Current Trends in Retiree Health Coverage Expected to Continue Under a Trump Administration
The landscape for retiree healthcare is not expected to change significantly under a first Trump term. However, several Republican proposals, if enacted, could incent group members to shift to the individual market over time.
Background - According to the September 2016 Kaiser Health Foundation (KFF) – Health Research & Educational Trust (HRET) Health Benefits Survey, 24% of large employers (200 employees or more) that offer health benefits to their employees still offer retiree coverage http://files.kff.org/attachment/Report-Employer-Health-Benefits-2016-Annual-Survey. Of the firms offering retiree coverage, 92% offer retiree coverage to early retirees and 72% to Medicare-eligible retirees. Over the past several decades, there has been a slow decline in employer coverage of retiree health benefits – down from 34% in 2006 and 40% in 1999. The 2016 level of 24% is similar to levels in recent years. Consistent with recent trends, employers are expected to continue to gradually reduce retiree coverage, but most employers that offer retiree coverage are expected to continue to offer this coverage in the next several years.
Impact of the Affordable Care Act (ACA) on Employer and Retiree Coverage – Use of the ACA Marketplace by employers has been low. The 2016 KFF-HRET Survey found only 17% of large firms offering retiree health coverage are considering shifting to Marketplaces that offer subsidies, which was lower than the percentage in 2015 (26%). So if the Marketplaces are repealed or substantially modified, the impact on employers should be small.
If the employer mandate is repealed, the penalties and much administrative burden on employers will be eliminated. This change would provide more flexibility on how retiree benefits are offered and could result in delaying any reduction in retiree offerings.
If the 40% employer Cadillac plan excise tax is repealed, more employers may retain their current retiree coverage and not follow in the footsteps of employers that have already acted to mitigate the Cadillac plan provision, e.g., switching to a lower cost plan, increasing cost sharing, selecting plans with a smaller network, or moving benefit options to account based plans. However, if an alternative price proposal to enact a cap on the annual tax exclusion for employer-sponsored benefits is enacted (e.g., $8,000 individual and $20,000 family), then employers may modify their plan designs and offerings.
Impact on Medicare Advantage (MA) Plans – MA Employer Group Waiver Plans (EGWPs) should continue to grow in markets that have not been fully penetrated over the next several years.
Defined Contribution Plans – In recent years, some employers have moved towards defined contribution plans, sending retirees to the individual market to choose a plan rather than remain in the group market. This trend has been smaller than predicted. In 2016, only 6% of large firms (200 or more workers) offering retiree health benefits report offering benefits through a private exchange, similar to the percentages in 2015. According to the KFF survey, an additional 21% of firms were considering a defined contribution approach. Assuming the individual market remains sound, some employers may move to a defined contribution in the future, thus eroding the employer group market over time. Some Republican proposals could spur this trend. For example, Tom Price’s 2015 repeal and replace bill (H.R. 2300) included a proposal that would cap the tax exclusion for employer provided benefits and permit employers to contribute to an employee or retiree plan in the individual market. If enacted, the proposal could make shopping in private exchanges more attractive and/or cause employees to leave the employer group plan because there would be more plan choices available.
Account Based Plans (Health Savings Accounts) – Many employers offer an account based plan, such as a Health Savings Account (HSA) or a Health Reimbursement Account, as part of their group coverage. A Trump administration is expected to pass legislation and regulations to allow more flexibility in these plans, and they can be expected to grow. For example, Tom Price’s 2015 legislation included a provision that would provide a one-time $1,000 tax credit for HSA contributions, increase HSA contribution limits to the maximum individual retirement account limit, broaden coverage of drugs before the deductible, and provide credit for over-the-counter (OTC) medications and fitness/nutrition services. Under the Price proposal, Part A Medicare beneficiaries would be allowed to contribute to HSAs while Medicare beneficiaries with Parts A and B could contribute to an Medicare Medical Savings Account (MSA) plan. While this change could make the MSA more successful than in the past, it would not address the small percentage of beneficiaries who understand the product and would be willing to move from a product that provides first-dollar coverage.
