Spring Cleaning: Have you thoroughly examined your MSP records yet?
Spring cleaning normally consists of taking a look around our homes and conducting a deep clean. It's a time when we can no longer ignore those often neglected, out of sight jobs that we know we must do in order to maintain a clutter-free, and healthy home.
In the government health care space, there is also room for a fresh start. Spring is the time CMS sends each Part D plan a full replacement COB file that includes records that would normally be included in the daily COB notification files and the full replacement COB data for all enrollees with other coverage. CMS released a recent HPMS memo on March 25th, which stated the COB file would be sent to plan sponsors during the week of April 7Th.
What does this mean for Plans? It creates an opportunity to thoroughly go through your MSP records, clean them up, and get them up to date. It means NOW is the BEST time to take a long look at your MSP data and perform an MSP spring cleaning! Yes, it's a big job, but well worth the effort as GHG MSP Analysts just recovered over $20M dollars for one of our clients (their expected A/R, plus millions more).
GHG has experienced MSP analysts and consultants that can do the work for you. Think of us as the "Merry Maids of MSP."
Find our Spring cleaning checklist below. (You can choose to perform one or all of the following.)
- Perform validation and clean-up of prior or current MSP and COB data with GHI and within internal systems.
- Analytics on current state process effectiveness, creating Business Process Redesign plans, and Project Management of a Robust MSP process.
- Training of Finance, Operations and Claim teams on processing and applying MSP and COB data.
- Working with GHI and CMS Central Office on rejections or appeals for payment beyond 36 months.
- Validation of P&L between validated CMS data and internal claim systems.
- Analysis and business process redesign of commercial Section 111 reporting process that may be negatively impacting MSP.
Think how good it feels when your home is sparkling clean.That's how good it will feel when you know your MSP data is clean and accurate, but better yet when you recover unexpected A/R!
A small investment can realize a huge recovery. Contact us today.
Resources
Join Gorman Health Group May 1 — 2 at the Red Rock Casino and Resort in Las Vegas for the 2014 GHG Forum where GHG experts will dive into the MSP validation process. This two-day event builds on the success of past GHG Forums and is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population. Register now >>
The Final Rate Announcement webinar hosted by Gorman Health Group Founder and Executive Chairman John Gorman, financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier is now on the GHG website. View the webinar now>>
The 2015 Medicare Advantage Final Call Letter = Unicorn Rainbow Farts
The Center for Medicare and Medicaid Services' (CMS) release of the final 2015 Call Letter for Medicare Advantage (MA) Monday after the close was a "unicorns farting rainbows" moment. Unicorn rainbow farts bring happiness and joy to all those that observe them, and then dissipate quickly. After a beating at the hands of the ever-more powerful insurance lobby for another draconian draft released in February, CMS reversed itself yet again and proclaimed a 0.4% increase in MA benchmarks. Lobbyists and Wall Street analysts rejoiced...only to find after a closer look that there are some nasty hooks in the pie CMS put on the windowsill.
We've tried for days to replicate CMS' math to get to a 0.4% increase, and can't, because it's vapor, magical horse methane. The truth is, we're looking at an average cut of at least 3% for MA next year, and our logic follows below:
Others agree: DeutscheBank says -3.5%; Morgan Stanley projects -3.1%, Bank of America says -3.3%. And that ushers in a two-year march in the desert for Medicare plans following the 6% hit they took in 2014. There will be wide variation among plans, with lesser negative impact for plans which can continue to bid below the benchmarks.
The trends by themselves cut the benchmarks a lot, to the tune of almost 8%. And there's a ripple effect there, on Star ratings of all things: the -4% trend on the old benchmarks lowers the ceiling, and the effect is to truncate Stars bonuses in almost half of US counties. Ironically, high-performing plans take a hit, especially in double bonus counties, in this final rate announcement.
