Lake Wobegone Exchanges
One of the most frequent questions I've been getting on the health reform speech circuit has been what our expectations are for enforcement activity in the exchanges in Year 1 -- and the answer is just about none.
For the 16 states launching their own exchanges this Fall, much of the focus will be on basic administrative functions involved in getting the millions expected to enroll through the system. For the 27 states where the Federally-Facilitated Exchange will be operating, the answer is really nothing. The Feds are painting a picture of "Lake Wobegone Exchanges", where all of the plans are strong, all of the brokers and agents are good looking, and all of the stakeholders are above average.
Year 1 of the Exchanges was always going to be about getting the "pig through the python" of the enrollment and eligibility process. It was basic fulfillment functions like verifying "clean" enrollments, entering and reconciling new members into plans' systems, and issuing membership cards that tripped up the launch of Medicare Part D in 2006. The rollout of the Exchanges will see the same struggles. But CMS's latest rule points to an enforcement "hall pass" for participating plans in Year 1.
CMS's latest exchange regulation estimated that there will be more than 250,000 agents and brokers registered in the Federal Exchange -- and went on to say it expected to suspend or terminate 2. Not a typo. CMS seems to be saying that their agent oversight role is limited since states have primary responsibility for broker licensing and monitoring -- but still, 2 out of 250,000? Really? CMS further estimated there will be 409 Qualified Health Plans (QHPs) in the Federal exchanges, but only 1 civil money penalty and only 1 plan termination. Talk about a paper tiger.
CMS will not do much but play "whack-a-mole" with anything egregious that comes up in QHPs. There will be little to no unilateral state enforcement in the first couple years of the Exchanges. And there won't be any kind of organized compliance process for plans in the exchanges like we see in MA until at least year two or three. So bottom line: the plans don't have to worry about the hammer coming down in Year One -- unless they kill someone with an administrative screw-up. Lake Wobegone for sure.
Resources
Listen to a three-part podcast series where GHG Executive Chairman, John Gorman discusses the Importance of a Readiness Checklist for the Exchanges for Sales Marketing Enrollment and Risk Adjustment.
Learn how Gorman Health Group's web-hosted modular software solution, Sales Sentinel, makes sales agent training, credentialing, onboarding and ongoing oversight a smooth and seamless process.
When reconciling Plan data to CMS' records, you have to deal with a number of issues. Listen in as Gorman Health Group's Senior Consultant Chris Groves discusses these issues and the importance of reconciling member data.
The Future of Medicare Advantage
The Alliance for Health Reform and the Kaiser Family Foundation (KFF) sponsored a meeting on the Future of Medicare Advantage (MA) on the day that KFF reported that MA enrollment had reached a historic 28 percent of the Medicare population. A major theme of the conference was whether MA enrollment could be sustained or increased in the face of substantial ACA budget cuts in the next few years. The discussion took place against the backdrop of substantially revised Congressional Budget Office (CBO) projections in their May 2013 Medicare baseline that modified a prediction that MA enrollment would decline to 11 million by 2017 to a new assumption that MA enrollment would increase to 21 million by 2023. CBO did not explain their shifting opinion and the panelists had no inside information on the CBO assumptions.
Most of the discussion was optimistic that MA enrollment could be sustained if not increased even in the light of budget cuts. MA plans are projecting enrollment increases of 9-10 percent for 2014. Mark Miller of MedPAC cited analysis that MA bids have come down in recent years (e.g. MA plan bids are 96 percent of FFS costs on average and HMO bids are 92 percent) suggesting that MA plans could continue to successfully compete against Medicare FFS even in areas that will be paid at 95 percent of FFS. Carl McDonald cited 2010 as a historical precedent when MA plans were able to manage large program cuts by lowering costs. He also noted research shows that current Medicare enrollees are very loyal and do not leave their plans even when premiums are increased or benefits reduced. Alissa Fox from the Blue Cross and Blue Shield Association argued that plans will have a hard time absorbing all of the upcoming cuts and that their Association is lobbying for Congress to repeal the upcoming $100 billion tax on insurers. George Strumpf of Emblem Health says he was pessimistic about future MA enrollment and reminded the audience of the experience in the late 1990s when budget cuts drove half of the Medicare managed care plans from the market.