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The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
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Opportunities for Growth in the New Administration
"Opportunities are like sunrises. If you wait too long, you miss them." ―William Arthur Ward
With the new administration coming into power this month, there is a lot of conjecture over what might happen. Overall consensus is the one business segment that is the most stable is Medicare Advantage. Trump is a supporter of Medicare Advantage, and so are Republicans, although long-term there is an opportunity to change the financing of premiums. The Marketplace (Obamacare) and Medicaid are in “limbo” until we get a better idea of what and when there will be changes and how drastic they will be for these programs. So if you are looking for growth in revenue and/or enrollment, Medicare Advantage can provide a good opportunity. The other good news is that in the past several years, the Medicare Advantage market has been stable, based on the metrics available, with few changes in average premiums, plan offerings, and insurer participation.
If you are looking at the opportunity to grow or expand, there are many parameters to consider. Whether you are a Medicare Advantage plan considering expanding either your service area or products, Medicaid plans looking to add either Medi-Medi plans or Special Needs Plans, or an Accountable Care Organization or Integrated Health System looking to jump into Medicare Advantage, now is the time to explore this opportunity. Many of our clients are finding the most prudent way to expand and grow is a strong, solid strategy and an implementation plan that begins with a feasibility study.
A feasibility study looks at the market, and that analysis helps to build a strategy going forward for three to five years. This analysis looks at the competitive, financial, and demographic factors of a market(s) to see what is the most viable. This leads to a feasibility model based on detailed financial projections, and Gorman Health Group’s feasibility study process utilizes an onsite strategy exploration to walk through the entire process of entering Medicare Advantage or expanding current products and service areas with an emphasis on risks and rewards. The next step is the development of product/network/benefit design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.
No matter what your situation, this opportunity could be your sunrise, so don’t wait and join us for our webinar on January 31, 2017 at 1:00 PM EST for an informative session on how to conduct a feasibility study and taking it to the next step. Register now >>
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CMS Provides Reminders on Key Dates in the MA-PD Application Process
Open Enrollment for the Affordable Care Act Marketplaces and the Annual Election Period for Medicare is underway. But this month also marks the start of required Centers for Medicare & Medicaid Services (CMS)-facing activities necessary for the application process.
Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group, points out “for many MA-PD applicants, activities are already underway. Oftentimes, Sponsors do not realize that the application requires all hands on deck until it is too late. It is a multi-disciplinary effort that requires attention to detail and collaboration at all levels of the organization.”
CMS recently released the following memos, providing reminders on key dates in the application process.
Release of Notice of Intent to Apply for Contract Year 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) and Related CY 2018 Application Deadlines
CMS released information and key dates about the Contract Year (CY) 2018 Notice of Intent to Apply (NOIA) web tool and key dates for the CY 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) application cycle.
2018 Application Activity Key Dates
NOI deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails…………………………........................................November 30, 2016
CMS User ID connectivity form submissions must be received.....................................December 2, 2016
CY 2018 applications posted on CMS websites..................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline.......................................................................February 15, 2017
Medicare-Medicaid Plan (MMP) Notice of Intent to Apply for CY 2018
CMS released information and key dates about the CY 2018 NOIA web tool and key dates for the CY 2018 MMP application cycle.
CY 2018 Application Key Dates
NOIA deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails……………………...............................................November 30, 2016
CMS User ID connectivity form submissions must be received by...................................December 2, 2016
CY 2018 applications posted on CMS websites................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline........................................................................February 15, 2017
Value-Based Insurance Design (VBID): Year 2 (CY 2018) Request for Applications
The Center for Medicare and Medicaid Innovation also announced the release of the Medicare Advantage (MA) VBID model test’s Request for Applications (RFA) for CY 2018. MA-VBID is an opportunity for plans to offer supplemental benefits or reduced cost sharing to enrollees with certain chronic conditions. Organizations that wish to participate in the model test in 2018, including those participating in 2017, must respond to the CY 2018 RFA by January 20, 2017, at 4:00 p.m. Eastern Time.
