Insights | GHG Advisors

New Part D Medication Therapy Management Model: Is It Right For you?

Drum roll, pleaseâ€¦beginning January 1, 2017, the Centers for Medicare & Medicaid Services (CMS) will pay Medicare Prescription Drug Plans (PDPs) to play in Medication Therapy Management (MTM)â€”and it's all about the money. Where before MTM costs were administrative, there will be two additional payments for plans approved for participation in the model program. The "model test performance period" will actually span seven total years (2017-2023) because payments will be made for two additional years after the five-year model performance period. There will be a prospective payment for "more extensive MTM interventions to members and providers" and a performance payment "in the form of an increased direct premium subsidy for plans that successfully achieve a certain level of reduction in fee-for-service expenditures and fulfill quality and other data reporting requirements through the model." The final approved prospective payment will be on a per member per month (PMPM) basis and will be paid per enrollee in the plan regardless of how many enrollees are receiving enhanced MTM services.

As of August 2015, there are 24 million enrollees in Medicare PDPs. Enrollees sign up because the PDP premiums are usually less expensive than MAPD plan premiums. However, these plans usually provide minimal MTM services meant to meet the letter of CMS compliance, not the intent. For example, provider interventions may have no feedback loop to ascertain whether or not the provider agreed or disagreed with or accepted the recommendations. And, therefore, any cost avoidance or actual cost savings data are missing or suspect.

This new enhanced MTM performance model has the potential to move the needle, but PDPs in the eligible regions will have to complete an accurate risk analysis for their members to determine what a viable program consists of and how new and innovative MTM endeavors will positively impact the CMS MTM goals of "optimized therapeutic outcomes through improved medication use, and reduced risk of adverse events, including adverse drug interactionsâ€”while reducing net Medicare expenditures."

"Gorman Health Group is ready to help work with PDP plans in identifying the cohort populations that would benefit from this demonstration," explained a Senior Consultant in Risk Adjustment & Healthcare Analytics at Gorman Health Group. "The successful MTM programs will leverage pharmacy costs and utilization to achieve savings in medical costs. CMS is looking for this savings, and participating plans need to monitor their effectiveness with new MTM programs."

Resources

Click here to download Gorman Health Group's whitepaper on the Part D Enhanced Medication Therapy Management (MTM) Model, written by Celia Girard, Director of Policy & Training and Caron Wingerchuck, Senior Director of Pharmacy Solutions.

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Recommendations Made by the National Quality Forum on Medicaid Measures

The National Quality Forum (NQF) is a non-profit organization working to evaluate and endorse standardization of healthcare performance measures. Recently, NQF submitted a series of reports to the U.S. Department of Health and Human Services (HHS) outlining recommendations on new measures aimed at improving Medicaid beneficiary quality of care. For the last four years, NQF started providing strategies to HHS on improving care for dual eligibles, adults, and children in the Medicaid program. These new quality measures were created to improve healthcare quality for more than 70 million adults and children. The key area of concentration was the beneficiaries' behavioral health and how it affects diabetic and cardiovascular care delivery.

In the reports, NQF tracked the effects behavioral health has on diabetics and the domino effect it has on a beneficiary's overall health. Many providers are seeing that therapies used on patients with serious behavioral health issues are causing significant health problems. An example is weight gain as a side effect of the medications given to treat mental health illnesses. They saw this turn into health issues, such as diabetes, in these patients. The report continues to state that not addressing the behavioral health problems of a beneficiary has led to higher glycated hemoglobin (A1C) which then resulted in cardiovascular issues. This problem of addressing both the physical and mental health needs of the Medicaid population has been in the forefront of the American Psychiatric Association and U.S. Psychiatric and Mental Health Congress.

NQF has made recommendations for the working age population of adults, which are also the most rapidly-growing population relating to controlling and monitoring cardiovascular health (e.g., high blood pressure) and medication management in those individuals who have serious behavioral health illnesses. NQF has also made recommendations for children and dual eligibles. Due to the complex needs of the dual-eligible population, the amount of measures was increased, many concentrating on behavioral health and comorbidities. They also concentrated on making changes to the care coordination and readmission rate monitoring.