CMS's second consecutive reversal of its proposed ban on diagnostic codes for risk adjustment from home visits was a huge win for the industry, and as we see it, the one ray of light in the final call letter. CMS delayed the change until 2016, and that delay makes up for most of the impact of the negative trends in the benchmarks. But this isn't an equal across the board fix. Given that the FFS normalization factor places a 4% multiple on every point of a plan's risk adjustment factor (RAF) score, plans have an even greater incentive to identify and document every diagnosis that maps to an HCC.
This is further amplified by the decision to roll back the phase in of the new HCCs. On average, the new HCC scores would cut about 2.6% out of MA plans' payments. In 2014, CMS is blending new and old HCCs, with new scores given a 0.75 weight. For 2015, they are rolling that back to a 0.33 weight. That's worth 109 basis points by our calculation. So, compared to 2014, one RAF point is worth 1.05 points in 2015. Given the deferral of the home risk assessment rule for at least another year, plans should be doing home visits intensively this year, and working to evolve their programs to be more clinically meaningful, e.g., a care plan for every diagnostic code submitted from a home visit, and making the house call into more of a "mobile medical home" including mobile labs, imaging and drug therapy counseling.
CMS also makes clear in the final call letter that Medicare Advantage plans ranked 3 Stars or less for 3 consecutive years will be nonrenewed. This means termination notices could be going out as early as August given plans have to execute 2015 contracts with the agency in September, before the Annual Enrollment Period. Many plans will choose to nonrenew rather than be publicly shut down by CMS for poor quality. Dozens of plans are now dead men walking, including several of the publicly-traded Medicaid plans and several Blue Cross/Blue Shield organizations. So in a matter of weeks, a Hunger Games-style "reaping" will occur that will change the face of this industry.
So the long walk in the desert for Medicare Advantage begins. Forward-looking plans will prepare by ramping up their risk adjustment operations, ensuring their Stars programs have the resources they need to keep scores moving up, revisiting their service models, and working daily on closer collaboration with their provider networks.
Resources
On April 11 GHG Comments on the Final Rate Announcement in a webinar hosted by Gorman Health Group Founder and Executive Chairman John Gorman, financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier. Register for the webinar >>
Listen in as John Gorman shares his reactions to the 2015 Final Call Letter from CMS. He covers the implications of the final rates, as well as what the pull back on risk adjustment means to MA plans this year, and beyond. Click here to download the podcast >>
Join Gorman Health Group May 1 — 2 at the Red Rock Casino and Resort in Las Vegas for the 2014 GHG Forum. This two-day event builds on the success of past GHG Forums and is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population. Register now >>
Are ACOs fulfilling expectations?
Many of the Medicare Shared Savings program ACOs are now in their second year of operation and some of the Pioneer ACOs are approaching year three. As a result, we are beginning to see published data on which of those ACOs are achieving shared savings. For those ACOs that began operating in 2012, (only ones for which any credible data is available), we know that of the 32 Pioneer ACOs only 23 continue to operate. We know that of those 23 operational Pioneers less than half generated shared savings. We also know that of the MSSP ACOs launched in 2012, about 25% shared in interim savings.
Based on those preliminary results, it is too early to pronounce the ACO program either a success or a failure. Additionally, success or failure should not be measured only in financial terms. Improved financial efficiency was only one of several objectives behind the ACO program. Others included better coordination of care, improved approach to the diagnosis of beneficiary medical problems and improved beneficiary access to care. ACOs that were able to impact practice and service delivery behavior patterns which led to improvement in coordination of care and patient access, I would argue had a successful year.
In debating the feasibility and sustainability of ACOs it is important to recognize that not all ACOs are alike, in fact, most are not. For example the Pioneer ACOs were selected by CMMI on the basis of their past experience in managing the financial risk for a defined patient population, either thorough capitation or percentage of premium contracts.
It is also important to note that for both the Pioneer and the MSSP program ACOs, participating members are not incentivized or obligated to seek medical care within the ACO. Thus the government sponsored ACOs are unable to manage the medical spend for each participating member thus impacting the ACOs ability to generate savings. Private ACOs can and do require participating members to seek care within the ACO or be subject to "out of network" restrictions.