The application process is an arduous one. Completing the application requires cooperation from your entire organization. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow-up questions. As always, Gorman Health Group is here to assist your organization with the application process.
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Don’t let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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Open Enrollment for the Health Insurance Marketplace Begins: Issuers and Enrollees Forge Onward with the Chaos
Beginning next week, consumers will start actively enrolling in the Health Insurance Marketplace for the fourth year of the Affordable Care Act (ACA). The open enrollment period for the Marketplace begins November 1, 2016, and runs through January 31, 2017. Consumers who would like to actively enroll for January 1 coverage are encouraged to enroll through healthcare.gov by December 15 to ensure they will have coverage in their selected plan the first of the year.
Specific to Qualified Health Plan (QHP) Issuers in the Marketplace, the Centers for Medicare & Medicaid Services (CMS) will once again challenge Issuers with navigating through a multitude of enrollee stressors this season. Here are just a few challenges:
- Redistribution of Enrollees to an Alternate QHP Issuer:Based on a number of QHP Issuers either exiting the Marketplace in specific counties/states or exiting altogether, 2016 enrollees are left to identify a new plan for next year en masse. As a means to encourage consumers to choose a new plan, CMS has targeted November 16 as the next notice date to urge consumers to actively select a new 2017 plan because their current plan will not be available through the Marketplace. Unique to other notices consumers have received, this notice will be the first time CMS will communicate an “Alternate Plan Option” by defining the health plan name CMS has matched to the enrollee for each member currently enrolled in the household. Included in the notice is language related to how the alternate plan will communicate with the consumer through a welcome letter and a bill for the first month of coverage if they choose to activate. Enrollees are encouraged to either select a new plan altogether or activate the alternate plan to avoid a gap in coverage.Issuers have the opportunity to gain membership in this scenario, but there is no way to predict consumer behavior, especially for consumers who have been inundated by communications regarding this shift.
- Renewals to 2017 Coverage Year:A week leading up to the opening of enrollment on November 1, QHP Issuers are receiving state-by-state files detailing current enrollees who are being passively re-enrolled into 2017 plans. As the renewal process is a constant challenge for Issuers and CMS, ensuring the right members are being rolled into the correct plan is critical. A major component of the renewal process is to pause and identify inaccurate renewal data and ensure membership is updated within both systems (Issuer and CMS). This also includes recalculated eligibility for Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR).
Now that policy-based payments (PBPs) are in place, errors generated from inaccurate Batch Auto Renewal (BAR) processing will create an immediate financial impact to the Issuer for January 2017 payment. Financial impacts based on bad membership data were not realized in previous Q1 periods, but with operationalized PBPs, CMS now pays Issuers based on the Federally-Facilitated Marketplace (FFM) system. In other words, if CMS passively enrolls a member but the Issuer does not, it will automatically generate a non-member payment to the plan.
- Unaffiliated Issuer Enrollments (UIEs) or Issuer Orphans:Based on comparing Marketplace membership data between the Issuer system and the FFM system through the reconciliation process each month, UIEs are identified which represent members who are present on the Issuer system but not found on the FFM. Understanding UIEs represent enrollees who would not receive an initial 1095A notice for coverage nor would the Issuer receive payment from CMS for providing the benefit, CMS has acknowledged a solution needs to be extended to all interested parties this year. While guidance is still pending, CMS has assured the industry 2016 members will receive a manual 1095A, and Issuers will receive a payment adjustment through an undefined process.
As for the good news, CMS is addressing the fix prior to year-end, but it is yet to be seen whether the solution includes a front-end fix to end the generation of UIEs altogether.
- Periodic Data MatchingOn a periodic basis, CMS uses data criteria to identify individuals who are receiving financial assistance by enrolling in the Marketplace but at the same time are eligible or are enrolled in other Minimum Essential Coverage (MEC) such as Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). If enrollees choose to stay dually-enrolled in a Marketplace plan, they will no longer receive APTCs or income-based CSRs per the regulation.
