Medicare Sales in the Age of COVID-19

There’s no doubt about it: COVID-19 will change the way we sell Medicare products.

In previous years, health plans relied on agents for seminars, town halls and “kitchen table” sales. This year, plans cannot depend on face-to-face interactions with Medicare beneficiaries to be successful in the upcoming Annual Enrollment Period (AEP). Medicare beneficiaries are one of the most vulnerable groups for this virus. Meeting with people one-on-one and/or in larger groups is unsafe in this environment.

Plans will need to adjust and get creative in order to make sales goals this year.

Over the last few months, GHG has been working with several health plans on pivoting strategies to navigate the new norms of COVID-19 and a Presidential election year upon us. Here are some tips to consider.


This year, Medicare sales will be defined by those who enable an effective virtual selling environment. Health plans should be in close contact with top brokers, helping to build tools to be utilized during new-to-Medicare/Initial Enrollment Period (IEP), Special Enrollment Period (SEP) and AEP. Most, if not all, one-to-one discussions and seminars will be conducted online; having access to audio and/or video conferencing tools will be critical. This also includes an online enrollment tool for agents/brokers, so if your plan does not currently offer it, now is the time to get one! Agents/brokers will want to walk prospects through the online enrollment process over the phone or via video conference (e.g., Zoom).

In addition, having the right tools is one aspect, but this type of selling is different from the usual one-to-one, in-person discussion. Even if you enable video for both parties, it’s difficult to read and understand body language during a conference call. Agents will need to adapt selling styles to take this into consideration.

Still, the path back to “normal” is unknown. Even when social distancing restrictions and stay-at-home orders are lifted, it’s questionable when “the most vulnerable” for COVID-19 risk will feel comfortable again. Plans will need to hold agents/brokers accountable for the health of prospects when entering homes, as well as how to safely approach a “kitchen table” sales environment—clean hands, disinfecting wipes, masks, etc.

This means that call centers will be very important for the future of sales.

Call Centers

Many plans utilize call centers as a way to answer questions and move prospects to the next step, such as fulfilling information requests or sending to an agent/broker. It may be time to rethink that strategy. Considering the impacts of COVID-19, plus Presidential election season, telesales will play a much bigger role in hitting sales targets for 2021.

GHG recommends using licensed agents who can sell over the phone and have the opportunity to set up an online conference call to take the prospect through the process, if that’s needed to close the sale. Having trained several internal call centers, we’ve found that many don’t know how to sell or close a sales opportunity. We cannot stress enough the importance of having a thoughtful call center strategy this year (and don’t wait until AEP to test new approaches—start with your new-to-Medicare program). Selling approaches and monitoring will be key to success.

Online Sales

Online sales have been increasing over the last several years, and COVID-19 will undoubtedly precipitate moving this to the next level. New-to-Medicare beneficiaries especially are gravitating towards digital platforms, and online/social media channels are now a viable and profitable form of advertising for most Medicare plans.

Plans today need a solid online presence that serves as a “real” sales channel, not just a website with CMS information and an online enrollment process. When a prospect visits your website, can they easily travel through a well-organized sales process? Is your market differential front and center? The sales experience should be easy and user-friendly for prospective members, with access to customer service via phone or chat to get answers to their questions quickly.

What's Next?

The next few months are certainly going to be interesting. Given the unpredictability of the current environment, be sure to cover your bases now to be prepared for this AEP—including establishing a backup plan if needed. With COVID-19 and the Presidential election, AEP will be a difficult endeavor, but plans can utilize the OEP, agents/brokers and new-to-Medicare advertising to drive sales during AEP.

GHG is available to answer any questions you have and help evolve sales strategies for this unprecedented environment. Contact us to start the conversation.

New Benefits & Special Enrollment Period (SEP) During a National Emergency

Since President Trump declared COVID-19 a national emergency in all 50 states and the District of Columbia, a Special Enrollment Period (SEP) for Medicare beneficiaries is allowed. The SEP runs from March 1st to June 30th.

What is a Special Enrollment Period?

The SEP exists for Medicare beneficiaries who were unable to make an election during the Open Enrollment Period (OEP), including both enrollment and disenrollment decisions. If an enrollee did make an election decision during OEP, they are not eligible for the SEP.

SEPs present a unique opportunity for Medicare Advantage (MA) plans to capture new enrollees. However, this effort may be best left to the sales team. The number of Medicare beneficiaries taking part in this new SEP is most likely lower than the OEP, so it would be difficult to achieve a high return on any new marketing investment.

