CMS Timeliness Monitoring Underway
The Centers for Medicare & Medicaid Services (CMS) timeliness monitoring is currently underway at organizations with active contracts in 2017 and 2018, with a few exclusions, such as Medicare-Medicaid Plans and organizations that underwent a program audit in 2017 and did not have any invalid data submissions in key audit areas. Is your organization excluded? See the Health Plan Management System memo dated December 12, 2017. If I had a nickel for every time someone referred to this activity as a timeliness audit, I’d have quite a pile of nickels. While it is not an audit, it sure feels like one as the validation activity is the same.
The first of three waves of letters is being issued this month. After upload, a data review will be conducted and a validation webinar scheduled. Once complete, timeliness rates will be calculated. To make sure this is an efficient process, here are some ways we have recently assisted clients:
- Coach and guide delegates in the timeliness monitoring requirements
- Evaluate universes for adherence to instructions
- Review both timely and untimely case samples for data accuracy
- Review systems to validate accurate population of fields
Data integrity continues to be a priority not only for informing Star Ratings and Independent Review Entity data accuracy but also for required Part C and Part D reporting and for the compliant operations of plan administration. Universe preparation steps are not one size fits all, as the methodologies for a small plan delegating very few activities and the steps a larger, more delegated model plan takes will vary. Not surprisingly, during the course of our review, our team often finds potential issues or concerns unrelated to timeliness. This gives our client partners the opportunity to conduct a deeper review to address and mitigate.
We currently provide guidance, suggestions, and best practices for universe development to address quality and identify potential risks. If your organization is not getting these data universes correct, you should ask yourself, what other reports might be flawed? Dashboard metrics? Board reporting? Identify and correct these issues before CMS and their contractors find them for you.
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
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Second NOIA Deadline Approaching
Applicants looking to enter Medicare Advantage, Part D, or the Medicare-Medicaid Plan space have two deadlines to submit a Notice of Intent to Apply, commonly referred to as a “NOIA,” for contract year 2019: November 13, 2017, and January 26, 2018. The first submission allows the Centers for Medicare & Medicaid Services (CMS) team to gauge what resources might be needed during this critical time of year. The second date is provided to allow potential suitors to review the final 2019 application requirements, which should be released here, here, and here around January 9, and then make a decision.
CMS initiated the NOIA process in 2007 for the 2009 application season and have always noted the NOIA submissions should be completed by the due dates, stating those that miss the date might experience delays in being assigned a contract number. Six years ago, CMS implemented a second NOIA submission date into their application activity timeline, noting they would continue to process NOIAs through the second date.
Remember, the NOIA is non-binding. Based on Gorman Health Group experience, CMS would prefer you make any decisions not to pursue the application as early as possible. The deeper you get into the process, the more taxing it is on the agency, on actuaries, and on your resources.
NOIA Links
- New/Initial Medicare Advantage or Part D Plans, click here
- Medicare Advantage or Part D Service Area Expansions, including adding a Special Needs Plan, click here
- New/Initial Medicare-Medicaid Plans, click here
- Medicare-Medicaid Plan Service Area Expansions, click here
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Provider Network Management New Year’s Resolutions for 2018
Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate these three key items into your Provider Network Management Department’s performance appraisal goals.
Dust off the antiquated access and availability policy and procedure and take the opportunity to develop an organic network monitoring program that fosters growth, collaboration, and partnerships with your providers. By the Centers for Medicare & Medicaid Services (CMS) moving network reviews from an application process to a plan operational requirement, plans will be subjected to stronger compliance actions. The short time frame in which a plan will have to submit their compliant Health Service Delivery (HSD) tables to CMS leaves no time for mitigation of network deficiencies. Plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS. In addition, while we have the policy down off the shelf, why not take the opportunity to break down the silos and see how that policy is working for Medical Management, Member Services, and your Star Ratings work plan.