Issuers continue to receive files from CMS to aid in outreach efforts to elicit action by the consumer and ensure they understand the loss of financial assistance before receiving a bill. Part of the process is helping consumers understand they are eligible for other coverage and to determine the appropriate MEC for them.
With the interim processes that are all too common for QHP Issuers, one fact is evident with managing membership – the data always tells the truth. Issuers will commit to working through the requirements as detailed above, support all open enrollment functions, and diligently work to resolve immediate membership issues that arise with January coverage. As with every new challenge that impacts enrollment, Issuers who have a robust reconciliation process to detect and resolve issues will be best positioned to measure and respond.
In parallel, the member experience leading into 2017 will be reacting to the some of the same challenges and a few more, including a 25 percent rise in premiums as stated by Health and Human Services (HHS) this week. Some enrollees will need a new plan, receive a manual 2016 tax notice, or be confused by notifications regarding their re-enrollment or other data matching issues. Others may receive a welcome kit and bill from a plan they did or did not select. When you review all the consumer touchpoints, it is evident the work ahead is a shared responsibility between the Marketplace, the member, and the QHP Issuer to ultimately get the member record right on all fronts. Collectively, the industry has made great progress this year, but we are still dealing with the chaos of a new government program.
Gorman Health Group’s proprietary tool, Valencia™, which currently reconciles 45 percent of the 11.1 million Marketplace enrollees, supports clients’ reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes – and the resulting payment – are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
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To learn more about our Valencia™ product, reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
New Webinar: The 2017 Star Ratings are out! Join John Gorman, GHG’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on October 27 at 1 pm ET for a cross-functional review of the 2017 Star Ratings ― from key program updates and 2017 Part D insights to emerging Pharmacy and Pharmacy Benefit Manager issues, new medication measures, and strengthening the connection between risk adjustment and Star Ratings. Register now >>
New Webinar: On November 1 at 2:30 pm ET, join GHG’s John Gorman and Melissa Smith as well as Eric Letsinger, President of Quantified Ventures, a firm committed to supporting the progress of the social enterprise community, and his colleague Brendan O’Connor, an Impact Manager, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Plan Now for Performance
As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has to be vigilant about identifying any weaknesses that could mean high costs or low expectations relative to budget. Parent companies have to be aware of line of business similarities and differences as Exchange and Medicaid business become more like Medicare Advantage in terms of programs and benchmarks. A recent article from Kaiser on retention makes great points about the line of business impact on retention and how it is a simple metric that encompasses many operational issues.
GHG is constantly improving its tools to identify outliers as well as relationships between different metrics that cross department lines. Finding root causes and quantifying them for the organization are more impactful than just handling them on an ad hoc basis. Just like compliance is everyone's responsibility, so is financial performance. Identifying weaknesses AND leveraging strengths combine to form a more complete business model for sustained growth.
GHG can prepare a tailored snapshot of your market and your company's performance. Contact us here.
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New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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2018 Proposed Notice of Benefit and Payment Parameters (NBPP) Summary
This year, some of the biggest industry leaders such as Aetna and UnitedHealthcare have exited the Affordable Care Act (ACA) marketplace. The outlook for the longevity of Obamacare looked grim without some drastic changes coming down from the Department of Health and Human Services (HHS) to balance the deficits seen by health plans as they navigate this new world of healthcare.
There is some light on the horizon for the health plans that are offering ACA plans on and off of the Exchange. The struggles and concerns expressed from health plans across the country are being heard and acted upon at HHS, which is evident in the 2018 Notice of Benefit and Payment Parameters (NBPP) that was released on August 29, 2016. The 2018 NBPP displays an array of proposed changes and updates that provides clarification, detailed rules, and specific changes to address the nuances associated with the commercial market. Such proposed changes and updates include the following:
- New Standardized Plan options and requirements
- Adjustments to user fees, cost share reduction (CSR) values, and coefficients
- Eligibility, enrollment, and benefit changes that impact special enrollment periods (SEPs), direct enrollment, and binder payments
- Recalibration of the risk adjustment model to address partial year enrollments, high-cost risk pool, and pharmacy utilization
- Risk Adjustment Data Validation (RADV) process changes and addition of new auditing requirements
- Actuarial Value (AV) calculator and rating adjustments
The healthcare industry has been eager to influence the structure of Obamacare. HHS has responded to what they are hearing, but the question is, are you ready to operationalize the technical processes and business support outlined in the NBPP to be successful? The ball is in the health plan's court now to take and run with. The approach to address the ACA is not your typical Medicare Advantage strategy. The commercial market has gotten much more complex and strategic. Being able to understand how each organizational decision impacts processes to promote a cross-functional organization and support rate setting, risk adjustment, data management, and EDGE server submissions are just a few pieces of the puzzle that should be considered.