New Benefits During a National Emergency

In addition to the SEP, MA plans may offer additional benefits during a federal or public health emergency. There are a variety of benefits that can be offered, but they must be offered uniformly to all plan members. Here are a few examples:

  • Introduce an OTC benefit or increase an existing OTC benefit allowance. (Must be health related, unless part of Supplemental Benefits for Chronically Ill Enrollees [SSBCI].)
  • Waive the plan premium
  • Offer new mandatory supplemental benefits, such as meals or transportation
  • Provide a cell phone and/or tablet. (Again, this must be for health-related services only, unless part of SSBCI and there is a reasonable expectation of improving or managing the health or overall function of the chronically ill member.)
  • Decrease and/or eliminate copays/coinsurance of any benefits

What Should Medicare Advantage Plans Do?

With the current COVID-19 environment, the upcoming deadline for bid submissions, constant communications with members, and navigating the new normal for AEP, it may be difficult for MA plans to consider a change at this time. However, introducing new benefits during this unprecedented time demonstrates your plan is committed to going above and beyond for its members. Just remember—if you decide to make changes and believe they are worthwhile, advertise them! You’re in an SEP, after all.

If you need help navigating this SEP or anything related to marketing through COVID-19 and a Presidential election year, contact us to start the conversation.

AEP Marketing During COVID-19 ...AND a Presidential Election

Developing a marketing strategy during a Presidential election year is difficult enough. But adding in the current, and eventually, post-COVID-19 environment, which is unprecedented, makes it even more challenging.

As we mentioned in a recent webinar, Medicare Advantage (MA) plans will need to “think outside of the box” when developing and executing a go-to-market strategy for the 2021 Annual Enrollment Period (AEP). Making slight modifications to last year’s plan will not cut it in this “new” environment.

The Medicare Advantage 2021 AEP Will Be Here Before We Know It

Now is the time to dissect your marketing and sales channels; waiting any longer will put you at a disadvantage. Below are a few ideas to consider when rethinking a 2021 go-to-market strategy.

Branding and Creative

Hopefully, you have already been communicating to members and the community about COVID-19 and how to stay safe. Those visuals and brand components, as well as the tone, should extend into AEP communications, especially for localized plans. The messaging should focus on ensuring both prospects and members know you were there for them during COVID-19 and will continue to be there every step into the future. Fear of change is difficult for this population, and particularly for the switcher market, plans must alleviate that feeling of fear through messaging.

Marketing Channels

Advertising during an election year is challenging. The tried-and-true tactics aren’t viable; everything else is more expensive than normal; and it’s even more difficult to capture beneficiary attention. What can MA plans do?

  • TV: Purchasing TV spots is typically a nightmare. When developing your media plan, take into account other ways you may want to utilize TV commercials. Incorporating them into social media, landing pages or websites warrants consideration.
  • Social Media: For the last several years, we have seen plans implement strong, cost effective social media campaigns. This AEP is the perfect opportunity allocate more marketing spend to social media. Recent survey results from Deft Research indicate a continued increase in the effectiveness of online media and websites for growing enrollment. Test different social media and digital channels to find the best strategies to capture Medicare beneficiaries shopping online.
  • Direct Mail: Medicare beneficiaries receive a lot of mail during election season. Postcards may get lost in the clutter. Instead, try direct mail “kits” that are designed and written to stand out. Timing and targeted are also critical. Front-loading your marketing with a strong finish will help you during the heat of the election. Also, developing strong direct mail response models is important for this AEP. This is the perfect opportunity to send more direct mail, but only mail to those who are most likely to respond and cut out the least responsive segments.

Backup Plan

We are in uncharted territory with this pandemic, and no one has a crystal ball to understand how, or if, the market will respond this year. That’s why we recommend having a backup plan. If TV is a non-starter, what will take its place? If results are not what you need them to be, is there an opportunity to send one more direct mail campaign? Is it worthwhile to invest more in social media? Are newspaper ads, Free Standing Inserts (FSIs) or radio ads ways to help increase overall marketing results? Having alternate or additional materials ready, if needed, could be the difference between exceeding lead and sales goals, and falling short.


This AEP, it will be critical for enrolled beneficiaries to feel comfortable about their decision—both during the sales process and long after. Plans must have a strong onboarding process to prevent buyer’s remorse, including materials that clearly explain what to expect during the enrollment process, as well as multiple communications touch points (e.g., delivery of their ID card). Capturing communication preferences early and honoring those decisions sets the tone for the entire member experience. Also, set up multiple ways to communicate benefits, such as virtual town halls and phone calls, to ensure members get acclimated to your plan.


Marketing/advertising strategy is one focus area that plans need to assess and rethink in the context of the COVID-19 pandemic and an election year. There are also sales channels. How will your sales strategies and goals need to change for the upcoming AEP? Stay tuned for additional recommendations on the GHG blog over the next few months!