ACOs may or may not survive long term as a discrete healthcare delivery structure. Irrespective, the long term contribution may be that the ACO program accelerated the recognition by providers and health plans that tools exist which, if implemented wisely, can positively impact patient outcomes while controlling costs. Doesn't that seem worthwhile regardless of nomenclature?
Finally those organizations that were already doing a great job of controlling the medical spend prior to organizing as an ACO are having a more difficult time generating additional savings.
Resources
Join us on 4/11 for a FREE webinar as Gorman Health Group founder and executive chairman, John Gorman, financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier offer insight on the Final Rate Announcement from CMS. Register today >>
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. Learn more about how GHG can help >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Find out how >>
Join Gorman Health Group May 1 - 2 at the Red Rock Casino and Resort in Las Vegas for the 2014 GHG Forum. This two-day event builds on the success of past GHG Forums and is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population. Register now >>
Member Engagement and Experience are the New Risk Adjustment
In this new era of Star Ratings in Medicare Advantage and Part D, where a 4+ score is now do-or-die, health plan survival comes down to two things: member engagement and the member experience. They're the new risk adjustment when rates in 2014-2015 will be at their lowest levels in more than a decade, and a low-quality rating is a kiss of death in government programs. Plans that can't evolve into kinder, gentler, more coordinated and Member-Centric service providers are already beginning to disappear.
Here's why: the vast majority of the Star Ratings performance measures, especially those that are triple-weighted, are utterly dependent on an engaged member. Example: breast cancer screening. All women hate mammograms, and this measure doesn't move unless the member shows up. Another: Diabetes Care -- Blood Sugar Controlled. "Controlled" is a clinical outcome. And you can't get there with daily testing and insulin treatment without a member who's paying attention every day. Less than 20% of seniors engage in all screenings and tests required in Stars.
Similarly, the patient's experience measures and surveys now comprise fully a third of the Star Rating and are all 1.5 weighted, which means they count 500 basis points more than simple process measures. Getting appointments and care quickly, handling of complaints and coverage disputes, interpreter availability -- just a couple examples, all 1.5 weighted and instrumental to getting or keeping those all-important 4 Stars. The Consumer Assessment of Health Plan Survey (CAHPS) and the Health of Seniors Survey (HOS) are enormous determinants of ratings, both conducted by government surveyors, and both strike fear in the hearts of health plans. "Has your health improved in the last two years you've been enrolled, and who do you attribute it to?" are two of the most critical questions facing our industry. You have no hope of a positive answer to these questions from your members if they don't know who you are and what you're doing for them.
Most of the tasks involved in the Stars measures are actually pretty simple, like getting a flu shot. And behavioral economics show us that simple tasks are susceptible to contingent, or "if-then" rewards. So plans need to have the ability to track member progress on health-related tasks and administer appropriate incentives when they are completed. And all of the patient's experience measures necessitate a responsive, proactive service model that could be lifted from some of the leaders of e-commerce.
So the more we thought about it, the more we realized we needed to offer our clients a platform that can help them execute better on Stars tasks, while ensuring dramatically better member engagement and a much more positive consumer experience. And that's where our new partnership with Novu comes in. Novu is a unique platform which creates a deep ongoing relationship between your plan and your members, and gives you the "stickiness" that keeps them around. Members engage in a fun, easy to use, and rewarding health engagement tool that has a proven record of getting people to actively participate in their health: 76% of members return to the site 2 or more times per week, and stay on the site almost 10 minutes per visit.
We're thrilled to offer this first-of-its-kind engagement platform specifically tailored to the needs of Medicare, Medicaid and ObamaCare exchange members with Novu. Check out the product on the GHG website: https://www.ghgadvisors.com/who-we-are/our-partners/novu
Resources
New Webinar with John Gorman: Join him on April 2 for this complimentary presentation. "Member-centricity is more than a catch-phrase. How enhancing member engagement impacts the top AND bottom lines." Register now.