Gorman Health Group (GHG) has a unique set of ACA expertise to assist those in the industry impacted by the ACA and the changes proposed in the 2018 NBPP navigate this new highly regulated world. Here is just a glimpse at what the industry has been asking GHG and the type of support GHG has been bringing to clients across the country:
- What are the key ACA processes health plans should be watching closely?
- Can health plans be successful with the current ACA regulations set forth?
- What impact do these proposed changes have on how plans partner with their Pharmacy Benefit Managers (PBMS's)?
- How critical is it to apply stringent processes for data management and submissions?
- What is the best way to approach all of the core functions associated with risk adjustment from an ACA perspective?
The more precise HHS gets, the more precise health plans need to be. Having the right technical infrastructure and membership platform in place is a great start. Look for a detailed GHG analysis around the proposed 2018 NBPP industry impact in the coming weeks
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This new industry brings about greater challenges than we've ever known in government programs while also providing immeasurable opportunities for health plans that prioritize high quality, clinical care, as well as proper coding and documentation and highly functioning enrollment and reconciliation functions. GHG has first-hand knowledge of vital plan operations and provides comprehensive strategies across a full spectrum of business needs. Visit our website to learn more >>
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2015 Risk Adjustment/Reinsurance Payments Published
Risk adjustment was designed as part of Obamacare to offset the impact of the underwriting process being eliminated to allow those individuals with pre-existing conditions to obtain health insurance. Now a health plan's risk is assessed after the member is enrolled. Health plans need to ensure the risk of their organization is reflected completely and accurately in the data submissions to the EDGE server since this is the information utilized for the risk adjustment calculation. Affordable Care Act (ACA) risk adjustment is a zero-sum game, so a health plan's overall risk will be measured against state averages and competitor results. Last week, the "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Benefit Year" was released by the Department of Health and Human Services (HHS). The report shows the risk adjustment payment transfers and reinsurance payments by state for each health plan that had an ACA plan in 2015.
The controversy around the ACA risk adjustment program is a hot topic and will continue to be the highlight of many discussions to come. With any new regulation or process, there comes a learning curve. Unfortunately, we are still in the early stages of a painful learning curve for a lot of health plans and co-ops. Slowly but surely, health plans are starting to realize the ACA risk adjustment program leaves no room for error. The complex nature of risk adjustment is not just the calculations or the interventions―it's the strategy and forethought behind the scenes to know how changes within the organization will impact the risk adjustment processes. Health plans can't just conduct some chart reviews, talk to providers, and send data to the EDGE server and expect to be successful within the ACA market. At that point, it's just going through the motions of what most individuals know as the core operations of risk adjustment without understanding what really makes the program tick. It's like a game of chess―you can't make the same moves in the same order every time you play and expect to win. You need to adjust your next move dependent upon the move of your opponent. That is exactly how risk adjustment needs to be approached.