If you have any questions or need assistance with your AEP marketing strategy, contact Diane Hollie.

Strategies to Support Value-Based Reimbursement During Uncertain Times

As we are all experiencing a new normal in our personal and professional lives during the COVID-19 pandemic, the ability to keep up with the ever-changing clinical and regulatory environment in healthcare has made even the most seasoned healthcare executive feel as if they were swimming against the current.

Providers and Accountable Care Organizations (ACOs) engaged in risk-bearing contracts with CMS and other private payers have rightly expressed significant concern over the ability to accurately predict and have an impact on potential shared savings and losses. A recent National Association of ACOs (NAACOS) survey indicated over 56% of ACOs would consider exiting the program if CMS did not offer amenable solutions to protect against downside losses.

What Can Risk-Bearing Providers and ACOs Do?

As we saw last week, CMS is adjusting the financial methodology, in order to support keeping ACOs in the program. The ability to pivot and deploy resources to manage membership, as well as be proactive and adaptable in your overall strategic plan, is critical for any ACO or provider group taking risk. A key to supporting value-based financial goals is quickly activating strategies to engage members and continue to drive and deliver on clinical goals.

Providers and ACOs should consider:

  • Developing member registries or lists to assist in prioritizing outreach to members according to need. Work with health plan partners to tag team on those members falling into a coronavirus high-risk category, engage members with chronic care needs to ensure monitoring for potential crisis indicators, or in areas that are not as hard hit by the virus, target members for proactive preventative health screenings that can be done via remote patient monitoring.
  • Utilize non-traditional personnel to support outreach strategies. We understand it has been difficult to keep staffing levels at full capacity. Engage underutilized staff to support outreach efforts by developing simple decision trees they can follow with an escalation plan should they come upon a member needing urgent clinical support.
  • CMS has offered latitude in its guidance around telehealth. If your office has not yet offered telehealth services to members, this might prove to be the perfect opportunity to explore how telehealth solutions and remote patient monitoring could enhance your practice in the transition from volume to value. More people are looking beyond the standard urgent care visit to have greater flexibility in receiving care, especially follow up visits, remotely.
  • As you and your team work through the member registries, it affords the perfect opportunity to look at patients through a social determinants of health (SDOH) lens and develop strategies for areas such as medication access and food security, which are putting them at risk for failing to execute on a care plan. When you are at risk for the total cost of care of your patient panel, enabling the member to be as successful as possible by including community services in their plan of care can be a critical element of improving health.
  • The pandemic has opened conversations on mental health issues to a broader audience. Identifying and addressing potential mental health issues as part of the outreach process is an important proactive measure for the overall health of your patients.


GHG has the depth of experience from working with numerous health plans and providers to assist you in focusing on and developing strategies, such as those discussed above, that will keep your practice or ACO ahead of the fast-paced regulatory landscape. It is critical to be adaptable to challenges with patient care, as well as on the lookout for potential financial opportunities, such as risk adjustment and payor contract analysis, to assist in mitigating losses.

Please reach out to Ellie Martin to further discuss how our team can support your ACO or practice during this complex and challenging time.

Dramatic Changes to the Telehealth Benefit Due to COVID-19

Over the last week, the Centers for Medicare and Medicaid Services (CMS) has released several documents providing guidance and relief to healthcare organizations amidst the COVID-19 pandemic. First, CMS broadened access and greatly relaxed regulations around telehealth services for Medicare beneficiaries. Through this expansion, Medicare can temporarily pay providers for telehealth visits for Medicare beneficiaries across the entire country.

Shortly after this announcement, CMS released two telehealth toolkits to help healthcare organizations navigate the expanded benefit: the General Provider Telehealth Tool Kit and the End Stage Renal Disease (ESRD) Provider Telehealth Tool Kit. According to CMS, “each toolkit contains electronic links to reliable sources of information on telehealth and telemedicine, which will reduce the amount of time providers spend searching for answers and increase their time with patients. Many of these links will help providers learn about the general concept of telehealth, choose telemedicine vendors, initiate a telemedicine program, monitor patients remotely, and develop documentation tools. Additionally, the information contained within each toolkit will also outline temporary virtual services that could be used to treat patients during this specific period of time.”

What Does Expanded Telehealth
Benefits Mean for Medicare Advantage Plans?

With the government and CMS directing
healthcare providers to deliver only essential and emergency care to patients,
those looking for non-essential services are suddenly unable to access the care
they need.

With the expansion of telemedicine, Medicare
beneficiaries are now able to receive various services through telehealth,
including common office visits, mental health counseling, and preventive health

Since Medicare beneficiaries are at a higher risk for COVID-19 (i.e., coronavirus disease), telehealth allows them to visit their doctor from the comfort of their home, instead of going to a doctor’s office or hospital and putting themselves or someone else at risk. Patients will now be able to visit with providers using a wider range of communication tools, including telephones that have audio and video capabilities, making it easier for beneficiaries and doctors to connect without a face-to-face encounter.

This change also broadens telehealth flexibility without regard to the diagnosis of the beneficiary or the coverage they have. The expansion is effective for all Medicare beneficiaries, not just those with Medicare Advantage (MA) that may already have a telehealth benefit within their plan. It is available to all Medicare beneficiaries whether they have no coverage in addition to Medicare, a Prescription Drug plan, a Medicare Supplement plan, or an MA plan. Note that CMS has requested that MA plans communicate the specific policies and procedures on how to manage the flexibilities with relaxed telehealth regulations to both members and providers.

What Does Expanded Telehealth
Benefits Mean for Providers?

Beyond the benefit to members, an
increased emphasis on telehealth for non-essential visits will reduce the
strain on the healthcare system overall, ensuring that doctor offices, urgent
care centers, and Emergency Departments are available to treat the most urgent
cases while reducing the risk of healthy beneficiaries contracting coronavirus
disease by unnecessarily visiting a healthcare facility in person.

The expansion of the telehealth benefit
will allow providers the opportunity to see more Medicare patients for non-essential—but
still important—services, such as diabetes control, a patient not feeling well
and is not sure what to do, prescription refill, and depression or anxiety
brought on by isolation.


Although telehealth has many benefits,
it is not without its complications. Providers were generally not prepared for
the onboarding of a telehealth platform, the expense, the change to the
structure of current practice operations, and the rapid timeline in which telehealth
needs to be implement in order to effectively manage the most vulnerable
members. Many of the specifics will require providers to quickly adapt (e.g., the
requirement that telehealth calls be initiated by the Medicare patient; the different
CPT and HCPCS codes).

As we look to the future beyond current COVID-19 flexibilities, in a recent proposed rule, CMS has also included the ability for plans to use telehealth services for certain specialties in order to expand their footprint into counties where they may not otherwise have been able to meet the network adequacy requirements. The success plans demonstrate in their ability to effectively care for and manage members remotely during this crisis may further support the expansion of relaxed adequacy requirements beyond those in the current proposed rule.

If you still have questions on how to navigate the expanded telehealth benefit, consider attending our upcoming virtual open forum on Thursday, March 26th, where the healthcare experts at GHG and analytics leaders at Pareto Intelligence will answer all of your specific questions across a variety of topics, including Marketing, Star Ratings, Risk Adjustment, Compliance, Network Adequacy and Development, Telehealth and Analytics.

In Light of COVID-19, Overcommunication is Necessary

Since COVID-19, otherwise known as coronavirus disease, surfaced in China at the end of last year, consumers have been bombarded with media coverage and corporate communications about the spread of the pandemic, the necessary precautions, the state of the global economy, and changes to operations, most of which has been less than positive.

In particular throughout this news cycle, the various health organizations, such as the Centers of Disease Control and Prevention (CDC) and World Health Organization (WHO), have continued to emphasize that older adults and people with preexisting conditions are at a higher risk for serious COVID-19 illness. Many of those people have Medicare.

Because of this, Medicare beneficiaries are understandably confused and scared. There is an unfortunate amount of false information being distributed, and every news organization has their “spin” on the coronavirus disease. How do they know what is real? Where can they go for reliable and accurate information? This uncertainty is compounded by being stuck in isolation, which can lead to or worsen depression. Medicare beneficiaries are extremely vulnerable right now, and they need a voice of reason, a source of truthful and factual information to calm their fears. As a health plan, you can be that voice.

What should be communicated to members?

Health plans have access to a wealth of knowledge about COVID-19 that can and should be shared with beneficiaries. If you haven’t already, you can be helping members understand:

  • What is coronavirus disease and the seriousness of the virus to the Medicare population 
  • The symptoms of the coronavirus
  • What to do if the beneficiary believes they have the virus
  • What actions to take to prevent the beneficiary from contracting the virus
  • How to stay healthy both physically and mentally
  • Any changes in benefits during this time, such as:
    • Telehealth Benefit: What is it and what can it be used for? Who should the beneficiary call for a telehealth visit? Are there copays when using the telehealth benefit?
    • Prescription Drug Benefits: Are there any changes to copays or refill amounts?
    • Access: What happens if someone is not at home and needs to see a doctor?

How should a health plan communicate to members?  

As important as the content of your message is, the method by which you deliver it is also important. Members need this critical information to exist in a place where they can easily access and understand it. Some suggestions include:

  • Your Website: Dedicate a section of your website/member website and/or build a landing page to address all of the communications topics listed above. Continue to fill those pages with daily content to update members. (For example, an FAQ section or Q&A from your medical director would be very meaningful.) This will help you become the source of truth.
  • Mail: Send a letter to all members explaining the expanded benefits granted by CMS, including any changes to current benefits for members, and then direct them to your website/landing page for the most up-to-date information.
  • Nurse Line: If not already done, consider adding plan-specific scripting for potential member questions. This can include the availability of after-hours support, the potential risks for contracting the virus, what members should do if they have a fever, where members can go for testing or if symptomatic, and prescription drug access.
  • Email: Email helps you communicate quickly and efficiently. Members should receive updates at least weekly during this time to reinforce that you are there for them, reiterate benefit changes, and share other critical updates. Always direct them to your website/landing page for the most up-to-date information.
  • Social Media: Facebook should be updated frequently with helpful lifestyle tips, such as how to get food delivered, senior hours at stores, and other information that might be beneficial. Use your most effective social media platforms to educate your members and nonmembers about the virus, as well as the expanded telehealth benefits available. Direct them to your website/landing page for the most up-to-date information.
  • Health Plan App: Use this as an additional channel for the latest facts and information, and direct members to your website/landing page for the most up-to-date information.
  • SEO: Optimize your website/landing page for search in order to bring members and nonmembers to your site. It’s important for truthful and factual information to be at the top of search results to drown out false claims and “spin.” Plus, you might also pick up a couple new members during the process!
  • Customer Service: Give your representatives the tools they need to be successful. They will be getting many calls and should have strong communication guidance to deal with the multitude of member questions. Consider a special task force of customer service members/clinical providers to be available to answer members’ complicated questions.
  • Public Relations: Seek out interview opportunities on the radio, TV and in print to help disseminate truthful and factual information to members and nonmembers alike.
  • Webinar: For a more creative approach, a webinar on coronavirus disease and how your health plan is working to support members allows you to get as close as possible to a “face-to-face” interaction while members are quarantined and staying in their homes.
  • Care Management: Conduct additional outreach to members who are the most vulnerable due to multiple comorbidities or high-risk illnesses such as heart disease, lung diseases and diabetes.

How often should a health plan communicate?

During this time, overcommunicating is actually a great idea. Adding web content daily is not too much. Sending weekly emails or emails as soon as you have significant information to share is not too much. Adding daily updates to Facebook is not too much, especially when Facebook content can be fun and informative (and many need a little fun right now). People want to know that their health plan is there to support them, and being in constant communication with helpful, truthful, and factual information is one way you can show that.

Who else should health plans be sending communications?

Members should be your highest priority, as they are the most vulnerable right now. But keep in mind the other audiences impacted by COVID-19 who also need to be hearing from you:

  • Providers: Providers need your full support in standing up a telehealth benefit and understanding how to properly bill it. Multiple methods and communications should be utilized to partner with providers on telehealth.
  • Brokers: In many situations, your brokers are your voice, and you want them to be educated on what is happening. Broker emails, portal communications, and webinars are all strong methods of communication to keep them informed and up to date on the latest developments. Plus, they should be made aware of how and when you are communicating to members.
  • Outreach Partners: Ensure State Health Insurance Assistance Programs (SHIP) and other organizations are aware of benefit changes and the lines of communications available to your members.
  • Caregivers: Many people are caring for their parents who have complex needs and are very vulnerable during this unprecedented time. Providing guidance on what they should do and how to monitor those in their care will help eliminate uncertainty and ensure both themselves and their loved ones remain safe and healthy.

Above All Else, Choose the Right Tone

Over the last several weeks, health plans have been wondering who, what, how, and how often in relation to their marketing and communications activities. Above all else, keep in mind the sensitivity of this conversation. Be clear, simple, and genuine. Do not condescend or demand. The right tone should be empathetic, understanding, and helpful, so that members feel less uncertain, confused, and scared.

If you still have questions on how to communicate with members and providers, consider attending our upcoming virtual open forum on Thursday, March 26th, where the healthcare experts at GHG and analytics leaders at Pareto Intelligence will answer all of your specific questions across a variety of topics, including Marketing, Star Ratings, Risk Adjustment, Compliance, Network Adequacy and Development, Telehealth and Analytics.

Remote Work in Challenging Times—Steps to Survive and Thrive

For many professionals, like those of us at Gorman Health Group (GHG), we were working from home (i.e., remotely) before the words “Coronavirus” or “COVID-19” were ever spoken. Prior to social distancing and “shelter in place” orders, 43% of US employees worked remotely at least some of the time. Surveys are currently underway to determine how COVID-19 will impact this statistic.

The reality is that mandatory work-from-home (WFH) policies are needed and necessary in this crisis. Although this change was not at all disruptive to the way GHG works, we understand that, for many others, this is new territory, and you may be faced with challenges you weren’t prepared to overcome. (Like arguing with a cat who insists on sitting directly on your keyboard.)

Drawing on our many years of experience in the
WFH space, the advisors at GHG wanted to provide some advice for working remote

Confirm you have adequate technology and connectivity.

  • This includes your laptop, charger, mouse, and keyboard.
  • Contact your IT department to ensure you have what you need to securely connect to servers and systems.
  • Utilize videoconferencing whenever possible. As humans, we need to feel connected—consider daily standups with your team or even virtual “coffee breaks” to bridge the gap created by social distancing.
  • Contact your internet service provider. Many companies are offering price breaks during this time for increased bandwidth.

Stick to your schedule.

  • Most of us have regular working hours. Whether that’s an 8-, 10-, or 12-hour day, continuing your regular hours and sticking to your usual schedule will help maintain a sense of normalcy.
  • Most people recommend getting ready and dressing for the day you would have had if you went into the office. While you likely can work in your “comfies” all day, research shows that you are more productive if you’re dressed and ready for the day, rather than lounging in your “lazy” clothes. Ultimately, it’s all based on your preference. However you feel most effective, stick to that!
    • If you participate in video meetings, continuing to represent your “professional self” is the way to go.

Dedicate a workspace.

  • If you have an office, that’s ideal. Your workspace should be as separate as possible from the places dedicated to other activities, like eating or sleeping.
    • Research shows that a delineation between workspace and living space helps you get into the right mindset, maintain focus, and stay motivated while working. If you try to work in the place where you live and play, you’re more likely to get distracted.
      • This also helps you disconnect when the day is over by leaving your work in that space.
  • If a separate office is not possible, consider an area in your bedroom, dining room or kitchen that is sectioned off from the main purpose of the room.
  • Let the family know that during work hours, that’s your space. Set ground rules.

Ensure you are being productive.

  • Limit distractions such as television, barking dogs, or children by wearing noise-canceling headphones.
  • Update your to-do list every morning and set time limits for each task when appropriate.
    • Like a financial budget where we allocate money to specific activities, you should do the same with your time using a detailed schedule. This will help keep you on task and progressing towards your goals.
  • If you manage employees, take extra time to meet with them virtually. Create an agenda that includes updates from each team member, so they can contribute. Employees need to feel valued, not disconnected, and regular video or conference calls help accomplish that.

Keep your scheduled breaks.

  • Don’t skip your morning coffee, whether you get a cup from your kitchen or the local drive thru coffee shop.
  • Take a scheduled lunch break, and enjoy a healthy, home-prepared meal. Consider a brief home workout to get your body physically moving.
    • Consider using any extra time for evening meal prep.
  • Take an afternoon break. Go for a brisk walk with the kids and/or the dog.

Find new ways to take advantage of commute time.

  • Take an online exercise class.
  • Do yoga, meditate, dance.
  • Read! Tackle that book you’ve been wanting to read but couldn’t find the time.

Remember that this is a trying time for
everyone. While working remote may come easy to some, for others, it will be a
significant challenge, and we need to be considerate of that. No matter how you
organize your day, it’s important to find moments that you can embrace. An
early morning coffee on the porch while the sun is rising. Extra time in the
shower or tub. The chance to write a letter to a loved one, service member, or local
nursing home or extended care facility. Above all, be patient and be kind.

And if you just can’t get the cat off your
keyboard, try putting a cardboard box next to your computer. That’ll keep them
entertained until everything is back to normal!

This is a time of great uncertainty, and the healthcare industry is at the forefront of a global battle against COVID-19. If you have any coronavirus disease-related questions, consider attending our upcoming virtual open forum on Thursday, March 26th, where the healthcare experts at GHG and analytics leaders at Pareto Intelligence will answer all of your specific questions across a variety of topics, including Marketing, Star Ratings, Risk Adjustment, Compliance, Network Adequacy and Development, Telehealth and Analytics.

Feeling the Madness! The 2020 CMS Program Audit Cycle Begins

This March, sports will not be the only excitement—health
plans are gearing up to receive audit notices as we enter the second year of
the four-year Program Audit Cycle. The ball is in your court… Your team’s
readiness depends on review of the current audit protocols and practice,
practice, practice.
Are you performing “mock” auditing to identify risks?

The Centers for Medicare and Medicaid
Services (CMS) started the current audit cycle in 2019 with a number of audit changes
and process improvements to assist plans, including:

  • Removal
    of Audit Element Review
    : Suspension of the review of Call Logs and the
    Website audit element from the Formulary and Benefit Administration protocol, as
    well as removal of the Enrollment Verification audit element from the Special
    Needs Plans Model of Care (SNP MOC) protocol.
  • Streamlining
    : Release of the Program Process Overview document with the
    Program Audit Validation and Close Out guidance, along with a Program Audit
    Frequently Asked Questions (FAQs) on the CMS program audit website.
  • Compliance
    Program Effectiveness (CPE) Protocol Changes:
    suspension of the CPE self-assessment questionnaire and several changes to the
    CPE universes.

CMS is continually seeking “…to improve
audits by soliciting sponsor feedback,” and recently opened for comment on the
proposed changes for 2020. Some notable changes include reductions in audit
elements and protocols, such as:

  • Removal of Part D Coverage Determinations, Appeals, and Grievances (CDAG) Table 9 (Standard Independent Review Entity [IRE] Auto-Forwarded Coverage Determinations and Redeterminations [SIRE]) and Table 10 (Expedited IRE Auto-Forwarded Coverage Determinations and Redeterminations [EIRE]), as well as removing Table 16 Call Logs.
  • Reducing timeliness CDAG sample size from 75 to 65 and increasing Grievances from 10 samples to 20, likely to compensate for the removal of Table 16 Call Logs.
  • Edits to the CDAG universe requirements, including updating the notification requirements to coincide with Parts C and D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance Section 10.5.3 and adding exclusion language throughout the remaining tables.
  • Removal of ODAG Table 14 Call Logs and reducing timeliness samples from 65 to 60 cases and Clinical Decision-Making from 40 to 35, while also increasing Grievance samples from 10 to 20.

The industry anxiously awaits the
distribution of the updates, as the current audit protocols are set to expire
April 30, 2020.

GHG assists plans with implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

5 Key Takeaways for Product Leaders from the Advance Notice

The news is out and one thing is clear: CMS is proposing significant changes across all focus areas for Medicare Advantage (MA) plans in the 2021 Advance Notice and 2021/2022 Proposed Rule. On top of that, CMS has announced that there will be no draft or final call letter this year. Instead, items typically released in the call letter will be provided through a combination of rulemaking (in the case of policy) and HPMS memos providing process instructions and other guidance.

With bid submissions on the horizon, these announcements must be
top of mind for MA plans. Below are the key takeaways for product strategy
leaders to prepare for 2021:

  1. In 2021, Medicare beneficiaries with ESRD will be able to enroll in MA plans. Also, organ acquisition costs for kidney transplants will be excluded from MA benchmarks, except for PACE organizations. Plans will need to account for this in the development of 2021 bids. In addition, plans will need to change enrollment forms, enrollment scripts and other materials that reference ESRD eligibility for 2021.
  2. In 2021, MA Part D (MAPD) and Prescription Drug Plans (PDPs) will be able to offer a second tier for specialty drugs with lower beneficiary cost sharing. This change allows plans to negotiate better deals with manufacturers in exchange for placing their drugs on the preferred tier. Plans will need to work closely with their Pharmacy Benefit Managers (PBMs) to understand if this will be offered and the types of drugs that will be on the list. Plans who extend this to their members have the opportunity to utilize it as a retention opportunity for current membership, as well as a sales opportunity.
  3. Plans will have more flexibility to include telehealth providers in certain specialty areas (e.g., psychiatry, neurology, and cardiology) and will be allowed a 10% reduction in the number of beneficiaries required to meet time and distance standards. This is especially important for rural areas. Plans that were not able to enter counties because of network issues in the past may want to revisit this for 2021.
  4. CMS is clarifying and codifying its previous guidance on supplemental benefits. For Special Supplemental Benefits for the Chronically Ill (SSBCI), there is a minor clarification to expand the chronic conditions for which SSBCI may be offered. Hopefully, CMS will release this guidance soon.
  5. CMS is not a fan of D-SNP look alike for many reasons. For plans where either the bid or actual enrollment exceeds 80% of members entitled to medical assistance, CMS proposes to not enter or non-renew the plan’s contract. (Where threshold exceeds 80%, members could be transitioned to a D-SNP offered by the organization.) If you don’t currently have a D-SNP, this could be a loss of membership. Plans who compete against these D-SNP look alike plans may see an increase in membership this year.

With the February enrollment data officially released, look out for another article next week on the results of the Annual Enrollment Period (AEP). And, join us on March 4th for an exclusive webinar on the Supplemental Benefits Trends to Address in 2021. In that webinar, Diane Hollie will highlight what we are seeing in the market that may influence your benefit and product decisions for 2021. Click here to register.

If you need help navigating the product and benefit design
implications of CMS’ recently released policies, contact Diane Hollie at

It’s Time to Prepare for Medicare Advantage Provider Network Submissions

Network management, directory accuracy, initial applications, service area expansions (SAEs), and the new triennial review process have exposed many Medicare Advantage (MA) plans to serious issues—from policy to process and staffing to technology. As we move into the countdown for network development, expansion, and Health Service Delivery (HSD) submission for 2020, as well as plan years 2021 and 2022, it is imperative for network strategy planning to start now in order to avoid the pitfalls plans have faced with the new regulatory guidance.

In previous years, plans submitted HSD tables along with applications. By the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network, allowing product teams to quickly move forward with the product development process.

With the timeline changes, bids are submitted prior to HSD tables being uploaded and reviewed by CMS. This requires plans to implement internal deadlines for the contracting process and decide whether to file a county on the edge of meeting network adequacy. The extra time and latitude offered by CMS in the network submission process resulted in additional contracting time; however, at the same time, this has exposed the increasing importance for strong network management that blends network and product strategy, as well as firm internal timelines for network expansion.

For example, last year, we saw plans suppressed from Plan Finder during the Annual Enrollment Period (AEP) due to unresolved network deficiencies. The resulting loss of anticipated membership that was budgeted for AEP became a last-minute challenge for sales and marketing, and a reset on the plan budget process. 

Additionally, as MA plans gain greater flexibility in designing and offering new types of benefits to members, blending network and product strategies becomes critical. When evaluating the impact a variety of supplemental benefits could have on sales and marketing strategy, especially when addressing the social determinates of health (SDOH) that most impact your geographic area and member population, we begin to see a vast gap in the playing field—from plans sticking to the basics with meals and non-emergent transport to plans willing to invest in innovative benefit options without knowing the exact return on investment a benefit will have on patient outcomes or financial upside/downside cost.

With these changes and supplemental benefits flexibility, we may see an upswing in strategic partnerships to improve member experience, including:

  • Post-acute providers, such as transitional assisted living and skilled nursing facilities
  • Vendors offering adaptive aids to keep patients at home longer
  • Meal or grocery delivery services
  • Resources to expand transportation services

From a provider network perspective, the move toward new partnerships will likely present a few stumbling blocks, such as how to code and pay for services, and require a ramp-up period we do not see with traditional MA providers. We encourage plans to start early and break down silos by having group discussions that include Sales & Marketing, Medical Management, Star Ratings, Operations, Credentialing and Provider Network departments to design a holistic strategy. These new, non-traditional providers will likely be dipping toes in the same deep end of the pool; extra lead time and planning will serve you well across the board.

For non-traditional providers, we would encourage all MA plans to have:

  • Planned education sessions/town hall meetings to educate new vendors/providers and better understand their needs
  • A plan for a lengthier contracting and credentialing process
  • A plan for additional onboarding and training with the new vendors
  • Additional member education time

Moving forward, as you internalize the new contracting timeline to include standard MA providers as well as any new, non-traditional supplemental benefit providers, communication and oversight will be key. This is especially important when managing provider network contracting and credentialing data, particularly when using outside sources to assist in contracting or a credentialing verification organization (CVO) to manage the initial credentialing process. Ultimately, the plan is responsible and held accountable for the compliance of the contracting and credentialing of its provider networks. Plans submitting initial and SAE applications should work backwards from the mid-June submission date and develop an actionable deadline(s) to ensure the network submitted meets CMS network adequacy requirements. 

What Should Medicare Advantage Plans Do?

Step one in any timeline is preparing a solid network strategy. In today’s marketplace, it is no longer acceptable to meet the bare minimum of network requirements. Consumers (and CMS) are demanding plan choices that include quality and cost efficiency as well as supplemental benefits.

Even further, with consumer-savvy, newly aged-in Medicare beneficiaries, there is a shift in patient expectations of the services available for their dollar. The new beneficiary is aging into a world of patient engagement and incentive/reward programs but will expect the same level of service. Plans need to find ways to evaluate existing provider networks and newly expanded networks to meet clinical and financial goals.

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, we’re here to help. Gorman Health Group has a long history of:

  • Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of senior consultants and network analysts to effectively and efficiently stand up a contracted provider network
  • Designing and developing network and product strategies that take into account the quality, financial, risk adjustment, and Star Ratings goals critical to success within the competitive landscape of your market(s)
  • Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements
  • Developing a network to support a competitive supplemental benefit program
  • Preparing plans’ HSD tables for a CMS filing or bid submission as well as preparing network exceptions to include all the required elements

Let us know how we can work together now to support your plan’s goals for the upcoming submission and plan year. Contact Elena Martin at