Learn more about the GHG-Novu partnership by reading our press release.
Join John Gorman, Novu's Tom Wicka, and dozens more industry thought leaders at the 2014 GHG Forum. Full agenda just released.
Lighting the Path in the Golden Age of Government-Sponsored Health Programs: Join Us for the GHG Client Forum
More than 300 guests will convene on May 1-2 at the Red Rock Casino in Las Vegas for the 2014 Gorman Health Group Forum, our annual strategic retreat for leaders in government-sponsored health programs. This year's gathering promises to be the most actionable, content-packed conference you could attend on how to succeed in this new Golden Age of government business. And when the learning and planning is done for the day, we will celebrate this unique moment in health care history as only GHG can in Vegas. Here's what's happening this year and why you've got to join us:
- The event features 27 content-charged sessions, including multiple presentations on Star Ratings tactics, quality improvement, risk adjustment, and compliance challenges unique to Medicare Advantage and Part D, Medicaid, and the ObamaCare exchanges
- A keynote presentation from CMS leadership
- An expert roster of presenters from Gorman Health Group and leading health plans in government-sponsored programs. No fluff, no sales pitches, no history lessons -- it's all about what to do NOW
- Approved for up to 12 continuing education credits from the Compliance Certification Board
- The perfect off-the-strip venue to minimize distractions during the day, but close enough to the action to make plenty of bad decisions in the evenings. ;)
Based on feedback from last year's Forum, I'm speaking in three separate sessions on overall strategy and implementation planning for government programs. If you've heard my "state of the industry" presentation before, you may think you know what to expect from me on stage. Think again. This is my favorite gathering of the year, and I'm building three brand-spankin' new presentations that are focused on specific steps and mileposts your organization needs to reach this year in care management innovation, risk adjustment, Star Ratings, and operational performance improvement. In each session I'll drill down to specific steps, and we'll leave you with a self-assessment tool in our closing session to help track your progress.
Many of our clients use the Forum as an offsite retreat for their government programs executive teams, and so we offer huge group discounts to encourage it. It's a unique opportunity for team-building and action-oriented planning and budgeting.
If government-sponsored health programs are central to your company's future, do yourself a favor and join us in Vegas. You'll come back tired, happy, and ready to win in this crazy new environment of health reform.
Don't believe me? Hear what last year's attendees thought about the event, and why they keep coming back for more.
Resources
Register today for The Annual GHG Forum held May 1-2 at the Red Rock Casino and Resort in Las Vegas. This two day event is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population.
On April 11, Bill MacBain and Jean LeMasurier will be back, and this time joined by John Gorman, Executive Chairman of GHG, to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now >>
Innovating in 2014
CMS has developed an Innovation Center to address health care payment and service delivery models. It is a great site to find information about current Innovation Model Partners, and a place to share your ideas on how care can be delivered and paid for in ways that will lower care cost and improve quality of care. As always, the service to beneficiaries is at the heart of these initiatives, and for the program to continue, partners must be innovative.
There is also room for innovation within a Medicare health plan or Part D sponsor in terms of operations and compliance. You have heard that necessity is the mother of invention, and we often hear that departments need more money, more staff, and more technological resources in order to meet their needs.
This doesn't mean that those needs are always met. That is why it is important to be creative with the tools and resources that you have. How can you implement best practices without the budget required? Without the outline or work plan for success? Have you developed a checklist of necessary things to do, and can you accomplish those things with the staff you have? Are you and your leadership all aware of what the highest risks are to the organization, and how those risks might be affecting Star ratings?
At this year's GHG Forum, we will be addressing these types of issues facing our partners, and you will notice that we will consistently be encouraging innovation throughout the event. No problem is solved overnight — except perhaps the problem of getting a good night's sleep — that can be solved overnight! Join us and fellow attendees to gain valuable insight into what works, what doesn't, and allow necessity to spark inventive actions that you can take back to your organization. In the meantime, tell me what troubles you in your efforts to maintain an effective compliance program, or even in operational shortcomings. We are always happy to brainstorm and share ideas. You just might get a Forum discount code from me just for sharing your pain points.