Plans have been making strides in shifting their networks towards value-based contracting, incorporating quality metrics, Star Ratings, and a variety of population health initiatives. However, a significant portion of Medicare Advantage (MA) remains based on traditional fee-for-service (FFS) reimbursement. As we evaluate the impact Medicare Access and CHIP Reauthorization Act (MACRA) will have on MA provider contracting starting 1/1/19, the traditional reimbursement statement current MA contracts typically use, “Provider will be reimbursed according to X% of the Medicare Fee Schedule,” becomes an old stand-by with potentially serious consequences. At a minimum, plans need to clarify the change MACRA will bring to the definition of “Medicare Fee Schedule” in their existing provider agreements and carefully evaluate how it aligns with any penalties/bonuses that can occur under both Advanced Alternative Payment Models (APMs) and Merit-based Incentive Payment System (MIPS).
As much as I would like to say there have been significant improvements in data integrity, inaccurate provider data continues to plague health plans and has far-reaching tentacles into health plan operations as a whole. We saw plans have quick success in updating provider directories only to fail at building sustainable processes with checks and balances and end up only slightly better than the first effort.
Please reach out to Gorman Health Group for assistance in developing a network management strategy to include the key items above.
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Three Considerations For Those Entering Medicare Advantage
Every few months the industry hears news of new players getting into the Medicare Advantage (MA) game. And why not? According to the Kaiser Family Foundation, more than 19 million Medicare beneficiaries are enrolled in MA plans this year. Either someone is building from the ground up or purchasing an existing structure, such as CVS Health Corporation’s recent agreement to acquire Aetna. I don’t expect this will be the last pharmacy benefit manager to look for an insurer partner with the promise of being able to lower healthcare costs. While analysts argue over the benefits and concerns, one thing is for certain: you need experienced administrators at the helm. I borrow from the late Mitch Hedberg who summarized just because you can do something really well in one field doesn’t make you an expert in everything:
Whether you are building from scratch or partnering with an established entity, you might be adept at one thing but not necessarily everything related to it, nor should you be. In Hedbergian spirit, I’ve outlined three pieces of advice for those entering this arena.
- If preparing for the Part C and Part D Application process, the clock is ticking. Make sure the right people are in place to implement this product. If the application submission is the wedding day, the implementation and execution are the marriage. What vendors are being considered vs. what will be built in-house?
- For those undergoing mergers, I speak from experience about its arduous process. Integration activities do not happen overnight, nor should they, but it is possible the drivers of success may get derailed during integration. Thoughtful engagement of the right people with the experience and skillset in the delivery of this product is imperative to make sure successful practices are not lost.
- Focus on what needs to be done in order to be successful, but first, make sure everyone agrees on the definition of success. Is it fiscal success for long-term viability? Is it the establishment of a sustainable product set with steady membership growth? Are Star Ratings and other quality measures part of the equation? We always hear about top-down communication strategy, but for those responsible for implementation, lateral communication is essential. Ensure everyone understands the organization’s priorities, and remove silos that impede progress.
- Know your members well. What does the market look like? What are their health and cultural needs? What are the product, benefit, and premium trends in the area? If you are submitting an application, you have likely already gone through these studies as outlined recently by my colleague Diane Hollie in a recent article on expansion strategy.
You do not want to set up your organization or team to fail – no one sets out that way. Before you apply for the first time, expand, or acquire an existing plan, establish the right team, be on the same page, and understand your market. If you need assistance, please contact me directly at rpennypacker@ghgadvisors.com.
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Pressure Test your 2019 Expansion Strategy in 3 Steps
Do it now! Get your benefit strawman, enrollment projections, and financial goals developed before benefit season begins!
Step 1: Market Analysis – Hopefully you have already performed this step before you submitted the Notice of Intent to Apply (NOIA), but if not, it’s not too late. A market analysis typically includes the following:
- Penetration analysis
- Enrollment trends and market share
- Product trends and growth patterns
- Competitive analysis
- Premium and benefit trends
- Demographic analysis
Now that the 2018 benefits have been released, it is time to relook at the product, benefit, and premium trends through a market analysis to see what has changed so you are fully prepared for the beginning of benefit season in February 2018. The Gorman Health Group (GHG) Marketing team was just evaluating a new product for a client and discovered their competitors added three new plans for 2018. This changes how you look at the market. It is important to understand how your clients changed their product and plan portfolio for 2018 and then look at the 2018 Annual Election Period (AEP) results in February to solidify your market analysis, but you will want to start building your strawman of benefits and premiums now.