Resources

Gorman Health Group can perform an analysis on your current quality programs and provide expert advice on benefit designs, as well as conduct a risk analysis to determine what a viable program consists of and expected outcomes. Contact us to learn more >>

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by GHG Advisors

Healthcare Implications Post Boehner Exit

House Speaker John Boehner announced last Friday he will resign his seat at the end of October. Following this announcement, House and Senate members immediately announced plans to pass a spending bill preventing a government shutdown by scrapping plans to block Planned Parenthood funding for the time being. Boehner's resignation makes this move possible because he no longer faces the threat of being ousted by the House Republicans if the bill he brings forward to the floor does not have Republican majority.

While the most imminent government shutdown has currently been averted, the threat of everything coming to a halt mid-December, at which point the spending bill funding would run out, is much more likely to materialize. The next funding bill will need to work out the funding levels for the rest of budget year 2016 in order to prevent a government shutdown. In an attempt to put the continual nightmare of annual shutdown threats off until the next administration, Senator McConnell just announced potential talks with President Obama to negotiate a 2-year budget, and cover fiscal year 2016 and 2017.

So what does this all mean for healthcare and the Affordable Care Act (ACA)?

Planned Parenthood aside, Boehner was actually quite a critical opponent of Obamacare and fought it to the very end, even bringing lawsuits against the administration. His only move seen as a positive in the healthcare industry is the support to repeal the flawed Sustainable Growth Rate (SGR) formula earlier this year. Because House Republicans are likely celebrating the win of the resignation, however, we will likely see many more attacks on the ACA despite all of them being unlikely to work, just as under Boehner's leadership.

Reconciliation bills are one likely tactic — House Ways and Means Committee already approved one today — to repeal portions of the ACA, such as employer and individual mandates, medical device tax, and the Independent Payment Advisory Board. The House and Energy Committee also introduced a reconciliation bill to defund Planned Parenthood. However, although Boehner stepping down may mean such bills could make it through both the House and Senate, they will certainly meet their end on the President's desk.

Unfortunately, this also puts any potential good bipartisan agreements at bay for the time being. Bipartisan bills to repeal the "Cadillac Tax," for example, will likely see much more punting around. Repealing the tax would create an $87 million budget deficit, and, with what is shaping up to be an aggressive fight in December, such a move is unlikely.

Under the new speaker's leadership, likely a more conservative pick, the Planned Parenthood fight may also stick around until December 2015. While Boehner was more willing to work across party lines on this issue, the current Republican majority is celebrating the resignation and may be much more emboldened in their fight in December.

The big issue is, of course, the 2016 budget. While the current spending bill will deal with emergency issues such as the imminent expiration of the transportation funding, the bill in December will need to tackle the FY 2016 budget as a whole. One huge one is Part B premiums — if Social Security is not adjusted and stopgap funding is not provided, this fund could run dry, and Medicare recipients under Part B will see significant premium increases. Another example is the temporary funding created by the repeal of the SGR, for example, funding for ambulance rides and physical therapy. These programs will face cuts if funding is not agreed upon in December.

Resources

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by GHG Advisors

Do More Than Survive AEP

How quickly another Annual Election Period (AEP) is upon us. This time of year is the perfect time to review your new member onboarding activities and AEP strategy. We all know the sale doesn't end when the application is turned in and membership begins. This is where the rubber hits the road.

