Medicaid | GHG Advisors

Republican Congress to Use "Inside Baseball" and Courts to Maim ObamaCare

Blowing in like a flu outbreak as year-end approaches, ObamaCare Derangement Syndrome has enveloped the Capital. Republican leaders in Congress are plotting to use arcane parliamentary procedures and the courts to do further violence to ObamaCare, and by extension, to the millions who have gained insurance through it. While it's red meat for the conservative base, the strategy presents a huge political problem for the GOP: they have nothing to replace it with.

Since the midterms last month, Republican Congressional leaders have been locked in a furious, behind-closed-doors planning effort to gut ObamaCare once and for all. While the GOP has finally awakened to the fact that repealing the Affordable Care Act ain't gonna happen on Obama's watch, Republicans are licking their chops to use an obscure fast-track budget process called reconciliation to deal it a mortal wound with only a simple majority. It's a longshot with many difficult parliamentary steps, but if successful, could deal a fatal blow to the marketplace subsidies, the Medicaid expansion, and/or the individual mandate. But I've consistently underestimated the effects of ObamaCare Derangement Syndrome, so I'm making no bets this time around.

Barring that, plans are also being laid to craft a bipartisan bill that would strip out more minor provisions like the device tax, the Independent Payment Advisory Board (IPAB), and restoring a 40-hour workweek. That seems to have a better shot, assuming the reconciliation effort doesn't poison the already toxic well on the Hill.

The second prong of the Republican attack is through the courts, with a goal of "repeal by Justices." GOP leaders are convinced that where repeal may fail legislatively because the President won't kill his signature domestic achievement, the Supreme Court just might do the dirty work for them.

The first test, of course, is King v. Burwell, the challenge to the Federal marketplace subsidies the Court accepted in a surprise move last month. The case hinges on payment of Federal subsidies to people who enroll in insurance marketplaces run by CMS, and not by states. It was basically a drafting error that now threatens to put ObamaCare into a death spiral if the plaintiffs win.

The Court has acted to hear the case early in its session in March, but we won't know their ruling until June 2015. I put it at 50/50, because four Justices don't vote to hear a case unless they're confident they can get a fifth for a majority ruling. That fifth vote, of course, is Chief Justice John Roberts, and he's a total wild card. He has voted for both sides of the Court, and is very mindful of his legacy and the institution's legitimacy. He said recently that the partisanship shouldn't penetrate the walls of SCOTUS, and that's encouraging for ObamaCare supporters.

Most Constitutional scholars here in DC seem to think the merits of the case favor the Administration, but there's a whole lot of liberal hand-wringing going on here. A win for the plaintiffs and the end of Federal subsidies to 4.5-7 million Americans would of course be lethal to the marketplaces, and there's little activity underway at the state level for that contingency. It would effectively wipe ObamaCare off the map entirely in Red States with no exchange and no Medicaid expansion. If it fails and the ACA's subsidies are upheld, Republicans are lining up multiple other challenges to the Affordable Care Act, all with a goal of getting them to SCOTUS.

I think a win for Republicans in King creates a huge political problem: they will tear health insurance away from millions of Americans, with no alternative or replacement in sight. Not even Medicaid expansion. And that would take some "splainin'" to do in 2016, when Hillary gets her second act on health reform.

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by GHG Advisors

Best Practices in Medicaid Claims Administration and Oversight

Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective.

Claims adjudication is the process of paying or denying claims after a series of comparisons (automated system logic or manually by claims staff) against a comprehensive set of requirements. These requirements are as follows:

Eligibility verification
Benefit administration (deducible, coinsurance, copayment, accumulators and Maximum Out of Pocket (MOOP))
Authorization criteria
Provider verification
Financial data and reimbursement guidelines (contracted or non-contracted)
Claim edits
Encounter edits
Correct coding edits (based on line of business and state or federal guidelines)
Medical review
Coordination of benefits

Best practices of efficient Medicaid claims operations are as follows:

Develop a strategy in enhancing claims quality control and oversight activities
Implement quality control auditing through pre-payment auditing reviews
Create a comprehensive oversight and monitoring reporting system
Ensure that processes starts ticking when the claim reaches the organization, not necessarily when it reaches the claims department
Increase auto-adjudication by complete set-up of pre-processing and routing logic. This results in higher first-pass rates and reduction in manual handling, which provide significant savings in operating costs
Continue to redefine procedures, as well as provide a mechanism to understand all terms and conditions of the State contractual agreement relating to overall operations, claims and encounter processing
Define and design configuration build at the product level by delineating lines of business (i.e., Medicare rules vs. Medicaid rules) which results in compliance with applicable regulations
Continue to define or redefine claims adjudication policies and procedures, and data management, including consistency within each product
Implement processes that monitor end-to-end claims adjudication

Execution of these best practices, and automating each procedural step of the claims cycle, results in quicker claim resolution. Monitoring operational performance helps track, adjudicate and measure claims as they flow through claims administration operations. As operational performance improves, auto-adjudication rates rise and the total cost per claim falls.

Gorman Health Group includes some of our industry's most experienced and proficient claims administration subject matter experts. Our consultants can help your organization implement best practices in claims administration. Please contact us at ghg@ghgadvisors.com to get started.

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GHG will help you by providing creative solutions to maximize cost effectiveness while building a solid framework to deliver results from eligibility to provider contract management to claims. Visit our website to learn more >>

Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>

by GHG Advisors

A Bad Couple Weeks for ObamaCare

It's been a bad couple weeks for ObamaCare. It started with a Republican gorilla-stomp in the midterms, a rout that included several Governors' mansions and state legislatures that essentially froze in place the Medicaid expansion map. Then, in a shocker, the Supreme Court decided to consider King v. Burwell, the case that could undo ObamaCare's marketplace subsidies and threaten the coverage of more than 4 million Americans. It's enough to give weekend bedspins.

Ice Age for Medicaid Expansion

In many states with rampant uninsurance, Republican candidates won critical Governors' races and in others the GOP solidified seats in their legislatures. The net effect: it's a new Ice Age for the Medicaid expansion map, with states taking the Affordable Care Act's (ACA) 100% Federal match for uninsured adults essentially now frozen in place. We may even see some backsliding.

Some 24 states have accepted the ACA deal and expanded their Medicaid programs in the wake of the last big SCOTUS ruling on ObamaCare. In fact, more Americans have gained coverage from Medicaid expansion than ObamaCare's subsidies in the new insurance marketplaces. But despite the fact that holdout states continue to pay their share for Medicaid expansion through Federal taxes, over two dozen mostly Red State governors continue to throw the middle finger at the guy in White House. Most notably, reelection of Rick Scott in Florida, Scott Walker in Wisconsin, Sam Brownback in Kansas, Nathan Deal in Georgia, and Rod LePage in Maine stuck a fork in coverage for the uninsured there.

Utah Gov. Gary Herbert will outline a formal Medicaid expansion plan this month. Republican governors in Tennessee, Wyoming, South Dakota and North Carolina have also flirted with Medicaid expansion plans in 2015. And a late recount win in Alaska for left-leaning Bill Walker may open prospects for coverage for 43,000 residents in 2015.

But we could see real retreat on Medicaid expansion in GOP states that were already moving forward. New Republican governors in Arizona, Arkansas, and Illinois have the power to threaten health coverage for hundreds of thousands who have enrolled in expanded Medicaid, and have done so during the campaign. Indiana Governor Mike Pence was negotiating a plan with the Obama administration pre-election, but now appears to have his own Presidential aspirations in mind and may put the plan on ice. Arkansas' controversial Medicaid expansion waiver to use Federal dollars to buy private coverage was already approved, but its new governor, former US Rep. Asa Hutchinson, is no fan of the plan, which requires annual approval by the legislature and is now very much in doubt.

It was a bad midterm election for the uninsured, especially childless adults. What remains to be seen is how hard a line the Obama Administration takes to force holdout Red States to take the money, using existing Medicaid funds as leverage. My guess is that hard line will be pretty limp. As George Burns said, "like shooting pool with a rope."

The SCOTUS Subsidy Surprise

The day after the election the Supreme Court made a surprise decision to hear arguments in King v. Burwell, what many thought to be a sideshow case in the lower courts around the Constitutionality of ObamaCare subsidies in the 36 states using the Federal exchange. It was basically a case challenging a drafting error in the law, which didn't make clear enough distinction between state-based and Federal marketplaces, and ACA opponents saw their opening.

Even being "strict constructionists" in their jurisprudence, one has to believe the conservative activist Court didn't take this case to rubber-stamp ObamaCare's subsidies. If the justices find for King, some 4-4.5 million Americans will see their martketplace subsidies at risk. Without subsidies, the vast majority of those insured will drop coverage like a hot rock, leaving only the sickest in the pool — what economists call a "death spiral" for insurers operating in the marketplaces. It would essentially lay a mushroom cloud on all private coverage options in those states, leaving ObamaCare a smoking wreck of mostly Blue State Medicaid expansions.

There's no ignoring this point: in Republican territory, the ACA and its marketplaces and Medicaid expansion are more vigorously opposed than in states that elect Democrats. If SCOTUS upholds King, then coverage and politics will truly converge in Red States. A win for King means Red States can effectively purge themselves of all vestiges of ObamaCare, by not expanding Medicaid and not establishing an exchange.

I think this would be a huge problem for Republicans, forcing them to come up with solutions that are politically palatable to them. All these new GOP Members of Congress, and Red State holdout governors, need to start thinking, now, about what to do if SCOTUS announces a decision in June 2015 denying tax credits to millions of their citizens, while they in turn continue to deny Medicaid coverage.

Resources

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by GHG Advisors

12 Years in the Making - Rules Guiding Medicaid Managed Care are Getting a Makeover

At the Medicaid Health Plans of America (MHPA) meeting last week in Washington, DC, there was a lot of buzz surrounding the upcoming release of an updated Medicaid Managed Care regulation. Per CMS officials speaking at the conference, the last update was 12 years ago!

Discussions surrounding the update were focused on three main themes:

Aligning Medicaid Managed Care with other public programs
Payment and accountability
Network adequacy

Aligning with other programs — This could take many different shapes and sizes. Certainly the well-established program guidelines of Medicare Advantage could become very prominent. In contrast, the newly evolving rules of the Exchange Marketplace could be drawn more into the spotlight. Being that Medicaid beneficiaries sometimes align with Medicare Advantage and sometimes with Exchanges, this is likely to draw a lot of comments from the industry when released in the coming months.

Regardless of how you think it should be done, the rationale to better align all of these programs makes good sense for both beneficiaries and the managed care plans that serve them. Beneficiaries can have common experiences; families with multiple program enrollments have an easier time navigating the system; and plans reduce unnecessary administrative burden to administer multiple programs.

Payment and accountability — Several hot button items are involved in this theme. All of these involve modernizing the regulation to the current day environment.

Using data to think about issues related to rate setting and rate review
Using program dollars wisely, as more is at stake as the program continues to evolve and grow
Integration of long-term services and supports into the regulation

Network adequacy — The OIG recently released a report identifying significant variation between states as it relates to access to care, and how those standards are being checked on a regular basis. With the recent significant growth in Medicaid Managed Care enrollment, this becomes even more concerning. We can expect CMS to take a strong stance on access to care issues including network composition, availability of primary care and specialists, and provider directory issues. As a major beneficiary protection issue, we also expect this area to draw a lot of comments from the beneficiary community.

We are very anxious to see the draft regulation and the "give and take" it is going to provide to the industry. With 12 years worth of ideas baked into it, it should be a fun ride!

Resouces

Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement. Visit our website to learn more about how we can help you with your Medicaid initiatives.

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by GHG Advisors

Little Reason for Optimism in Red State Medicaid Expansion

For months several Wall Street analysts and others have predicted near-total adoption of the Affordable Care Act's Medicaid expansion by the states. To date, only 27 have, and I see little optimism for more than a handful to do so anytime soon.

Red State governors are WAY more entrenched than anyone anticipated, and they're getting too much political mileage out of throwing a middle finger at the guy in the White House to stop. Even if Democratic candidates leading in states like Florida win next week, the barrier is often their state legislatures. Virginia is a great example of a pro-expansion Democrat thwarted by his state lawmakers -- one that will be repeated many times in 2015.

Last week we heard mixed news on Medicaid expansion: it appeared likely that Utah governor Mike Herbert would accept an Arkansas-style expansion in a rare compromise with the Obama Administration, and also pretty certain that Indiana governor and 2016 GOP Presidential possible Mike Pence would reject one. Even if Herbert takes the deal, Utah may be another example like Virginia, with a supportive governor blocked from expanding by his state house.

At least six states could adopt Medicaid expansion, including Florida, Georgia, Kansas, Maine, Wisconsin and Alaska, if -- and it's a huge if given the political headwinds -- Democrats and one independent candidate win their gubernatorial races. The obstacle is getting state lawmakers on board in Florida, Georgia, Wisconsin and Kansas, where Republicans control the legislature.

So maybe it's really just Maine and Alaska that have any real shot at expansion? Maine lawmakers are poised to expand Medicaid if Tea Party wingnut Governor Paul LePage is defeated next week. LePage has vetoed several bills to expand the program after they were passed by the Democrat-controlled Maine legislature, and he is trailing in the latest polls. Alaska isn't nearly as far along.

A handful of new Republican governors could move for expansion, albeit after the midterm elections. Tennessee GOP Governor Bill Haslam said he plans to submit a plan later this year, although state Republican leaders warn it will be difficult to win approval. Wyoming Governor Matt Mead, also a Republican, said he will present an expansion plan to his legislature early next year, but prospects also seem slim there.

In many of the remaining Red States, where uninsurance is most epidemic and the ACA is needed most, there seems to be little hope of elected officials actually doing their jobs and meeting the needs of their constituents:

In Mississippi, expansion doesn't have a snowball's chance in Hell. GOP Governor Gary Bryant made it clear Mississippi would not participate, leaving 138,000 residents, the majority of whom are black, with no insurance options at all after infighting killed the state's embryonic health insurance exchange.
In South Carolina, where expanding Medicaid could reduce the number of people without health insurance by one-third, the state's health plan association doesn't expect any movement until at least 2017. Even its state medical association won't back expansion, apparently preferring bad debt and fewer customers to Medicaid payment.
In Louisiana, payers aren't hostile to expansion, they just don't see any point in pushing it. The state health plan association chief said "it's a state where both the House and the Senate, and the governor, are pretty much on the same page of not being interested in moving toward expansion this year or next year."
In Alabama, even the state's health plan association is openly opposed to expansion. "I agree, and I think my members agree, that [Governor Robert] Bentley is doing the right thing" by saying no, the association CEO said. In its current form, "expanding Medicaid makes zero sense for Alabama."
In Texas, which has more uninsured people than Colorado has people? Um, no.

With Republicans poised to retake the US Senate next week and expand their dominance in the House, all this hopeful chatter about Medicaid expansion seems more like liberal dreaming than reality. Maybe 2-3 more states in the next two years, if we're lucky.

Resources

GHG is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement. Visit our website to learn more >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

by GHG Advisors

ObamaCare Derangement Syndrome Fades, Medicaid Expands.

Last week's approval of Pennsylvania's Medicaid expansion waiver by the Centers for Medicare and Medicaid Services (CMS) may have been good medicine for ObamaCare Derangement Syndrome among Red State governors. Growing numbers are beginning to see the light and resistance to expansion is beginning to crumble like stale crackers. Expansion momentum is building in Republican-led states after Pennsylvania's change of heart. Indiana, Tennessee, Utah and now Wyoming (!) may be next in line seeking CMS approval for their conservative-oriented expansion proposals. These custom Medicaid expansion proposals include administration by risk-bearing private health plans, increased beneficiary cost-sharing, job search requirements, and mandatory health assessments, among other conservative tenets.

What's finally bringing them to the table after PA's approval? A flurry of studies this summer, including the White House Council of Economic Advisors, the Urban Institute, and a PwC Institute report, noting that non-expansion states will lose out on over $420B in federal funds between 2014 and 2022, but are still contributing to expansion in other states through Federal taxes, and are doing violence to hospitals, often economic anchors of their communities. Urban's conclusions were particularly clear:

The decision of state leaders not to expand Medicaid also means their local hospitals will collectively forgo $167.8 billion in Medicaid reimbursement payments over the same timeframe.
Based on analyses of state budgets, for every $1 a state spends expanding Medicaid, $13.41 in federal funding flows into the state.
In total, hospitals in states not expanding stand to forgo $167.8 billion in reimbursement funding from 2013 to 2022.

The drumbeat has stripped raw the opposition for what it is: the last vestiges of ObamaCare Derangement Syndrome. Economic rationality is beginning to take hold. And that's good for the nation's health.

While the Obama Administration has laudably and consistently shown its willingness to deal with Republican Governors on Medicaid expansion, it definitely isn't writing blank checks. PA applied for 29 different statutory waivers for its expansion program and was awarded 5. AR and IA got tough-love deals from CMS too. This next cabal of RedGovs will need to show similar willingness to compromise -- imagine that -- to get their Medicaid expansion visions realized.

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by GHG Advisors

PA's Corbett is Latest GOP Governor to Take Medicaid Expansion. Will Others?

Last week the Center for Medicare and Medicaid Services (CMS) announced the approval of Pennsylvania's Healthy Pennsylvania plan to expand Medicaid coverage to more than half a million low-income people, becoming the 27th state to do so under the Affordable Care Act (ACA) and the 9th Republican governor.

It's a big step for Governor Corbett, who joins GOP governors in Arizona, Iowa, Michigan, Nevada, New Jersey, New Mexico, North Dakota, and Ohio in breaking party lines and taking the expansion. The plan would require certain Medicaid-eligible people to pay directly for a portion of their care, utilizing ACA funds to purchase their benefits on the private market. A huge factor in Corbett's decision: hospitals, which carry huge leverage in PA, both academic and for-profit. Politically speaking, Corbett had little choice. Economically speaking, he's the latest RedGov to awaken to the fact that it makes no sense for states to pass up on the ACA's huge Federal matching funds.

Does this mean more GOP governors will see the light and stop the obstruction on Medicaid expansion, enabled by last year's infamous Supreme Court ruling? Yes -- but not all.

As I wrote back in June, there are still 23 holdout Red states, whose governors like Rick Perry (TX) and Bobby Jindal (LA) continue to be hell-bent on throwing a middle finger at the White House while thousands of their constituents literally die because of inaction. Speculation is that a growing number of Red states will fold and take the Medicaid expansion money â€” but not until after the midterm elections. Here's why:

Funding: the Feds are funding 100% of Medicaid expansion through 2016, scaling down to 90% in 2020+. While the initial ACA backlash may have provided cover for states not to expand, it will be increasingly difficult to continue to defend not taking the federal money to insure a significant population group. Remember, Red states have the highest rates of uninsurance per capita, largely due to their historically stingy Medicaid programs. Texas, for instance, has more uninsured people than Colorado has people.
Access: most states that choose not to expand created a significant coverage gap. This happens because subsidies on the exchange are available from 100%-400% of the Federal poverty limit, but not below that, leaving a low-income population paying significantly more for healthcare coverage.
"You're Still Paying for It": The ACA funds Medicaid expansion largely from tax revenue. States like Texas and Florida are among the highest contributors to general tax revenue and have the highest number of uninsured population. They are helping to fund Medicaid expansion for other states via higher income taxes, yet not receiving any of the benefits for their own population. Medicaid accounted for about two-thirds of all federal funding to states in 2014, up from 43 percent two years ago.
Hospitals: hospitals traded in insufficient DSH funding and bad debt for Medicaid or exchange coverage in the ACA. Hospitals in Red states that didn't expand Medicaid are now reporting they can't even issue bonds for capital projects, and are dying on the vine as the DSH funds are taken away without a substitute. Considering hospitals are often the largest employers in their communities, and especially in rural Red states, their lobbying might is expected to break anti-ObamaCare partisanship after the elections are over. They were a huge factor in Pennsylvania.

I'm not as optimistic as some on Wall Street that all RedGovs will fold in the face of these arguments, but suspect that several more will as we head into 2015. Immediately after the PA waiver approval, Tennessee's governor said he may submit a similar proposal to CMS to help provide coverage for approximately 180,000 individuals. The driver there? Once again, hospitals: Community Health Systems, HCA, and LifePoint all have a significant presence in TN, including the headquarters of several. And given the central and growing role Medicaid plays in healthcare financing -- it is the largest health insurer on earth now -- health plans are awakening to the fact that if they're not in it, they won't be around long.

Resources

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by GHG Advisors

Health Plan Strategists: Fish Where the Fishes Is -- in LTSS

One of the best pieces of advice I ever got in business was to "fish where the fishes is", and for health plan strategists it holds up. In this Golden Age of Government-sponsored Health Programs, one of the biggest fishing holes is Long-Term Services and Supports, and a new primer from KFF lays out the opportunity beautifully. And the hazards: patients who require LTSS are of course the most vulnerable and complex patients in the entire US health system, literally the final frontier for health plans and coordinated care. Huge risk, huge rewards.

LTSS -- often totally unfamiliar to both Medicare and Medicaid plans, and requiring new types of providers in-network -- help the elderly and disabled with activities of daily living, and include nursing home care, adult day care, transportation, and caregiver supports. As a nation in 2012 we spent $368 billion on LTSS, 40% of that from Medicaid, and 20% from Medicare, and likely to be around $400 billion today. That's way more than what we're spending on ObamaCare's exchanges and subsidies on an annual basis. It's unsustainable already, and is now a top-2 item in most state budgets. And with seniors 85+ now the fastest-growing segment of the US population, and their needing LTSS at four times the rate of their younger cohorts, the urgency to convert these vulnerable patients to a coordinated care environment has never been greater, and it's happening fast.

Most LTSS reforms occurring at the state level involve transitioning frail elders and the disabled from the human warehouses of nursing homes and rehab hospitals to home and community-based settings, often under a capitated financial arrangement. With a year of nursing home care costing $90,000+ but a home health aide or adult day care running about $20,000, it's not hard to see why 45 cash-strapped states are pushing this transition.

The catch is that with the complexity of these populations, and the growing resistance of beneficiary advocates, especially for the developmentally disabled, this transition will involve an unprecedented degree of transparency and accountability from health plans. If you think Medicare Advantage Star Ratings measures are tough, you ain't seen nothin' yet. Many quality standards for the frail and disabled, like provider visit timeliness and drug adherence, haven't even gotten off the drawing board yet, and they often vary by state. What's clear is that service and coordination expectations of regulators will be far more robust for very old and disabled beneficiaries. That means more emphasis on data-driven case management and coordination, in-home and in-community interventions, robust reporting for regulators and actionable clinical intelligence for providers.

So strategists should "fish where the fishes is" and plan to participate in these groundbreaking programs -- but come equipped.

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by GHG Advisors

Navigators, In-Person Assisters and Brokers

The Alliance for Health Reform held a briefing on August 5, 2014 on "Navigating the Health Insurance Landscape: What's Next for Navigators, In-Person Assisters and Brokers?"

Consumer enrollment in Qualified Health Plans (QHPs) offered in the Exchange Marketplaces for 2014 was greatly assisted by Navigators, In-Person Assisters (including Certified Application Counselors) and Brokers. 28,000 navigators and assisters helped 10.6 million consumers during the first ACA open enrollment period. The Kaiser Family Foundation just completed a survey and issued a report entitled "Survey of Health Insurance Marketplace Assister Programs: A First Look under the Affordable Care Act". The survey did not include agents and brokers. The survey reported that there were 4,400 assister programs nationwide. Certified Application Counsellor Programs account for 45 percent of the assister programs, in-person assistance programs were 26 percent, the FQHC share was 26 percent, Navigator programs represented only 2 percent and the Federal Enrollment Assistance program provided only 1 percent.

According to the Kaiser study, the federal government spent over $400 million on these assistance programs during the first year. $100 million came from Exchange establishment grants, $208 million from grants to FQHCs, and $105 million from CMS ACA implementation funds. In addition, there was substantial additional funding from private sources including non-profit community programs, hospitals and health care providers, state and local governments. Funding for assister programs in the state-based marketplaces and federal-state partnership markets was substantially higher than funding in the federal marketplaces. The uneven funding distribution meant that the number of assister staff per 10,000 uninsured was about half in the federal marketplaces.

Assistance was time intensive involving on average one to two hours for each client. The top three reasons consumers sought assistance included their limited understanding of the ACA and the need to understand plan choices and their lack of confidence in applying on their own. Information from QHP websites was inadequate and plans did not have dedicated phone lines for assisters. Assisters faced a number of challenges including lack of health insurance literacy, transportation issues in rural areas and lack of trust in certain hard to reach communities. States had only 10-12 weeks to hire and train most assisters. 92 percent of assisters wanted additional training especially in the areas of subsidies, tax penalties, and immigration issues. Successful techniques in reaching the target uninsured populations included partnership with community agencies, building on Medicaid and CHIP networks, use of mobile navigators and media outreach efforts. Back-end access to Exchange portals in some states, e.g. Maryland and New York greatly helped the assisters with their jobs. States with larger funding were able to conduct more outreach and education events and schedule one on one appointments.

There is no data on the number of agents and brokers that participated in the 2014 open enrollment period. The National Association of Health Underwriters (NAHU) reported high broker interest and their 2013 survey found that almost 75 percent were obtaining marketplace certification. HHS reported that 70,000 agents were certified by the federal marketplaces. State exchange data shows 30,000 additional agents and brokers were certified. The NAHU reported that agent and broker services had an 89 percent customer satisfaction rate. In general, state based exchanges were designed with better broker participation mechanisms than the federal marketplace, although all exchanges experienced technological issues. The level of collaboration between brokers and assisters varied across states. Some assisters were wary of brokers, largely because they received commissions from the plans. Others valued the expertise of the brokers.

90 percent of assister programs reported post-enrollment problems after the ACA open enrollment ended in April. The top problems identified included not receiving an insurance card, Medicaid eligibility determination problems, and failure to receive a premium invoice. Three fourths of the consumers lacked understanding of the basic insurance concepts. About one-third of the enrollees picked the wrong plan, for example because they didn't understand high deductible plans or innovative benefit designs that covered some benefits but not others.

76 percent of the assister programs plan to continue during the second open enrollment. This open enrollment is 50 percent shorter than the first enrollment period and overlaps with tax season. The assisters will also be facing the QHP renewal process as well as uncertainly on the functionality of the online portals. New QHPs will be entering the marketplace. Federal Navigator funding will be $8 million less. States can continue to use their grants for the 2015 enrollment period, but they must be self-supporting in 2016. Additional education will be needed on tax penalties which will be three times larger if consumers don't sign up in 2015.

NAHU expects broker participation in the 2015 open enrollment period to be high, although slightly lower than 2014. A June survey found that 69 percent of brokers plan to sell on the individual exchange in 2015. Brokers see opportunities with new plans entering the marketplace and the availability of the SHOP exchanges. Brokers and agents experienced a number of challenges in 2014 including payment and liability issues resulting from the failure of applications to record multiple assisters. NAHU recommends broker portals, additional fields to record multiple assister numbers on applications, ability to edit enrollment records to add NPNs and addition of a complete list of brokers on HHS.gov.

Resources

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by GHG Advisors

PBMs are the Health Plan Industry's Achilles Heel

In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs). Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille's Heel of insurers.

PBMs historically made most of their money on commercial insurance and have lagged on government programs, a trend exacerbated by a brain-drain of talent following a wave of PBM consolidation. The danger has never been greater for health plans, and their choice of vendor has never been more important.

First, Medicare's Star Ratings system has several critical performance measures directly tied to PBM performance, notably those related to drug plan service, formulary administration, patient adherence to drug therapies for chronic diseases like hypertension, and readmission prevention (many hospital readmits are due to drug over/underdose post-discharge). The numbers don't lie: Medicare Part D Star ratings and formulary administration were the two leading reasons for CMS-mandated corrective action plans dropped on insurers in the last year. Of plans scoring less than 2 Stars by performance domain, Drug Plan Customer Service came up worst in CMS's last review cycle -- followed by Member Experience with the Drug Plan, and Member Complaints, Problems Getting Care, and Improvement in the Drug Plan's Performance. It's a dismal record and getting worse.

Then consider that the two critically-important health plan quality improvement measures -- C33 and D07 -- are now weighted 5, a first for CMS and a huge development. The concern here is that PBMs are often terrible at data management, and under these measures a plan can be reduced to 1 Star where mishandled data resulted in bias or error, or where appeals and grievances handling is in question. With that 5-weighting, this has come as a rating killer for several plans and a major vulnerability for the rest, as most don't keep good logs of non-compliance issues or audit results.

PBMs are generally good at managing the drug benefits of commercial members, but the complexity of seniors and the low-income and the previously uninsured continues to confound these companies. Gorman Health Group ran 15 solicitations for government program PBM services for its clients in the last 12 months, and we wouldn't wrap fish in one of the responses we received. All varying degrees of suck.

In this last round of contract and service area expansions for 2015 Medicare Advantage and Part D, in our 18 years we have never seen more rejections due to PBM failings like pharmacy and home infusion network adequacy -- literally dozens this cycle, due both to PBM sloppiness and a new resolve at CMS to directly address it.

As PBMs continue to consolidate, plans need to protect themselves from weak execution by bringing renewed focus on PBM-directed Star ratings measures and most importantly, inspecting what they expect. The delegation oversight plan for this vendor is the most important document in compliance right now. Payers are now literally at the whim of the government programs sophistication of their PBM account manager, and that is not a comfortable place to be with literally billions of dollars and millions of seniors and the vulnerable hanging in the balance.

PBMs need to awaken to the new reality of the primacy of government programs today, and make a serious commitment to catching up.

Resources

If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>

The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult -- to say nothing of actually managing to them. Contact us today to learn how we can help >>

by GHG Advisors