I was at CMS when the Medicare managed care market practically collapsed and I hope that will never happen again. The environment is very different now and will be in the future. For example, demographics have changed and baby boomers who are experienced with managed care can be expected to choose a private plan when value can be demonstrated. MA plans have more of an incentive to stay in the program since governmental spending is now a significant and growing part of their business. Even if some plans leave the program because they are unable to manage the cuts, there are a large number of plans available in the market so beneficiaries will not have to return to FFS Medicare. But more importantly, for the foreseeable future, the FFS program is expected to remain unmanaged and inefficient and thus most MA plans, even if they have to raise premiums and reduce extra benefits, will be able to successfully compete with FFS and its unpredictable high out of pocket costs or FFS with high priced Medigap supplemental policies
Resources
Visit our website to learn more about how Gorman Health Group can help support your Medicare Advantage goals.
No matter what delivery system arrangement you currently have, or what course you intend to pursue, GHG can help. Visit our website to learn more.
New in our Reality Check Webinar Series!
Complimentary Webinar June 25: "How Medicare ACOs and Other Risk-bearing Provider Organizations can Transition to Medicare Advantage"
Choosing a Call Center? Five Must-Ask Questions
This fall promises to be one of the busiest in history for health insurers with the flurry of Health Insurance Exchanges (HIE), Annual Election Period (AEP) and the implementation of the Affordable Care Act (ACA).
Unanswered calls to insurance companies by potential customers will become forfeited opportunities that may never be reclaimed. Many companies will rely on call centers to handle their call overflow, many for the first time. Consider these five questions when selecting a call center:
1. TECHNOLOGY: Does their technology meet your needs?
The complexity of the insurance industry calls for innovative technology solutions: practical solutions that improve the process for agents and customers alike, and proactive solutions that are flexible enough to handle diverse responsibilities in intuitive ways. Can their call center directly connect your callers with agents in the field instantly? Can they track responses at the individual record level? Do they offer dashboards and reporting in real time?
2. TRAINING EXCELLENCE: Are their CSRs well-trained on Medicare and your plan's protocols?
Harper Lee wrote in To Kill a Mockingbird, "We're paying the highest tribute you can pay a man. We trust him to do right. It's that simple." Like Atticus Finch, trust in the training call center agents receive is a key consideration in a partner. After all, they represent your Medicare plan(s), your brand and your relationships. Could your call center partner handle the scrutiny of a CMS audit?
3. AGENT EXPERIENCE: How experienced are their CSRs?
Exerience is critical in the insurance industry. Experienced agents could mean the difference between a successful sales campaign and a failed one. Because AEP is condensed, inexperienced agents shouldn't gain the necessary experience on the fly.
4. QUALITY & COMPLIANCE Is a robust quality and compliance program with metrics reporting in place?
Quality and compliance go hand-in-hand. Everyone's accountable to CMS. A good compliance program protects clients, plan members and prospective members alike.
5. ADAPTABILITY: How much flexibility and input is permitted?
Flexibility and adaptability are the bread & butter of a vendor partnership, particularly when responsibilities are outsourced. Will you have access to a support team when needed? Such access ensures seamless support of day-to-day campaign challenges. A high-quality support team is agile, adaptable and attentive to detail. Partnering with an experienced call center helps you stay competitive, provides excellent caller experiences, and helps grow your membership.
Resources
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
Every OEV Call Should Be a Welcome Call
In the world of insurance sales, making the right call during a sales presentation and getting the call right for compliance purposes is critical. Outbound Enrollment Verification calls (OEV) calls are not just for an applicant's protection — they're the insurance industry's version of instant replay!
Verification calls are "welcome calls" with a new member. A verification representative should be on every OEV call. Just because OEV calls are a CMS requirement does not mean verification specialists should just "check the box" and read the questions in a Ben Stein-monotone.
Remember, all plan sponsors are required to conduct OEV calls for enrollments originating from both independent and employed agents/brokers to ensure applicants understand the plan's rules.
Here are some other tips to ensure a plan sponsor makes the most out of every OEV call:
- WRITE YOUR OWN SCRIPT: The OEV call is your first call with a new member following enrollment. It's important to create a natural, personable script to make a favorable first impression. A good OEV script should flow comfortably.
- STAY POSITIVE, WARM AND ENGAGING: Verification calls are often a customer's first point of contact since their enrollment. It's important that OEV agents help to put their company's best foot forward. Verification agents should use a warm tone and shouldn't shy away from emphasizing their company's brand. Use the opportunity to engage the member.
- EMPLOY A COHESIVE PROCESS: Some plans face challenges with OEV calls because their process is disjointed. Instead, work to create internal automation that pushes the calls and letters when necessary, or partner with a vendor that can do it for you.
- CONDUCT OEV CALLS ASAP: Make CMS-mandated OEV calls as soon after the enrollment as possible. (OEV calls must be made to an applicant after the sale; they cannot be made at the point of sale.) Make the call sooner rather than later.
- ARM OEV AGENTS WITH RESOURCES: Plan sponsors should ensure their verification agents have a strong knowledge base of plan details like doctors and hospitals in the network (if applicable), the co-pays for different prescriptions and the maximum out-of-pocket. In short, verification agents should be well-trained and have access to resources.
- IT ALL STARTS AT ENROLLMENT! The enrolling agent can help the OEV process by setting expectations. Our Bloom phone and field agents explain applicants what the OEV process is, when to expect the call and what to expectduring a call. Enrolling agents should stay connected with OEV agents to ensure a healthy level of coordination and cooperation.
Remember, you get only one chance to make a first impression -- and that impression begins with the OEV call!
Resources:
The Bloom Call Center is licensed in 48 contiguous states and offers marketing, call center and technology solutions to the health care industry. Since 2007, Bloom has participated in over 55 million conversations about insurance products, submitted over 200,000 applications for insurance, and set over 150,000 appointments for seniors to meet with Licensed Agents. Bloom is a proud partner of Gorman Health Group. Click here to learn more.
To learn how you can put Bloom's Call Center agents to work for you, visit our website.
Drugs and Patient Safety - the Disconnect
The recent Washington Post piece published May 11, 2013, on the prescription drug dangers for Medicare patients raises some interesting points about the current prescribing habits of some outlier physicians/prescribers, as well as the lack of a coordinated effort to exclude those same prescribers from participating in Medicare.
The use of atypical antipsychotics (identified by CMS as protected class drugs) in the elderly is particularly troubling in light of numerous studies and a FDA Black Box Warning which states in part "Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Although the causes of death were varied in clinical trials, most of the deaths appeared to be either cardiovascular (e.g. heart failure, sudden death) or infectious (e.g. pneumonia) in nature." Those with family in Long Term Care facilities or those working in LTC settings know that the staffing model is dependent on quiet, non-disruptive patients—unfortunately atypical antipsychotic medications are often used to ensure that scenario.
The High Risk Medication list or revised Beers criteria is one of the Part D performance or Star measures. Part D sponsors have been fairly successful in the past couple of years at deleting these drugs from the formulary or adding a CMS approved prior authorization edit for > 65 years old. Has this completely eradicated the use of drugs like carisoprodol (Soma) or cyclobenzaprine (Flexeril)? No, but physicians do have to provide a medical necessity explanation or describe why the benefit of using the drug outweighs the risk.
More troubling and potentially in most need of action is the inability to exclude those "prescription mill" physicians/prescribers from participating in Medicare. The data available to plan sponsors listing the highest volume opiate prescribers is actionable information. Where documented, proven and egregious prescribing behavior is found, State Board, Medicaid and Medicare exclusion should be a logical outcome and the best route to enhanced patient safety.
Resources:
Senior Consultant, Pharmacy Services, Roxanne Spalding dives deep into the barriers to medication adherence, for both providers and health systems, and outlines varied multi-faceted strategies to overcome them in this white paper.
Learn how GHG 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.
Gorman Health Group can help you develop unique and adaptable management programs for use across the many departments managing components of your Star Rating, visit our website to learn how.
Proposed Benefits Manual Changes
On April 25, 2013 CMS issued a proposed update to the Benefits and Beneficiary Protections Chapter (Chapter 4) of the Medicare Managed Care Manual. The CMS cover letter provides a good summary of the changes that they are proposing to make. Most of the changes are clarifications to existing policy, for example, providing Medicare Advantage plans (MA) with the option of charging beneficiaries higher cost sharing for non-emergency out-of-network services and prohibiting MA plans from imposing policies that prevent enrollees from accessing a Part B drug administered in a physician's office. CMS is removing the example of how total beneficiary cost-sharing (TBC) is calculated and instead stating that TBC requirements will be included in the Call Letter, as they did for 2014.
CMS is adding several items to the list of services that are not eligible to be approved as a supplemental benefit: electronic medical records and electronic data storage devices; loaner DME when rented or owned DME is being repaired since this is required under Medicare Part B; rewards and incentives used as marketing tools; brain training and memory fitness services since these services are not clinically accepted; and case management and care coordination services since these are required in all coordinated care plans.
CMS is adding two rules to ensure coordinated care that could result in new documentation requirements for some plans: (1) enrollees are informed of specific health care needs that require follow up and receive information to support and promote their own health and (2) systems are employed to identify and address barriers to enrollee compliance with prescribed treatments or regiments.
CMS is adding a definition of prior authorization and referral including a clarification that a coordinated care plan cannot require a gatekeeper referral for out-of-network dialysis. CMS is also clarifying renewal policies to allow a non-segmented plan to renew as a segmented plan or to consolidate into a segmented plan and ask to transition current enrollees to plan segments.
CMS is clarifying benefits during disasters so that CMS may use waiver authority to authorize Medicare Administrative Contractors to pay for Part C services and have the Contractors seek reimbursement from MA plans retrospectively.
Resources:
Get access to the same tools and analysis our consultants use to stay on top of their game, get the Point today.
Attend the 2013 GHG Forum and hear from the experts about the integrated strategies you must implement to ensure success across government health care programs.
Sign up for the Point and get direct access to more regulatory summaries from Jean LeMasurier.
Medicare Essential — Is this the future of Medicare?
According to The Hill's Elise Viebeck President Obama is receptive to combining Medicare Part A (in-patient hospital) and Part B (outpatient and doctor) deductibles, into a single deductible just like every other insurance scheme in the US. Predictably those to his left complained, maybe because Virginia's Eric Cantor also likes the idea. The impact would raise the deductible for people who use only physician services, lower it for anyone who is hospitalized, and, net, save Medicare money by shifting more costs to beneficiaries. However, some of the savings would also be used to add an annual out-of-pocket cap on what beneficiaries would have to spend. This is good insurance logic: don't cover relatively low cost, predictable expenses. Focus coverage on protecting beneficiaries from catastrophic loss.
The combined deductible idea is echoed in a recent article in Health Affairs that proposes unification of Parts A and B, and Part D drug benefits. The Health Affairs article also proposes reducing beneficiary cost sharing to levels comparable to Medicare Advantage plans, eliminating the need for Medicare Supplemental coverage. The new Medicare plan, called Medicare Essential, would become the default for people who qualify for Medicare for the first time. New Medicare beneficiaries could opt out and take old traditional Medicare, and go buy their own Part D and Medicare Supplement plans, or they could buy Medicare Advantage plans. Medicare Essential would have a much higher premium than Medicare Part B, but the authors of the article claim that the overall cost would be less than Part B plus Part D plus the full-coverage Medicare Supplement Plan F that most seniors select. So proponents could argue that the added cost of the increased premium is a bargain and that people could always opt out and avoid the higher cost if they wanted to. Medicare Essentials could show significant savings by avoiding the broker commissions that add to the cost of Medicare Supplemental and Medicare Advantage plans. Whether the new program would be able to achieve the supposed 2% administrative cost ratio sometimes claimed for Medicare is highly suspect, but elimination of the need to re-process claims to pay Supplement benefits, along with simplification of coverage rules overall, would probably yield some further efficiencies.
This proposal could significantly change the dynamics of the Medicare market place. For starters, Medicare Supplemental plans would be in trouble. Who would opt to pay more for similar coverage when you are already enrolled in a less expensive plan? Also, it's not clear whether Part D plans would survive for long if Medicare Essential provides the same drug coverage. The effect on Medicare Advantage is less obvious, but Essential would certainly put pressure on Advantage premiums, since the benefits would be comparable.
For those who want to speculate further, imagine a competitive marketplace along the lines of Paul Ryan's plan, but with Medicare Advantage plans competing with Medicare Essential. In the competitive market, the federal subsidy would equal the premium of the second cheapest plan in each market, and the current benchmark approach would go away. Beneficiaries choosing a more expensive product, whether Medicare Advantage or Medicare Essential, would pay the difference. People who pick the cheapest plan get a check for the difference.
Oh, and one more thing. Medicare Essential benefits would be more generous for services provided by preferred providers, just like a PPO benefit design.
This is something to watch. The Health Affairs article, available to subscribers, or to others for a fee, is titled "Medicare Essential: An Option to Promote Better Care and Curb Spending Growth," in the May 2013 edition.
Resources
Attend the 2013 GHG Forum June 13-14 in Washington, DC to hear more about Medicare's Future and what it means for Medicare Advantage.
Visit our website to learn how Gorman Health Group can help support your Medicare Advantage goals.
Medicare Shared Savings Program Circa 2014
Anyone who has paid attention knows that since 2011 more than 200 Medicare ACO's have been operationalized. If you add in commercial ACO's, the number is closer to 400.
Still sitting on the fence wondering if ACO's will survive? Consider this, the underlying construct for a Medicare Shared Savings ACO is to promote accountability for care of Medicare Fee for Service (FFS) eligible beneficiaries, to improve coordination of care under Medicare Part A and B, and to encourage investment in infrastructure and redesign in care processes. Not a bad set of goals when it comes to patient care under any circumstance, right?
So why not seriously consider whether an ACO initiative is right for your organiztion?.
If you are interested in pursuing a Medicare Shared Savings ACO, the first step in that process is to file your Notice of Intent, (NOI). You can file that notice anytime between now and May 30th, 2013.Keep in mind that it is non-binding, but by doing so; you get a seat at the table. After you fill out the NOI, you will receive a confirmation notice from CMS containing your ACO ID number, which will be needed to complete the CMS user ID form required to submit an application. The due date for obtaining and submitting a User ID form is June 10th, 2013. It takes up to three weeks for CMS to process your User ID form so the form should be filed immediately after you file the NOI. In other words act early.
Once processed you can now begin to work on the actual application, which is due anytime between July 1st and July 31st, 2013.
Upon reading this blog, don't go out and look for the application on the CMS website because you won't find it. CMS has announced that it will post the application sometime in June of 2013. However, don't let that deter you from beginning to pull together content for the various application components.
Having helped multiple interested organizations in successfully filing ACO apllipcations during the last two years, and actually serving on the board of a currently operational ACO, we know what CMS is looking for in respect to application content. We also know what the challenges and lessons learned are with respect to ACO implementation.
If you are interested, contact us today. We know we can help you.
Resources
Attend the 2013 GHG Forum, June 13-14, in Washington, DC and hear from key decision makers at cutting edge ACOs across the country about lessons learned during their organizations' evolution — from conception to execution of varying ACO models.
Read more on ACO opportunities in our white paper on the topic.
Read about how three Gorman Health Group clients were approved by CMS to become Operating Accountable Care Organizations.
QHP Submission Reprieve
OK, so maybe reprieve is not the right word, since according to Google it is defined as "a cancellation or postponement of a punishment". If you consider a deadline a punishment, then I suppose this is a reprieve, but I digress.
HHS sent out an email Thursday night informing the industry that those issuers who have begun the QHP application process as of 8 pm, will be considered as having met the deadline. This was subtly inserted at the start of the third paragraph so look again if you missed it. This doesn't mean you should rest on your laurels; they expect everyone to attempt to correct and submit all required pieces by 8pm tonight.
Issuers who have completed submissions and would like to submit a petition requesting a Limited Corrections Window must do so by 9pm EDT (formerly 5pm EDT) on Friday, May 3rd by sending a signed letter to CMS_Issuer_Communications@cms.hhs.gov with the subject line "QHP Data Correction Request" and specific HIOS Issuer ID(s), as outlined in the instructions distributed on Monday, April 29th.
If you are trying to decide if you need to submit a petition, CMS states that if you are simply having technical issues with the uploading and the physical acceptance of your documents, then you do not need to do a petition, but instead you have a new window of this coming Monday until 11:59PM Eastern in order to try to get the system to accept your documents. (Remember, HIOS is down this weekend for maintenance.) According to how CMS is responding to Issuer questions on their Open Q&A call, it sounds like they want the petition process reserved for non-technical corrections on completed submissions, such as last minute content changes, or if you just received clarifying guidance and now need to change something that has already been submitted.
Issuers are asking "Well what if we still have technical problems on Monday and didn't submit a petition?" and "Will you have an Open Q&A call on Monday?" At this point, CMS is taking the "We'll-Cross-That-Bridge" stance, so stay tuned.
Resources
Don't let the application process get in the way of your organization's goals. Learn how Gorman Health Group can help ensure you have a smooth and compliant process.
So You Want to File a QHP Application
This will be the title of my instructional pamphlet that I envision sitting in a doctor's office, among other great pamphlets such as "Talking to Your Kids about Drugs" and "Depression: Not Just a Hole in the Ground".
Many of you reading this may also be in the midst of QHP uploading, on the receiving end of such terms as Error, Failure, Pending, and Invalid. Not what you'd call a walk in the park. I had a dream last week that President Obama himself told me personally that the QHP submission deadline would be extended. Anyone else required to eat, sleep and breathe this submission knows what I'm talking about. The message I'd like to send to anyone reading at CMS is this: we are trying. The industry is trying. We would be dismayed to see consumer choices limited due to trivialities such as technical errors.
That being said, my team is grateful for the additional days that CMS granted for the FFM submissions. If your organization falls short due to one of the reasons outlined in CMS' memo, make sure that you submit a detailed petition to CMS by 5:00 PM Eastern Time on Friday, May 3. It must be signed by an officer of the company and include:
- The specific data elements that need correcting
- The HIOS issuer ID(s) in question
- The reason why the data elements must be corrected
- Evidence that documents the issuer made timely and good faith attempt to address the issue at least 48 hours prior to the new deadline, that is, as of May 1, 8:00 PM Eastern Time. Help desk ticket numbers, screen shots, send it all.
Anyone willing to share their battle stories once you are on the other side of the deadline (Friday May 3 at 8:00 PM Eastern Time), feel free to email me. There's satisfaction in knowing you are not alone in Navigating this maze. (Yeah, you see what I did there.)
Resources
Don't let the application process get in the way of your organization's goals. Learn how Gorman Health Group can help ensure you have a smooth and compliant process.