These are the four questions to consider going into AEP:

Are all plan resource documents updated with the 2016 plan benefits? Picture this: A friend newly eligible for Medicare recently enrolled in a Medicare Advantage plan. He experienced a benefit problem that nearly ended in a sales allegation all because a representative was relying on outdated benefit information. This would have been avoided if everyone at the plan had the new benefit designs.
Does health plan staff see the big picture? It's easy for us to focus on our individual operational components. After all, the number of regulations and processes to manage a compliant Operations Department is significant and takes our full attention, but the big picture allows for cohesive programs and the ability to see what part we play. Does Enrollment know the top issues that Reconciliation experiences? Is there a feedback loop established to catch improvement opportunities early as we move into AEP? Has Sales shared the advertising schedule and advertisements with Customer Service? Customer Service can maintain that strategy and answer member questions about the campaigns for 2016.
Are operational oversight tools in place? Not only should all operational staff know the requirements governing their processes, they should know how to tell they are meeting those requirements. The ability to oversee our own processes and know we are in compliance is empowering. Not only can corrections occur immediately, but staff can be confident and efficient, focusing on the important actions supporting new and existing members.
Is everyone focused on the goal — ensuring a positive member experience? If applications are incomplete, is the Enrollment staff focused on sending a letter to get the application off their plate or focused on reaching out to the member to complete the member enrollment? Are welcome calls in place to answer any lingering questions and ensure new members feel confident and engaged in their plan choice?

AEP was quick to arriveâ€”it will be equally quick to come to an end. Make sure it's the AEP you designed rather than the AEP you survived.

Resources

In Operations, we naturally focus on our own internal processes and efficiencies, but now is the time to invest in making sure staff knows how their contributions impact members and the health plan. Gorman Health Group's experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations. We've been in your shoes and know how to navigate through AEP. Visit our website to learn more >>

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by GHG Advisors

Star Ratings Plan Preview #2

It's hard to believe, but it's that time of year again. Yes, it's football seasonâ€”and it's also the beginning of Star Ratings season.

The Centers for Medicare & Medicaid Services (CMS) annual Star Ratings plan preview periods have become as much an annual ritual for Medicare Advantage (MA) plans as the Advance Notice and Call Letter, and plans throughout the nation are feverishly working to understand their 2016 Star Ratings so they can quickly determine what still needs to be done during the fourth quarter to close out 2015 strong.

Although there were few surprises in the 2016 Star Ratings measure specifications, there was much to be gleaned from the long-awaited removal of the remaining pre-determined 4-Star thresholds. As expected, almost as many 4-Star thresholds were decreased as were increased. The plan preview measure specifications show 4-Star cut points were tightened on 20 measures and relaxed for 13 measures. Measures where the 4-Star cut points were relaxed included those with significant patient lifestyle and perception impacts, such as medication adherence, diabetic blood sugar control, and several Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) measures. In contrast, measures with tightened cut points include many of the Healthcare Effectiveness Data and Information Set (HEDIS^®) process measures, where plans and providers have a long history of focus and attention to gap closure. In contrast, 4-Star cut points were only relaxed for one administrative, or plan-controlled, measure, which demonstrates plans are "controlling the controllables" within the program. Again, no big surprises in these changes. But the absence of surprise does not mean it will be easy for plans to adapt to these changes.

So what can we take away from the plan preview?

CMS continues to use the Star Ratings program to compel health plans to increase their strong focus on quality improvement in their service to beneficiaries.
Plans must continue investing efforts in longer-term strategic relationships with members and providers to continue improving health outcomes, meeting beneficiary expectations, and performing well in the Star Ratings program.
With the increasing competition in MA and full adoption of the bell curve within the Star Ratings program, the definition of success is likely to continue to rise. There is simply no such thing as "good enough" in Star Ratings.

With approximately five percent of MA plan revenues tied to Star Ratings performance through Quality Bonus Payments, an objective review of a plan's Star Ratings infrastructure, strategy, and performance can be a wise investment.