Step 2: Market and Enrollment Opportunity – Understanding your market opportunity is critical, and too many times a Medicare Advantage (MA) plan develops enrollment projections on the back of an envelope or in a board meeting instead of looking at the market and understanding the “real” market opportunity. Understanding the market potential and then looking at how much of the market you will be able to gain is a much better way to estimate your enrollment projections.
Our Product team recently worked with a client who was trying to determine why there was such a variance between their current sales results and enrollment projections. During GHG’s review of the client’s enrollment projection methodology, GHG identified certain demographic and market considerations were not included despite being taken into consideration when developing their marketing and sales strategies.
“These exclusions [demographic and market] are common,” says Nilsa Rudisill, Vice President, Sales, Marketing & Strategy, “and even more so is disconnect between company enrollment projections and sales and marketing strategies.”
Step 3: Financial Feasibility Study – The next step is to pressure test your hypothesis with a financial feasibility study. Although a feasibility study is not an actuarial study, it does test whether a hypothetical benefit design could work in a target market based on revenue and cost characteristics of that market. It also takes into account assumptions about the Centers for Medicare & Medicaid Services (CMS) payment trends, enrollment, premium and costs, and projected enrollment over a period of five years.
GHG’s Finance, Marketing, Sales and Product teams work very closely together to customize the assumptions that impact this study for our clients based on level of comfort, capabilities, and growth opportunity, even if it means the overall opportunity does not look promising in the end. For example, this study was performed for a client who was interested in offering a Special Needs Plan statewide. Although the financials appeared sound, we looked beyond the numbers to tell the client “what it really” takes to launch a successful product in their particular market by providing multiple financial scenarios, including a scenario that appeared less profitable in the short term but actually more manageable as a company new to MA.
This process allows you to make smart, informed decisions about your current or potential market without all the investment upfront. This type of process is not a one and done! It tends to be a very iterative process to understand how to dial the levers in the market to see if and when you can expect profitable growth. So take the time now to get it done right, or spend the money later by guessing incorrectly.
Resources:
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Benefit Administration Testing – From a Compliance, Audit, and Best Practice Perspective
In 2016, 41 million individuals (72 percent of all Medicare beneficiaries) were enrolled in Medicare Part D. Of those enrolled, 60 percent were in stand-alone Prescription Drug Plans (PDPs), and 40 percent were in Medicare Advantage Prescription Drug plans (MA-PDs). Plan sponsors must adjudicate pharmacy claims for the Part D benefit in accordance with their Centers for Medicare & Medicaid Services (CMS)-approved formulary and Plan Benefit Package (PBP) bids.
Most Part D sponsors delegate prescription claim adjudication to their Pharmacy Benefit Manager (PBM). Formulary and benefit coding performed by a plan sponsor’s PBM is a compliance risk area. Sponsor oversight and auditing of their PBM’s claim processing systems include key formulary administration and transition processes for new and current enrollees that are consistent with 42 CFR §423.120(b)(3).
Benefit Administration Testing on a yearly basis allows for prompt identification and correction of formulary and benefit coding errors prior to go-live. Early detection and correction of areas of non-compliant Part D claim adjudication ensures accurate benefit set-up, minimizes member disruption and access to care issues, and is paramount for a compliant Part D formulary and compliant benefits administration.
A comprehensive Benefit Administration Testing review requires a strategic and systematic process to ensure accurate adjudication of the CMS-approved formulary and PBP. This includes testing for accuracy of all covered drug copayments, tiering, and Utilization Management (UM) and confirming pharmacy claim processing is in compliance with CMS guidance as stipulated in 42 CFR Parts 422 and 423, including guidance located in the Medicare Managed Care Manual, Prescription Drug Benefit Manual, and CMS Program Audit Findings and Best Practices Memos.
Gorman Health Group's (GHG’s) Benefit Administration Testing service provides MA and Part D sponsors with an assessment from not only a compliance, audit, and best practice perspective but also an indication of how the organization would likely perform in an actual CMS audit.
The GHG comprehensive Benefit Administration Testing review includes:
- Test suite that validates a broad sample of claim types for copayment, pharmacy network, True Out-of-Pocket (TrOOP)/Maximum Out-of-Pocket (MOOP) accumulator, lesser of logic, formulary and non-formulary, excluded drugs, etc.
- Strategic custom scenarios for each formulary and plan design variation and includes point of sale National Council for Prescription Drug Programs (NCPDP) and custom messaging review.
- UM edits for Prior Authorization (PA), Quantity Limit (QL), Step Therapy (ST), and grandfathering.
- A special focus on protected class drugs, transition of care, and look-back logic.
- Concurrent drug utilization review (cDUR) logic per CMS recommendations for the following, but not limited to, criteria: therapeutic duplication, age/gender-related contraindications, over-utilization and under-utilization (e.g., early refill), drug-drug interactions, incorrect drug dosage, or duration of drug therapy and drug-allergy contraindications.
Common coding errors identified and corrected include:
- Coding of QLs resulting in inappropriate rejections:
- Maximum daily dose limits that were more restrictive than the CMS-approved QLs and/or Food and Drug Administration (FDA) maximum recommended daily doses.
- Quantity over time coding that failed to consider unbreakable packaging.
- Applying a CMS-approved QL specific to brand drugs only to generic versions of the drugs.
- Coding errors for transition logic resulting in inappropriate claim rejections for new and continuing beneficiaries transition supplies:
- Applying PA edits on claims for continuing beneficiaries with a utilization history of protected class drugs.
- Failure to afford long-term care beneficiaries multiple transition fills as necessary during the entire length of the transition period.
- Failure to correctly identify drugs with a negative cross-year formulary change.
- Imposing UM edits that are not appropriate during transition (e.g., edits are not related to Part A or B vs. Part D determination, FDA maximum daily dose, early refill, etc.).
- Benefit was coded to reject transition-eligible claims for drugs in their smallest available unbreakable package size when the calculated days’ supply exceeded the transition days’ supply limits.
GHG additional offerings include:
- Marketing Materials Review
- Post Go-Live Claims Review
Now is the time to lock in your Benefit Administration Testing project for go-live January 1, 2018. GHG’s Pharmacy experts can create and conduct a thorough and strategic Benefit Administration Testing plan for your organization to ensure your PBM is processing claims consistent with your CMS-approved prescription drug benefit before the new plan year begins as well as on an ongoing basis throughout the year through post go-live claim reviews.
Resources:
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
The 2019 Application - Key Dates
As a follow up to my last article on the Notice of Intent to Apply, I give you an enhanced chart of 2019 application activities outlining things you should have been doing or should be in the middle of now. Thanks to the Centers for Medicare & Medicaid Services (CMS) for creating a base, published recently via memo – my colorful additions peppered throughout for your perusal. If past activities have not been done yet, it is time to get a move on, or you risk missing the deadline.
| Calendar Year 2019 Application Activity | Date |
|---|---|
| Determine the feasibility of applying for a new plan or expanding an existing plan; identify vendor partners to contract with who will support administrative or health services, begin contracting process or review existing contracts to ensure application requirements will be met | Ongoing process |
| Review past finalized application guidance, determine licensure needs, contact pertinent state(s) to establish their needs and timeline | June 1, 2017 |
| Review the 60-day release outlining the proposed changes to the 2019 applications | August 1, 2017 |
| Tell Provider Contracting not to rest on their laurels | August 2, 2017 |
| Comments due on the 60-day release of the applications | October 2, 2017 |
| Read CMS’ Notice of Intent to Apply (NOIA) memo dated October 13, realize there are 36 calendar days between the release of the final application and submission, suppress panic | October 13, 2017 |
| Read this chart, and if anything is making you twitch, let me know | October 16. 2017 |
| Create a draft project plan, assigning specific tasks to your application project team; establish an earlier submission date; field angry emails from the team but hold firm; obtain the team’s vacation schedules now through submission date, establish back-ups | October 30, 2017 |
| Review the 30-day release of the draft 2019 applications (approximate time) | November 10, 2017 |
| NOIA deadline to ensure access to the CMS Health Plan Management System (HPMS) | November 13, 2017 |
| New applicants should download the CMS User ID connectivity form (aka CMS Access Request Form) and distribute to the application submission team and C-suite team members who will need to complete attestations. Provide specific instructions on filling out the application, or don’t, if you like a lot of re-work. Ensure back-ups. Send originals via traceable carrier to CMS. | November 15, 2017 |
| CMS sends NOIA confirmation e-mails to entities meeting the November 13 NOIA deadline to ensure timely HPMS access | November 30, 2017 |
| CMS User ID connectivity form submissions must be received by this date to ensure user access to HPMS by January 9, 2018 | December 1, 2017 |
| Try to enjoy the holidays, because that application work is coming | January 1, 2018 |
| Calendar Year 2019 Medicare Advantage (MA), Part D, and Medicare-Medicaid Plan (MMP) applications posted on CMS website | January 9, 2018 |
| Finalize project plan based on the final guidance, adding any new tasks and team members required; register for CMS user calls; re-communicate internally established submission date | January 9, 2018 |
| Final day to submit NOIA for 2019 | January 26, 2018 |
| If you believe stragglers will cause you to be working up to CMS’ deadline, order flowers for your significant other so Valentine’s Day isn’t completely ruined | February 12, 2018 |
| CY 2019 MA, Part D, and MMP applications submission deadline | February 14, 2018 |
Resources:
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Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Notice of Intent to Apply
The Centers for Medicare & Medicaid Services (CMS) Annual Call Letter calendar marks November 13, 2017, as the first due date for the Notice of Intent to Apply. It is expected the Center for Medicare will release a reminder memo this month outlining the details. In general, the agency requires a Notice of Intent to Apply to be submitted when an organization plans on submitting a request for any of the following:
- Offering a new product type (such as a Medicare Advantage Prescription Drug plan or Prescription Drug Plan)
- Transitioning an existing non- or partial network Private Fee-for-Service (PFFS) to a full network PFFS
- Expanding the service area of an existing contract
- Expanding only an employer-only service area
- Adding prescription drug benefits to an existing contract for the first time
- Adding Employer Group Waiver Plan (EGWP) market to an existing individual-only service area for the first time
- Adding individual market to an existing EGWP-only service area for the first time
- Adding or expanding the service area of a Special Needs Plan
- Expanding the service area of an existing Medicare-Medicaid Plan
While organizations will have another opportunity once the final application guidance is released in January, for the most part, those who have properly planned are generally certain by November if they intend to pursue this initiative. Feasibility discussions have occurred to help leadership make that “go/no-go” decision. “Along with feasibility discussions, network analysis to determine adequacy and potential gaps is a critical component to consider as you decide on submitting your Notice of Intent to Apply,” states a colleague on the Operational Performance team. “Those steps will help set up the plan to move forward with their application filing.”
Turning to the application, interested parties have certainly already gone through the draft Part C and Part D applications with a fine-tooth comb to determine what’s new for the coming submission and what isn’t needed. If you haven’t reviewed the documents by now, what’s changed may surprise you.
The Notice of Intent to Apply is due in about a month. If you’ve conducted a feasibility study but are still unsure of what to do, don’t be alarmed. (Well, ok, be a little alarmed, but take a step in the right direction and contact us.) Then, once you have made the decision to pursue an application, ask us for assistance. Gorman Health Group has a proven track record of successful application assistance and support. Going in with a clear understanding of the process and expectations helps you put your organization’s best foot forward in the pursuit of this new endeavor.
Resources:
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>