It's a not so surprising reality that the co-ops are struggling with staying solvent given the magnitude of payments they are required to make for risk adjustment. Unbeknownst to individuals outside of a risk adjustment department, the strategy and operational structure to a fully-functioning successful risk adjustment program is extremely complex. When implementing Obamacare in preparation for the effective plan dates in 2014, co-ops, like most other health plans, did not put a lot of focus on developing a risk adjustment strategy and supporting operations. Some health plans simply did nothing, which was the worst of all scenarios. Risk adjustment was one of the "new processes" that came to be in the commercial market because of the ACA. Those individuals who had never worked with a Medicare Advantage plan before probably never even heard of risk adjustment. These things all played a role in the importance of risk adjustment being under-estimated during the development phase of the ACA for health plans. Now that everyone in the country is aware of the importance of risk adjustment and the magnitude of financial impact it carries, it's an uphill battle for the co-ops having to face making large transfer payments, some are upwards of $30 million.
So how did your health plan do? Was all of the effort and hard work done by your organization realized in the payment transfer outcome?
Being able to answer those two simple questions is a lot harder than you would think. Most health plans measure the success of a risk adjustment program by the magnitude of the payment transfer. By doing this, you will be missing the root cause of operational changes that need to be made to establish a long-term efficient risk adjustment program. Before you can realistically answer these questions, you need to understand where your health plan started and measure success at each step of the way. Then you will be able to see if the events that unfolded were in line with what you intended to happen. If not, then adjust accordingly. If health plans don't start looking at their internal operations relative impact to risk adjustment, then it's only a matter of time before you will become the next sinking ship in the calculation of the payment transfer.
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Now that the FFM is paying Issuers directly from the FFM system, Issuers need to shift gears and begin thinking about how they can impact a timely and accurate payment of Advanced Premium Tax Credit, Cost Sharing Reduction, and User Fee charges. Are you thinking about your overall payment strategy? Read the full article >>
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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.
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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 >>
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The Evolution of Healthcare.gov — It's Time to Play Ball!
Now that the Federally-Facilitated Marketplace (FFM) is paying Issuers directly from the FFM system versus the Issuer's system, we are participating in a different type of ball game. Issuers now need to shift gears and begin thinking about how they can impact a timely and accurate payment of Advanced Premium Tax Credit (APTC), Cost Sharing Reduction (CSR), and User Fee (UF) charges. Two key areas are at play here: the reduction in tracked discrepancies and ensuring action is taken to resolve and apply consumer data corrections to the FFM system to be in sync. As Issuers react to the May payment cycle and prepare for June payment, they are beginning to think about their overall payment strategy from this point on.
When considering the Issuer's role, the days of not establishing the necessary resources to research and resolve all discrepancies simply because the volume is too high will not suffice during an audit or bring revenue in the door either. So when we talk about an overall payment strategy, it is important for Issuers to recognize they are playing on the team responsible for tracking, fixing, and overseeing their reconciliation program, which includes building an expected payment and outstanding payment based on data cleanup that is pending.
Bringing transparency to the FFM model is the first step towards alignment of data between the Issuer and the FFM and true reconciliation. Imagine being able to discuss with your government partners the substantial payment impact your organization is experiencing simply because the FFM has not applied all outstanding data corrections. That phenomenon is actually occurring today. Since January 2016, the FFM suspended the application of field-level corrections to the FFM system until this month. Issuers should finally see six months of updates reflected in their July payment and are working towards quantifying what that impact will be.
As the FFM model continues to evolve, Issuers are still working towards solving their own challenges:
- Lack of strategy for timely and accurate payment of APTC, CSR, and UF charges
- Unmanageable volume of discrepancies and inability to prioritize
- Backlog of submitted disputes and delays with the Marketplace updating system corrections
- Struggling with measuring and managing the chaos
- Missed revenue opportunities
- Not audit ready
Based on the importance of being in sync with the Marketplace — both FFM and State-Based Marketplaces (SBMs) — Gorman Health Group (GHG) has launched a new reconciliation service with a focus on reducing the volume of enrollment and payment discrepancies while building best practices within Issuers' Finance and Enrollment departments. Now that discrepancies represent real dollars, the stakes are high.
Through GHG's Marketplace reconciliation services, Issuers will be able to track and resolve enrollment and payment discrepancies and quantify the financial impact of those reconciliation efforts. GHG's reconciliation experts will equip Issuers with the knowledge to predict their payment (prospective and retrospective) each payment cycle and build a process to react when the actual payment is not what your organization expected, either through a submitted dispute or internal update.
Our proprietary tool, Valencia™, which currently reconciles 42 percent of the 12.7 million Marketplace enrollees, supports clients' reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes — and the resulting payment — are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
To learn more about the GHG's reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
Resources
Gorman Health Group has launched a new reconciliation service with a focus on reducing the volume of enrollment and payment discrepancies while building best practices within Issuers' Finance and Enrollment departments. Now that discrepancies represent real dollars, the stakes are much higher. Visit our website to learn more >>
With Gorman Health Group's Valencia™, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments. You'll also have complete control of rigorous, compliant and transparent workflow controls that complement your enterprise system. Set up a demo today >>
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What a Clinton Administration Could Mean for Government Health Programs
So the people spoke and we are heading for an epic cagematch smackdown general election between reality TV star Donald Trump and former Senator and Secretary of State Hillary Clinton. And you're asking, what's going to happen to Medicare, Medicaid and ObamaCare? The answer is plenty -- below the waterline and out in the states. Stakeholders will need to pay attention or get left behind.
First, the likely scenario is that Hillary is going to win this thing big. While other Republicans may have had a chance to capitalize on her high negatives with likely voters, nobody's negatives trump Trump's. He's the most unpopular major-party candidate since polling began. Most polls have him losing by double digits in November.
At this moment, Trump's likely to lose so bad that many down-ticket Republican Senate and House seats are now in play. So: Hillary in the White House, Democrats likely running the Senate again, and poor Speaker Paul Ryan trying to corral an even more radical, noisy and smaller Tea Party caucus in the House. The only people those guys hate more than President Obama are the Clintons. So betting on more gridlock is safe money. Little or nothing gets done in Congress except the bare minimum to keep government running.
That means most of what happens in Medicare, Medicaid and ObamaCare will occur "below the waterline" in Administrative policy, regulation, and guidance, or is driven by the states. Here's what that could look like:
- Medicare: the forced march to value-based payment across the program will continue. The recent MACRA rule makes it clear that a fundamental change to traditional Medicare is coming and that fee-for-service is dead. By the end of Hillary's term, a majority of Medicare dollars will be tied to provider performance. Medicare Advantage will continue its steady 5-7% annual growth and exceeding 25 million enrollees in 2020. But CMS raises the bar through a rapidly-maturing Star Ratings program and an aggressive compliance and auditing initiative carried over from Obama's last year in office. Regulations and guidance are pumped out in regular order, drafted by newly-emboldened career CMS staff and making the program a laboratory of continuing performance improvement with claws and teeth.
- Medicaid: on the heels of the biggest regulation in 12 years, Medicaid converges more than ever with Medicare Advantage and ObamaCare, but also goes down some very strange alleys. With Obama out of office, several more red states like OK and TN finally take the Medicaid expansion deal from the Affordable Care Act. But with it they insist on "conservative principles" like work requirements and drug testing that dampen coverage and introduce new complexities to the program. At the same time, blue and red states alike flood CMS with new home and community-based services waivers to force dual eligibles into health plans and implement managed long-term care programs.
- ObamaCare and health insurance exchanges: health plans in the public exchanges continue a market correction and shakeout for another two years. During that time, CMS issues even more regulations dove-tailing exchange operations with Medicare Advantage rules, and several states currently running their own marketplaces like CO revert to healthcare.gov.
Health plans and other stakeholders in these programs will need to pay more attention than ever to stay ahead as government solidifies its role as their biggest customer. These are changes that won't necessarily be splashed across major media, but rather in trade rags and expert blogs. The only thing that's certain: it won't be dull.
Resources:
The Centers for Medicare & Medicaid Services (CMS) issued the final Medicaid "mega-rule," a huge regulation that makes changes to every part of the current managed care rules. Read more >>
Under the provisions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians and other practitioners will face a Hobson's choice: live with a more aggressive risk-based adjustment to payments or join forces with an alternative delivery model, like an Accountable Care Organization (ACO), that is taking risk. Read the full article >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>