Resources

Whether your plan missed the overall 4 Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4 Star rating, we can help. Our team of experts understands the Star Ratings program and knows how to influence performance. Contact us to learn more >>

by GHG Advisors

Medicare Advantage Value-Based Insurance Design: Key Considerations

The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed demonstration that will test varying benefit designs based on health status. The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model will allow organizations to offer targeted supplemental benefits and/or reduced cost sharing to enrollees with specific chronic conditions to further the goal of improving beneficiary health, reducing the utilization of avoidable high-cost care, and reducing costs for plans, beneficiaries, and the Medicare program. The overall goal of this demonstration is to improve clinical outcomes while reducing plan expenditures.

Do you qualify?

This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the announcement, only current MA organizations in good standing in those states will be allowed to participate. The demonstration is aimed at Health Maintenance Organizations (HMOs), Health Maintenance Organization Point of Service (HMO-POS) plans, and local Preferred Provider Organizations (PPOs) in order to determine how it affects beneficiaries and costs in the most common plans. Special Needs Plans (SNPs), Regional PPOs, Medicare-Medicaid Plans (MMPs), Private Fee-for-Service (PFFS) plans, Employer Group Waiver Plans (EGWPs), Health Savings Accounts, and cost plans are not eligible.

How we can help:

Applications

The CMS process begins with the submission of a Request for Application (RFA), which is currently due on November 15, 2015. Organizations failing to submit an RFA cannot participate in 2017 but may be allowed at a later date during the five-year demonstration period. Organizations must submit an RFA that has sufficient detail to allow CMS to determine if the benefit plan addresses targeted beneficiaries, will provide measureable results, and is appropriately structured for the demonstration. We can work with your organization through every step of the application process, from gathering the right data and completing the application, to submitting the application and responding to follow-up questions.

Financial Analysis

The key to designing a successful MA-VBID model is to establish programs to simultaneously manage revenue through best-in-class Star Ratings operations and targeted risk adjustment for these prevalent diseases and avoid adverse risk selection as well as an ongoing review of cost and utilization drivers from medical and pharmacy claims. An initial assessment of claims and financials can help highlight existing strengths and weaknesses in medical management (including pharmacy) as well as provider networks. With annual bids as the source of financial truth, targets need to be realistic and timely.

Benefit Design Analysis

Organizations can propose any myriad of combinations of benefits or services provided they are based on the proposed chronic conditions listed in the announcement. Most importantly, CMS notes participating organizations can initiate the demonstration with a limited benefit and can expand their benefit plans during the five-year term of the demonstration. While the benefits will be mandatory supplemental benefits, CMS proposes to prohibit marketing these benefits to non-member beneficiaries.

Resources

We can work with your organization to design and implement a comprehensive data analysis to guarantee you have the right products, programs, and capabilities in place to compete and ensure you are go-to-market ready.

Is this the right opportunity for your organization? Attend our webinar to find out. Join John Gorman, Founder and Executive Chairman at Gorman Health Group, and I on Tuesday, September 29, from 1-2 pm ET, as they outline the MA-VBID plan requirements as well as what you should be doing now to prepare for January 2017. Register now >>

by GHG Advisors

ACOs Should Run for the Exits and Into Medicare Advantage

CMS recently released results from the Medicare Pioneer Accountable Care Organization (ACO) Program and the Medicare Shared Savings Program (MSSP). Once again the results are a mixed bag: quality is up, but the ROI for most participants is a joke. The update should have the most sophisticated demo sites running for the exits and into Medicare Advantage — but they need to move fast with the holidays and a February filing deadline for 2017 looming.

Pioneer ACO Program

CMS initially selected 32 health systems to participate in the program. It's down to 19 today. For the year 2014, 622,000 beneficiaries participated. Findings:

Pioneer ACOs generated total savings of $120 million in 2014, a 24% increase from 2013 ($96 million) and $88 million in Year 1 savings.
Eleven health systems generated gross savings beyond the minimum goal and received performance payments totalling $82 million. That's a pittance for what's been invested to participate. Of the 11 companies, a few reported notable savings:
- Banner Health in Arizona generated roughly $18.7 million in savings
- Partners Healthcare in Massachusetts generated roughly $13.2 million in savings, with around 70,000 beneficiaries participating.
- Beth Israel in Massachusetts lowered costs by 3.7% and generated roughly $9.8 million in savings.
- OSF Healthcare System in Illinois lowered costs by 3.0%
- Michigan Pioneer ACO in Michigan lowered costs by 6.3%
- Monarch Healthcare in California lowered costs 4.0%