Resources
Register today for The Annual GHG Forum held May 1-2 at the Red Rock Casino and Resort in Las Vegas. This two day event is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population.
On April 11, Bill MacBain and Jean LeMasurier will be back, and this time joined by John Gorman, Executive Chairman of GHG, to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now >>
2015 Medicare Advantage Draft Rate Notice is a Bear: Messy, Noisy, and Smells Like Roadkill
Friday after the close of business, CMS released the draft 2015 "call letter", the rate announcement for Medicare Advantage. As expected, it's a bear: messy, noisy, and smells like roadkill. It's just about a worst-case scenario for flabby, distracted, uncommitted health plans in Medicare -- the roadkill to come. The table is now heavily tilted against low performers who can't keep up. Some topline observations:
- The benchmark calculations were anticipated and about as rough as they could be under the Affordable Care Act. Having said that, for the "glass half-full" types, the average MA benchmark is still 103.4% of Medicare fee-for-service expense. In the 1990's under the old AAPCC methodology, all plans got 95% of fee-for-service, and plenty of plans were profitable -- and that was before risk adjustment and Stars. We knew the Bush party was over. It's time to get over it and push forward because the only way out now is through.
- The Star Ratings quality demonstration is officially over, and those plans below 4 Stars are now leaving a blood trail in the snow. After this year, as required under the ACA, all plans above 4 Stars will get a 5% bonus, while those below get nothing.
- CMS makes it clear in the call letter that it will terminate sub-3-Star plans for three consecutive years at the end of 2014. The reaping is coming in a few short months.
- The demo's conclusion is a grave wound for 3.5 Star plans, who just missed the threshold and take an additional 3.5% cut for added misery.
- At the same time, CMS made a big move to remove Stars as a barrier to market entry for new plans, especially those spawned by high-performing veteran organizations. A new plan starts out with a 3.5 Star rating now -- and will receive the 3.5% bonus; a new plan born of a veteran MA organization gets a weighted average of all its other plans. It's a welcome mat for Stars heroes like Kaiser, Providence, and CIGNA to expand to new markets, especially those with weak competition.
- The risk adjustment provisions were very tough, but leave significant maneuvering room for sophisticated plans to adapt their much-maligned home visits into a mobile medical home model that closes gaps in care for the chronically ill.
- It's the beginnings of good policy but not there yet, and CMS is giving the industry an opportunity to shape it. We should not fight this policy change and should embrace the dialogue.
- The home is the most underutilized source of care for frail elders, and risk adjustment must be much more than a data collection exercise.
- While we got some hidden rate relief in a slightly favorable FFS normalization factor, we only anticipate 300 bps improvement on average, but for those flabby plans who can't keep up, the impact will be much less.
Our estimate is that the average MA plan will experience a real cut in payment of -4.9% if the draft is finalized in April. This includes a rough estimate of the impact of the new risk adjustment rules, and the average impact of the end of the Stars demo.
If this rate announcement is enacted, it's survivable for the adaptable and the high performers -- like the old adage about walking in the woods with a friend when you get chased by a bear, you just have to outrun the other guy. There is no question the 2015 call letter is an evolutionary event and some inferior species will be eliminated.
Want to know more? Watch this space for tons of additional resources from the veteran Gorman team.
Resources
Sign up for a Free GHG web account and receive an alert when GHG's summary of the draft 2015 "call letter" is available.
Join us on Thursday, February 27 to hear financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier review critical take aways from the CMS Advance Notice, and what MA plans should prepare for in the next 45 days. Register >>
John Gorman featured in Wall Street Journal article "Government Proposes Cuts to Insurers' Medicare Payments." Click here to read more.
On April 11, Bill MacBain and Jean LeMasurier will be back, and this time joined by John Gorman, Executive Chairman of GHG, to offer insight on the Final Rate Announcement from CMS. You will walk away from this session with critical to-do items and issues to tackle in order to ensure your success in 2015 and beyond. Register now >>
Register today for The Annual GHG Forum held May 1-2 at the Red Rock Casino and Resort in Las Vegas. This two day event is designed to provide best practices for the decision makers of organizations serving Medicare members, Exchange beneficiaries, and the Dual eligible population.
John Gorman Comments on CMS Proposed Rate Cuts in Modern Healthcare Magazine
CMS is scheduled to release initial guidance on Medicare Advantage (MA) rates for 2015 that insurers have estimated could reduce payments by as much as 7 percent next year. Insurers say cuts of that magnitude could cause premium increases and benefit reductions that could severely impact seniors.
In a recent article featured in Modern Healthcare Magazine regarding proposed MA rates, Paul Demko, provides insight into the scheduled release and interviewed Gorman Health Group's Executive Chairman, John Gorman, on what is likely to happen when CMS releases proposed cuts later this week.
Create a free Modern Healthcare web account and read the full article here,
Resources
Join Gorman Health Group financial expert and former health plan CFO, Bill MacBain, and former regulator and industry-renowned policy expert Jean LeMasurier for a 60 minute webinar presentation on February 27. Bill and Jean will review critical take aways from the CMS Advance Notice, and what Medicare Advantage Plans should prepare for in the next 45 days. Register now.
A recording of the webinar is now available on the "Financial Impacts of Growth and Attrition." Gain insight into the significant gains and losses health plan leaders need to account for when formulating their strategy in response to enrollment fluctuations. View the recording now.
ObamaCare's Winners and Losers -- Consumer Edition
I got my start in DC some 23 years ago as a reporter, and the profession's credo is always to "afflict the comfortable and comfort the afflicted." ObamaCare is the story of a lifetime for enterprising journalists, and the really poignant anecdotes that can shape and move public opinion -- and therefore politics -- are just beginning. Small stories will go viral in the echo chamber of 24-hour news cycles and social media in the coming weeks as enrollment and coverage begins in earnest. Here's how these very personal stories of what ObamaCare means to consumers will break down.
University of Michigan professor and senior Brookings fellow Justin Wolfers created a chart depicting the "winners and losers" under the Affordable Care Act, sourced to a Ryan Lizza article that used estimates from M.I.T. economist Jon Gruber, a former adviser to Mitt Romney.
The chart shows how the GOP and ObamaCare dead-enders have pumped up media coverage of the relatively small number of Americans whose substandard individual market plans were cancelled. It also shows how many Americans are unaffected by health reform. But it's not without its problems and does manage to oversimplify things, but as a visual processor, I appreciate this stuff.
You could say the biggest losers under ObamaCare are patients with expensive medical conditions who don't qualify for the just-extended state high risk pools and whose current plans have been canceled, and who are having trouble getting through HealthCare.Gov to purchase coverage by Dec. 23 -- the deadline for buying insurance that begins January 1. WaPo had a good piece with some gut-punching anecdotes here: ObamaCare losers who have given up hope. The best you can hope for in first quarter of 2014 is that vulnerable patients don't die because of an administrative screw-up or lapse in coverage. Those are the kinds of anecdotes that could become serious liabilities for the President, and it'd only take a few to shatter what little public or political confidence in ObamaCare still exists.
Other losers include those with lower incomes who live in states that decided not to expand their Medicaid programs. The Advisory Board looked at which states will have the most uninsured in 2016. Being uninsured but too poor for exchange subsidies in a state that refuses to expand Medicaid, or being an undocumented immigrant and ineligible for ObamaCare benefits, means you lose out.
ObamaCare's consumer winners thus far include the "bro's" and young invincibles who can now remain on their parents' health plans until age 26; consumers with serious pre-existing conditions who have been denied health insurance; and residents of states that opted to expand their Medicaid programs up to 138% of the federal poverty level. Anecdotes abound here too, from across the country, like these from Nebraska:
Obamacare will benefit retired Windstream Manager John Gapp, who now pays $1,375 a month for a plan available through his former employer that covers him and his wife. The premium is high because he pays both company and employee shares. Gapp, who isn't yet 65 and eligible for Medicare, wasn't able to get less expensive private health insurance last year because of a pre-existing condition -- a mild heart attack in 2012. He hasn't signed up for an ACA policy yet, but he has done some online window shopping. Because Gapp's income is less than 400 percent above the federal poverty level, he will qualify for some subsidy and likely will pay $580 to $800 less per month, depending on the plan he chooses. Without the subsidy, his insurance premiums under ACA plans would be similar to what he's now paying, $100 less for one plan and $125 more for a so-called Cadillac plan that has better benefits than the one he has now.
Lori Schwartz will pay $200 less a month for a better insurance plan under Obamacare, because insurers no longer can charge people more or deny coverage because of pre-existing conditions. Schwartz, who has diabetes, has been buying insurance under a state program for people who couldn't get health insurance on the private market. She was paying more than $750 for a policy with a $5,000 deductible. Her husband, Mark, recently signed her up online for an ACA-approved plan that will cost $526 a month, even with no tax subsidy. And it is a much better plan, with a $1,500 deductible, she says.
There will be plenty of ammunition in the coming weeks for both sides of ObamaCare. The trick for issuers is to ensure you're not the one plastered across your hometown paper or Twitter by a wipeout in your enrollment department this month.
Resources
Every health care organization is looking for improved outcomes, better compliance and enhanced process efficiency when it comes to managing membership and premium payments. GHG's Valencia was designed specifically to meet those needs.
Aaron Eaton, Chief Development Officer at Gorman Health Group, discusses the latest announcement from CMS related to payment process changes for the Health Insurance Marketplace. Access the podcast >>
In this recorded presentation Gorman Health Group strategy and data analysis experts discuss actual case studies that show how plans can mine data for precious insight that can help improve performance.
CMS announcement regarding 820 payment files and the interim process poses a new challenge for Issuers in the Health Insurance Marketplace
It's a rough road ahead for Issuers trying to get paid in the Health Insurance Marketplaces.
The latest announcement from CMS on Monday, December 2, 2013 related to payment process changes for the Health Insurance Marketplace present yet one more challenge for Issuers. As GHG predicted several weeks ago, each new phase of the rollout is going to have bumps in the road or road closures in some cases.
The announcement that 820 Payment Files will not be issued in January to track detailed subscriber payments for Advance Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR) subsidies is a total road closure. Please follow the Detour signs if you want to get paid.
The detour, in this case, is an interim process designed to allow the Issuers to get paid the subsidies they need in order to operate this line of business. But it will not come easily. The burden has been shifted from the government back to the Issuers to produce a monthly file requesting payment for the subsidies.
While this seems simple on the surface, the last minute changes present several challenges that must be solved:
- Ability to develop new systems and processes to accurately calculate data fields needed for payment
- Transition from interim process to 820 files once they become operational
- Effective 820 and total premium reconciliation following interim process
For GHG's take on each of these critical areas, listen to our podcast where I dive into particular details regarding each one. Access the podcast now >>
Resources
Every health care organization is looking for improved outcomes, better compliance and enhanced process efficiency when it comes to managing membership and premium payments. GHG's Valencia was designed specifically to meet those needs.
GHG announced its partnership with TriZetto to offer an end-to-end reconciliation solution that will enable health care payers to successfully participate in the Health Insurance Marketplaces. Together, Valencia™ and TriZetto will provide health plans the necessary reconciliation capabilities needed to analyze data quickly and efficiently. Learn more about the service >>
Join us December 11 from 2:00 — 3:30 pm ET for a lively session with Gorman Health Group strategy and data analysis experts who will discuss actual case studies that show how plans can mine data for precious insight that can help improve performance. Register now >>