoming developments, and more.
While the agency has not given everyone the keys to the kingdom, the transparency of process improvements and changes can be likened to someone meeting you halfway. If you expect CMS to meet you where you are, you'll be waiting a long time. Sponsors need to do the rest: digest the free information provided, distribute to all affected parties, and implement. Practice until each step of an audit runs like a well-oiled machine. Sound cliché? It should. The core focus of this audit model has not changed in years. You may argue that you've had staff turnover or have switched delegates for a certain function. None of it matters. The requirements are still the same, and they are in line with many items your organization attested to upon application.
My summary and analysis of the conference can be downloaded here, however, it is no replacement for watching the webcast recordings on your own and making necessary changes to your program.
Resources
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Medicare Program Audits — Four Things Operations Should Be Doing Today
Do you think the Centers for Medicare & Medicaid Services (CMS) program audits are stressful? We often make it worse for ourselves than it already is. Imagine being in the audit webinar pulling up a case and having CMS say that case was to be excluded from the universes. Instead of showing your department, processes, and system capabilities, CMS is getting the impression you don't even know your data well enough to pull a correct universe. What can Operations departments do to get ready? Here are four things you can begin doing today to be ready:
- Set up automated universe pulls, both with internal systems and delegates. Automating these processes will allow you to pull them quickly and use them on a regular and ad hoc basis. Additionally, automating the process will help you identify which fields are not being captured properly or at all in your system. This can be the biggest difficulty in pulling universes and not something you want to find out when you receive your CMS audit notice. Start this process today.
- Learn to use the data in the CMS audit universes. CMS uses these formats for a reason. CMS has fine-tuned this process to allow them to most readily identify outliers and potential issues. This will help you as you monitor your own operational departments and identify hidden trends. It will also help you regularly monitor your delegates.
- Set up time to complete mock audits of the potential outliers. Pick 10 sample outliers on a monthly basis to review to determine if there are issues with your processes or universe pulls. It makes sense to do this within each operational area internally. You should know what is happening within your department before anyone else identifies it; this includes members, Compliance, or CMS. You will be surprised what you will learn through this review.
- See it to the end. Think like CMS when you complete your reviews. Put aside your thoughts on system limitations and department politics and how many times you have tried to address an issue. How does what you find impact members? How does this follow guidelines? If you identify issues, complete the process by running a beneficiary impact and root cause analysis. This will let you know scope and give you the information you need to address the issue. This may be supplying the information to allow a prioritization of a fix you haven't been able to get prioritized before.
When we in Operations see CMS audits as something that is managed by Compliance, we do ourselves a disservice and lose out on one of the most valuable tools we should all have in place. Implementing these processes will change the dynamics of your department, promote ownership, and make a live CMS audit easier.
The Gorman Health Group Operational Performance practice consultants have been in your shoes. We have faced the multiple priorities and pressure to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department, we can help.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Click here to learn about GHG's Operational Performance services >>
Gorman Health Group has decades of experience stress-testing hundreds of operational business units and can assist with implementing CAPs post-audit or in proactively addressing operational problems before regulators come knocking. Visit our website to lean more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Health Plans Need to Start Talking About Disparities in Care
On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services' Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It's a game-changer in advancing health equity and reducing disparities.
The new regs, implementing Section 1557 (the nondiscrimination provision) of the Affordable Care Act, prohibit discrimination, marketing practices, or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability. This will escalate disparities from simply being a "quality improvement need" to being a huge compliance issue. It goes without saying that an investigation of your plan by the civil rights cops splashed across local news would be devastating. As the Centers for Medicare & Medicaid Services (CMS) has begun more aggressively using their data to identify these disparities, health plans certainly should begin doing the same.
The final rule prohibits sex discrimination in healthcare, including by:
- Individuals cannot be denied healthcare or health coverage based on their sex, including their gender identity and sex stereotyping. These last two items are of particular importance given transgender policy enforcement is relatively new. OCR has prosecuted cases recently where transgender patients were discriminated against in hospital admissions and room assignments, denying mammograms to transgender females, denial of gender reassignment surgery as "cosmetic," and harassment by medical transport drivers.
- Women must be treated equally with men in the healthcare they receive and the insurance they obtain. OCR has prosecuted several cases recently where hospitals assigned male guarantors when a wife obtained services but not the other way around.
- Categorical coverage exclusions or limitations for all healthcare services related to gender transition are discriminatory.
- Individuals must be treated consistent with their gender identity, including in access to facilities.
- Sex-specific health programs or activities are permissible only if the entity can demonstrate an exceedingly persuasive justification.
The regs also include important protections for individuals with disabilities and those with limited English proficiency by:
- Requiring covered entities to take appropriate steps to ensure communications with individuals with disabilities are as effective as communication with others.
- Covered entities must post a notice of individuals' rights, providing information about communication assistance, among other information.
- Covered entities are required to make all programs and activities provided through electronic and information technology accessible to individuals with disabilities, unless doing so would impose undue financial or administrative burdens.
- Covered entities cannot use marketing practices or benefit designs that discriminate on the basis of disability.
- Covered entities must make reasonable changes to policies, practices, and procedures, where necessary, to provide equal access for individuals with disabilities.
- Requiring covered entities to make electronic information and newly constructed or altered facilities accessible to individuals with disabilities and to provide appropriate auxiliary aids and services for individuals with disabilities.
- Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.
Resources
CMS recently announced the release of the 2017 Medicare Marketing Guidelines for Medicare Advantage Organizations and Part D Sponsors, which include added language, clarifications, and new requirements. Join Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Carrie Barker-Settles, Director of Sales and Marketing Services, on Tuesday, June 28, from 1-2 pm ET, to discuss what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Medicare Marketing Guidelines Summary of Changes — Have They Left You Scratching Your Head?
On June 10, 2016, the Centers for Medicare & Medicaid Services (CMS) announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors.
Added language, clarification, and new requirements seem to be the theme with the recent updates. So how do these changes affect business as we prepare for the 2017 Annual Election Period (AEP)?
At Gorman Health Group (GHG), our team of subject matter experts comes together to provide you with clarification around a few key changes from the final MMG Summary of Changes and recommendations for your organization.
Marketing — Diane Hollie, Senior Director of Sales & Marketing Services, says, "Although CMS has stipulated provider and pharmacy directories are considered non-marketing material, it doesn't mean the provider directories don't get submitted to CMS. In fact, all plans must submit their hard copy provider directories to CMS on an annual basis."
CMS is now referring Sponsors to the Medicare Managed Care Manual, Chapter 4, for provider directory guidance and the Prescription Drug Benefit Manual, Chapter 5, for pharmacy directory guidance — making it a more complicated process. The following are just a couple of provider directory rules found in Chapter 4, which were announced earlier this year in a 4/28/16 Health Plan Management System (HPMS) memo.
- All hard copy directories must be uploaded into HPMS as a non-marketing material under the XXX submission code.
- All hard copy directories must be uploaded prior to making the directory available by September 30.
- Because provider directories are considered non-marketing, MAOs should not include a status after the material ID.
- To distinguish the provider directories as non-marketing, the following material ID should be used: plan's contract number, followed by an underscore, followed by a series of alpha numeric characters chosen at the discretion of the plan, followed by an underscore, followed by the letters "NM." Example: HXXXX_ABC124_NM
While it is noted the MMG has referred readers to the PDBM, Chapter 5, for pharmacy directory guidance, there is no cross-referenced information. This could be an indicator a revised Part D Chapter 5 will soon be released. Without it, Sponsors will be left scratching their heads.
Sales — Carrie Barker-Settles, Director of Sales and Marketing Services, understands the importance of agent/broker oversight and Sponsor sales activities. "Helping plans/Part D Sponsors and agent distribution channels navigate the dos and don'ts of the rules and regulations can be very overwhelming, but at GHG, we can make that challenging task less daunting for both."
Below are just some of the changes relating to sales oversight:
- Telephonic Contact — Plans/Part D Sponsors may call their current MA and non-MA enrollees or use third parties to contact their current MA and non-MA enrollees about MA/Part D plans. Examples of allowed contacts include calls to enrollees aging into Medicare from commercial products offered by the same organization and calls to an organization's existing Medicaid/Medicare-Medicaid Plan (MMP) enrollees to talk about Medicare products. The updated guidance clarifies, when discussing Medicaid products, Sponsors must follow all applicable Medicaid marketing rules. Plans/Part D Sponsors, sellers, and telemarketers may conduct these telephonic activities, but we recommend you fully understand all the regulations for both unsolicited and solicited contact before reaching out to Medicare beneficiaries.
- Compensation Payment Requirements — Whether you use employed, captive, and/or independent agents, you must inform CMS yearly by the end of July which channels you will be using as well as the compensation payment rates or ranges. The compensation structure must include:
- How the Plan/Part D Sponsor intends to disseminate compensation, specifying payment amounts for initial and renewal compensation.
- CMS has clarified in the revised guidance the compensation structure must stay the same for the compensation year that was put in place by October 1.
- How the Plan/Part D Sponsor intends to disseminate compensation, specifying payment amounts for initial and renewal compensation.
Some Plan Sponsors may have already been following this process, but if not, yearly requirements outlined in the MMG suggests all Plan Sponsors check policies and procedures to ensure they adhere to their clarification.
"I come from a trust but verify world," says Regan Pennypacker, Senior Vice President of Compliance Solutions," and when the updated MMG is released, it's important Compliance teams disseminate the document to ensure affected business units can determine impact." "It's also important," she states, "to reconcile and ensure supplemental memos and clarification emails sent between revisions have also been rolled into the new guidance." For example, the Part C aspects of the August 13, 2015, "Clarification of CY2016 Medicare Marketing Guidelines" has indeed been rolled into the MMCM, Chapter 4, but as noted above, the Part D aspects pertaining to pharmacy directories has not. "This means plans will need to continue to reference that memo to ensure they are following the guidance as it pertains to pharmacy directories."
"Overall," states Regan, "it will be important for Compliance to partner with Sales and Marketing staff to ensure adherence to all changes and clarifications."
We have highlighted just a few of the key changes, but to learn more, register to join our upcoming webinar on June 28, 2016, from 1 - 2 pm ET.
Resources
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