Three Pioneers incurred the nightmare scenario of a giveback payment to CMS in 2014, including Beacon Health in Maine ($2.9 million), Dartmouth-Hitchcock in New Hampshire ($3.6 million), and Franciscan Alliance in Indiana ($2.5 million). All had to inform CMS of their decision to stay or exit the program by September 14. After two years of consecutive losses, Dartmouth-Hitchcock planned to exit Pioneer and apply instead for the Next Generation ACO program. It's a black eye for the system that's home to Dr. Elliott Fisher, widely considered to be the inventor of ACOs. Beacon Health is also exiting the program after facing losses for two years in a row, and will also apply for Next Generation.

Total model savings per Pioneer was $6.0 million in Year 3 (2014), up from $4.2 million per ACO in 2013 and $2.7 million per ACO in Year 1 (2012). The mean quality score among Pioneer ACOs increased to 87.2% in 2014, an improvement of 200bps from 85.2% average performance in 2013, and way ahead of 71.8% in Year 1. The Pioneers improved on 28 out of 33 quality measures. So most are delivering the quality goods, but aren't seeing much if any return for the effort.

Medicare Shared Savings Program

In 2014, there were 333 participants in the Medicare Shared Savings Program, and 92 of these ACOs kept spending below their targets, up from 58 ACOs out of 114 in 2013. The victorious 1/3 earned $341 million in performance payments. Takeaways:

$465 million of the savings generated will accrue to the Medicare Trust fund, $341 million will be returned to participants.
89 ACOs actually reduced health care costs compared to their benchmark, but did not qualify for shared savings because they did not meet the minimum savings threshold. So 2/3 of ACOs are winning on expense, but only half of those got paid. That's a problem.
Veteran ACOs were more likely to generate performance payments. Twice as many ACOs that entered the program in 2012 got paid vs. freshman systems (38% vs. 19%).

Lined up alongside other innovation failures like the bundled payment and nursing home quality demonstrations, it's clear CMS's innovation agenda has been hobbled by poor design and lack of business acumen. There's never been a better time for an industry veteran like Andy Slavitt to lead the agency out of the darkness.

The clock is ticking for ACOs to make the evolutionary leap into the one "devil we know" of Medicare Advantage.

Resources

Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Visit our website to learn more >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model Test

The Centers for Medicare & Medicaid Services (CMS) announced on September 1 a proposed demonstration that will test varying benefit designs based on health status. The overall goal is to improve clinical outcomes while reducing plan expenditures.

This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the announcement, only current Medicare Advantage organizations in good standing in those states will be allowed to participate. The demonstration is aimed at Health Maintenance Organizations (HMOs), Health Maintenance Organization Point of Service (HMO-POS) plans, and local Preferred Provider Organizations (PPOs) in order to determine how it affects beneficiaries and costs in the most common plans. Special Needs Plans (SNPs), Regional PPOs, Medicare-Medicaid Plans (MMPs), Private Fee-for-Service (PFFS) plans, Employer Group Waiver Plans (EGWPs), Health Savings Accounts, and cost plans are not eligible.

The demonstration will waive certain regulations so benefit plans can vary for enrolled members based on their diagnosis, condition, or need for a medical service. Currently, health status distinctions in providing benefits to enrolled beneficiaries are prohibited by regulations. Organizations can propose any myriad of combinations of benefits or services provided they are based on the proposed chronic conditions listed in the announcement. Most importantly, CMS notes participating organizations can initiate the demonstration with a limited benefit and can expand their benefit plans during the five-year term of the demonstration. While the benefits will be mandatory supplemental benefits, CMS proposes to prohibit marketing these benefits to non-member beneficiaries.

The CMS process begins with the submission of a Request for Application (RFA). Organizations failing to submit an RFA cannot participate in 2017 but may be allowed at a later date during the five-year demonstration period. Organizations must submit an RFA that has sufficient detail to allow CMS to determine if the benefit plan addresses targeted beneficiaries, will provide measureable results, and is appropriately structured for the demonstration.

RFAs are currently due by November 15. CMS will bind the organization to the proposed benefits in the RFA to their bid proposal for 2017. Consequently, conducting in-depth data analyses is necessary to propose a benefit plan in the RFA. This is the critical step that must begin in the very near future to meet the RFA submission date.

Is this the right opportunity for your organization? Attend our webinar to find out.

Join John Gorman, Founder and Executive Chairman at Gorman Health Group, on Tuesday, September 29 from 1-2 pm ET, as they outline the MA-VBID plan requirements, as well as what you should be doing now to prepare for January 2017.

Resources

Health plans in the applicable states need to place emphasis on data analysis and strategic planning as well as application support. We can help - Contact us today.

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by GHG Advisors

Final Rule for Medicare Prescription Drug Benefit Program Coordination Requirements

Where has the summer gone? When you get your formulary submission approval email, you breathe a sigh of relief and can relax forâ€¦a second. It's time to start planning for Part D Readiness and Benefit Administration testing so when November 15 arrives, you are well on your way to having those completed.

For Medicare Advantage plans, the heat is on for point of sale Part B versus Part D determinations. The regulation set to take effect on January 1, 2016, follows:

Final Rule, MA, PDP, CMS-4159-F2

MA-PD Coordination Requirements for Drugs Covered under Parts A, B, and D — The Centers for Medicare & Medicaid Services (CMS) acknowledges beneficiary access to needed drugs is impeded when a Medicare Advantage Prescription Drug plan (MA-PD) does not properly adjudicate claims for drugs that may be covered under Part A or B, rather than Part D, at the point of sale (POS). Thus, CMS is requiring MA-PDs to establish and maintain a process to ensure appropriate payment is assigned at the POS. If a denial under Part D is based on the existence of coverage under Parts A or B, the MA-PD plan should authorize or provide the drug under that other benefit without requiring the enrollee to make a subsequent request for coverage under that other benefit. According to the preamble of the final rule, CMS is amending 42 CFR §422.112(b)(7) to "require MA-PDs to coordinate with their network pharmacies and prescribers to improve existing processes and develop new ones in order to ensure that enrollees receive their Medicare-covered prescription medications, without delay, when they present at the network pharmacy." While CMS did not include beneficiary advocates' request to require plans to treat a POS claim transaction as a request for a coverage determination under Part D, this new rule should nonetheless improve coordination of and access to drug coverage for MA-PD enrollees.

Benefit administration testing is a relatively inexpensive insurance policy for 2016. Picture yourself on January 1 watching the adjudication system paying claims, adhering to the CMS-submitted benefit parameters, and no calls to 1-800-MEDICARE. That could be your experience with the enhanced benefit administration testing expertise GHG employs. We use a set of approximately 100 specific parameters against which to test approximately 1,000 claims. When we find issues, we work with you and your Pharmacy Benefit Manager (PBM) to get them resolved BEFORE live claims start rolling in on January 1. The countdown is onâ€”123 days until January 1!

Resources

We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Contact us to learn how >>

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by GHG Advisors

The CMS Fall Conference: 4 Ways to Solve the Preparedness Problem

The Centers for Medicare & Medicaid Services (CMS) held their Fall Conference and Webcast on September 10 in Baltimore. The presentations and videos from the event are found on the Compliance Training, Education & Outreach site here. CMS covered various aspects of the Medicare Advantage Prescription Drug (MA-PD) program, but here I've focused on four lessons I heard loud and clear: work with CMS, prepare ahead of time, seek continuous improvement, and don't wait until the last minute.

Linda Anders from CMS hosted two Aetna representatives who discussed lessons learned in beneficiary and pharmacy outreach stemming from strategic network changes taking place over 2014 to 2015. They had developed a communication strategy but soon understood a lack of clarity and misinformation caused significant beneficiary and pharmacy confusion. Ms. Anders stressed there is much to be learned from Aetna for any plan contemplating changes to their program. Aetna recognized their Part D network configuration was "generally consistent" with CMS requirements. It is recommended any plan contemplating program changes not tested in the industry work closely with CMS on these initiatives.

Gregory Woods gave valuable information regarding the Value-Based Insurance Design (VBID) Model Test. Things will move quickly for the VBID model. While they are beginning this test for 1/1/2017 effectives, the Request for Application (RFA) responses will be due sometime this November or December. This is new, so Compliance and Product teams, prepare yourself for a new onslaught of questions from Clinical and Actuarial, because they are coming.

As a lead-in to a presentation from MAXIMUS Federal Services, CMS confirmed they are working with a small number of plans on point of sale rejections. They hope to share more information about that in the 2017 call letter. Some helpful reminders were then provided regarding appeals going to MAXIMUS. Make sure your organization is referring to the most updated process manuals provided by MAXIMUS for Part C and Part D appeals. Additionally, there is a significant amount of appeals data dating back to 1997 showing your plan's percentage of upholds and overturns. Organizations can compare to other plans to benchmark or simply leverage to spark internal process improvements. Cathleen MacInnes, Project Director, also addressed the development of a submission portal for electronic upload of case info to MAXIMUS. If your organization is interested in participating, contact either her or her Part D counterpart. From an operational perspective, that should make sharing case info much easier, so long as it is secure, secure, secure.

The icing on this conference cake was the update from Jennifer Smith, Director, Division of Analysis, Policy and Strategy, Medicare Parts C and D Oversight and Enforcement Group, on 2015/2016 program audit protocol, processes, and activity. The changes she outlined are exciting — here are some, and since I've already written plenty, you can either watch the video or contact me for more details and my thoughts.

Edits to record layouts will include not only those outlined during June's Oversight and Enforcement conference but also additional edits based on plan and auditor feedback. Extraneous fields will be gone, headers will be added to record layouts, and more clear instruction will be incorporated as to what should be included and excluded.
Beneficiary Impact Analyses (BIAs) will not be requested at the time of the self-identified and self-disclosed issue reporting. Organizations should still anticipate a BIA request if an issue is found during an audit.
CMS is also revising their policy on the "three strikes" for universe submission.
The two anticipated pilot audit areas are being moved to 2016.
Compliance Program Effectiveness (CPE) will be conducted either onsite or virtually.

"It is also important to remember the audit protocols are more like a pop-quiz than a final exam," says Charro Knight-Lilly, Senior Vice President of Client Relations. Don't lose sight of the need to comply with all requirements and testing performance through monitoring, auditing, and annual risk assessment. Ms. Smith said something that resonated with me and likely others in the industry: Don't wait until the audit notice to practice universe pulls and activities. If you do, you are behind the 8-ball.

Resources

CMS outlined areas of poor performance within the release of the Outlier Notification in August. In addition to audits and Corrective Action Plans (CAPs), this notice also referenced Compliance Letters (C and D) and Star Ratings (C and D) as areas of concern and indicators of poor performance. Both of these areas require advance planning, preparation, and coordination in order to make an impact a minimum of one full year later. Don't exhale as we head in to the 2016 Annual Election Period (AEP) — now is the time to plan strategy for 2017. Contact us to learn more.

Join John Gorman, Founder and Executive Chairman at GHG, for our upcoming webinar on MA-VBID Model plan requirements, needed strategies for data analysis and benefit development, as well as what you need to be doing now to prepare for January 2017 on Tuesday, September 29, from 1-2 pm ET. Register here

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors