2016 Readiness Review Smaller Size, Bigger Punch.

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won't have an official website for plan sponsors to attest to the readiness this year, they will use other methods to validate compliance. No matter the validation method, CMS' expectations are clear: Part C and Part D plan sponsors should review and validate compliance for each item.

In reviewing the 2016 Readiness Checklist, there are some new and modified requirements as well as other areas of CMS concern.  Regardless of whether or not the items are new to the readiness checklist party, they should all be known to you. If they aren't familiar, you may want to check your Health Plan Management System (HPMS) and regulatory guidance distribution process. CMS indicates at the end of almost every requirement where the guidance for that item came from―what Medicare manual or HPMS memo provides the supporting information for that item. CMS makes it convenient to validate what you are asked to validate and attest.

If you have waited until now to implement or validate new guidance from 2015, it will be a stressful few weeks in what is already a very busy time of year. Several items are heavy-hitters and get into the nitty gritty of processes. As in past years, any items which won't be in compliance are to be reported to your CMS Account Manager. No one likes to be on that list.

Many sections of the Readiness Checklist are smaller but have more potential process changes. "By no means should plans see an abbreviated Compliance and Fraud, Waste, and Abuse (FWA) section and start resting on laurels," said Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). Regan went on to say, "In this year's checklist, CMS issues another reminder about the May 24, 2014, regulation change which requires mandates on Medicare Advantage (MA) organizations to require all of their first tier, downstream, and related entities (FDRs) to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement."

Another change highlighted in the readiness assessment is plan sponsor's appropriate use of extensions for organization and coverage determinations and appeals. In audits, we often see plan sponsors who have failed samples due to extensions granted for contracted providers or when extensions are used early in the process and on a routine basis rather than as an exception. CMS is expecting plan sponsors to review their process for exceptions and ensure they are in compliance.

One change Regan called out is CMS included a recommendation that plan sponsors making pharmacy network changes provide both those pharmacies whose network status is changing and enrollees using those pharmacies with notices of changes specific to their situation. "This is almost certainly a result of CMS' close work with one plan sponsor on effective notification strategies as part of pharmacy network changes. While the plan sponsor had indeed sent letters to supplement the Annual Notice of Changes' (ANOC's) notification of changes, the recommendation is to move to a more personalized notification approach," indicated Regan. "This will allow beneficiaries to make a more informed decision and will also aid pharmacies in understanding their network status."

A senior consultant of Pharmacy & Clinical Solutions at GHG, stated, "The Readiness Checklist is always an excellent method of making sure you have the bases covered for new guidance which takes effect in the new plan year (2016)."  Deb went on to indicate there are three items plan sponsors must pay particular attention to in the 2016 Readiness Checklist for Part D.  They are as follows:

  • The long-delayed requirement "physicians and other eligible professionals who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, unless the prescriber is an ‘Other Authorized Prescriber'." This takes effect on June 1, 2016, and, therefore, plans must confirm their contracted providers, including dentists, are eligible to furnish Part D prescriptions.
  • Also, providers must have a valid prescriber National Provider Identifier (NPI) number for Part D claims to be valid. Specifically, "for plan year 2016 and thereafter, claims for covered Part D drugs must include a valid prescriber NPI. Part D sponsors must submit to CMS only prescription drug event (PDE) records containing an active and valid individual prescriber NPI."
  • Starting on January 1, 2016, it is CMS' expectation Medicare Advantage Prescription Drug (MA-PD) plan members will not leave a network pharmacy without their prescription for a medication(s) where coverage may available under either Part D, Part A, or Part B. Plan sponsors and/or their PBMs must have processes in place so the network pharmacist can exchange information with the plan sponsor or PBM about the member to make the determination about which arm of Medicare will pay.

Parting words from Regan, "CMS makes it clear these are key requirements, and the checklist is not an exhaustive list. Consider these items to be hot topics CMS will hang their hat on in the coming year." The key to successful MA and Part D programs is to know your business better than anyone, including CMS. The Readiness Checklist is one additional tool to do just that.

Resources

If you need assistance in assessing your organization against the Readiness Checklist or in strengthening your MA or Part D program, GHG's knowledgeable team is here to help you. We've been in your shoes and know the pain points and how to move through them. We can help you prevent that punch from being a knock out. Contact me directly at jbillman@ghgadvisors.com.

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>

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by GHG Advisors

A New Report by Kaiser Family Foundation Found Part D Premiums Will Rise an Average of 13% in 2016

We blogged earlier this month about Medicare Advantage (MA) premiums showing slight decreases to no decreases across the board for 2016 based on the Centers for Medicare & Medicaid Services (CMS) estimates.  But what does the landscape look like for Part D?

CMS stated in a September 2015 article, "Premiums in the Medicare Prescription Drug Program (Part D) will [also] be stable next year." Earlier this year, CMS announced the average basic Medicare prescription drug plan premium in 2016 is projected to remain stable at $32.50 per month.1  CMS' Part D average premium estimates include both Medicare Advantage Prescription Drug plans (MA-PDs) and Prescription Drug Plans (PDPs).  If we carve out PDPs from the Part D premium average reported by CMS in September, data shows, for most PDP enrollees, premiums are projected to be higher in 2016 than in 2015, and many will also see higher deductibles and more cost-sharing tiers with coinsurance.2  As cited in a recent Kaiser Family Foundation study on Medicare Part D plan offerings for 2016, the average PDP premium is projected to increase by 13 percent from 2015 to 2016, from $36.68 to $41.46 per month. When looking at the $0 premium PDP options, low-income subsidy (LIS) enrollees will have fewer to choose from.  This means either plan reassignment or beneficiary plan switches will occur for beneficiaries to continue without a premium.

What will this mean for MA plans offering Part D coverage in 2016?  Increased 2016 PDP premiums may contribute to a potential shift in membership from PDPs to MA-PDs this Annual Election Period (AEP). Leveraging this opportunity will require time investment from MA-PDs, educating beneficiaries on how making plan changes could lead to beneficiary cost savings and still meet their Part D coverage needs.

"Premium" may be the first category beneficiaries are looking at, but it is not the only thing beneficiaries consider when comparing Part D options. The entire point of AEP is to offer Medicare beneficiaries the opportunity to evaluate their plan options and choose a plan which best meets their needs.  This means, in addition to premiums, beneficiaries are looking at deductibles, cost-sharing, formularies, and network pharmacies.

In 2016, 84 percent of PDPs will use tiered pharmacy networks, with lower cost-sharing in selected network pharmacies and higher cost-sharing in other network pharmacies. Two-thirds of all PDPs will have deductibles, with a growing share of PDPs imposing the maximum deductible allowed by law, which increased from $320 in 2015 to $360 in 2016, the largest increase in the deductible since the start of the program.2

Now that the cards are on the table, your immediate strategy, as well as that for next AEP, should be examined.  Are you at risk for losing members to competition due to pricing increases?  Are your retention efforts aligned to address this issue? Have you identified opportunities to gain membership and benefit from your competitors' increases?

Have questions or need information?  Contact me directly at nlennig@ghgadvisors.com or Charro Knight-Lilly, Senior Vice President of Client Services, at cknightlilly@ghgadvisors.com.

1 CMS, "Medicare Prescription Drug Premiums Projected to Remain Stable" available at  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-29.html.

2 Oct. 13, 2015 | Jack Hoadley, Juliette Cubanski, and Tricia Neuman, Medicare Part D: A First Look at Plan Offerings in 2016, http://files.kff.org/attachment/issue-brief-medicare-part-d-a-first-look-at-plan-offerings-in-2016

 

Resources

The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>

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by GHG Advisors

The 2016 Star Ratings: Finding Calm in the Chaos

All great changes are preceded by chaos, and the Centers for Medicare & Medicaid Services (CMS) release last week of the 2016 Star Ratings certainly introduced a great deal of chaos for Star Ratings teams throughout the industry.  With approximately 5% of additional reimbursement tied to ≥4-Star performance, health plan leaders are either taking a deep breath this week (if they earned ≥4 Stars and qualified for Quality Bonus Payments) or doing their best to quell the inevitable panic if the 4th Star eluded them.

CMS continues to leverage Star Ratings to support improvements in member perceptions and longer-term, sustainable improvements in health plan performance and health outcomes. CMS continues to make rapid, continuous changes among measures, cut points, and program criteria.  The speed and extent of change reinforces the need for a seasoned, dedicated Star Ratings leadership team which embraces and manages Star Ratings as a holistic, silo-busting program. It's vital for health plans to simultaneously excel not only in their clinical and pharmacy quality functions but also in every other health plan function.  This includes everything from care coordination, network operations, member experience, risk adjustment, appeals and grievances, and compliance, to claims and encounter data and analytics, marketing, and every other department in the organization.

As we adapt to the first Star Ratings cycle with no predetermined thresholds, it's clear there is very little low-hanging fruit left in the Star Ratings program.  It's time for us to climb the tree.

With budget season upon us, it is an ideal time to evaluate Star Ratings strategies and work plans to ensure 2017 investments are wisely made.   Now that the 2016 Star Ratings are out, take an objective look at your Star Ratings programs to ask:

  • Are we investing adequately in the areas where we need the most Star Ratings lift?
  • Will our Star Ratings initiatives achieve our goals?
  • Are we conducting the right interventions, with the right members, at the right time?
  • Are we adequately integrating medication management and behavioral health into our Star Ratings programs?
  • Are we adequately coordinating provider and member engagement activities?
  • Are our provider contracts and pay-for-quality programs designed adequately to sustain success in the new Star Ratings environment?

If your plan achieved 4 Stars this year, this is no time to rest.  The 178 plans at 3 or 3.5 Stars in 2016 are working hard to achieve 4 Stars this year, and with CMS' bell curve, this means some of the current 4-Star plans will drop in 2017.  And don't forget — there are another 188 Medicare Advantage plans not rated in 2016.  This huge group of plans will impact the bell curve as they receive their first ratings.

If your plan missed a 4-Star Rating this year, now is not the time to panic.  There is still time to influence your 2017 Star Ratings, particularly since the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) and Health Outcomes Survey (HOS) surveys will not be fielded until early 2017.  But since time is definitely of the essence, it is important to invest time and resources wisely into the areas with the greatest opportunity for short-term improvements.

We can help.  Gorman Health Group understands the complexities and nuances of the Star Ratings program and measures.  We know how to design programs, initiatives, and tactics to improve Star Ratings performance.  From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.

With time waning to influence the 2017 Star Ratings, find calm amidst the chaos and prepare for the great changes to come.

 

Resources

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>

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

by GHG Advisors

2016 Star Ratings are Working, and the Bar is Rising

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning.  The usual practice is to wait until Friday after the close.  It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan performance, but insurers and their provider and pharmacy benefit partners are struggling on a similar number of metrics. What is clear is that Star Ratings are now the fulcrum of competition in government health programs — and man, this stuff is hard and getting tougher.

There are clear winners and losers in this release.  There is a "Divine Dozen" of 5-Star-rated plans, including a couple of new arrivals to the 5-Star world. CIGNA traded its 5 Stars in FL (the legacy HealthSpring plan at the legendary Leon Clinic) for its Arizona plan. Sierra (9 states), Tufts (MA), Group Health of MN, and Essence (IL and MO) made it into the Pantheon.  Repeat 5-Star rock stars include Kaiser in 8 states, Martin's Point (ME and NH and will soon own Medicare in Northern New England), and Gunderson in IA and WI.

The half-dozen "walking dead" — plans scoring below 3 Stars for 3 consecutive years —included Wellcare of LA, Sierra Health, Touchstone, Cuatro, Windsor, and GHS (owned by HCSC).   Three will be terminated by CMS at the end of 2016.

Star Ratings are proving to be tremendously effective in moving markets and forcing industry investments in population health and the member experience and are driving big improvements in Medicare quality.  Roughly half of MA plans (179 contracts) earned 4 Stars or higher for their 2016 overall rating, a nearly 9% increase in a year and the first time a majority scored over 4.  On an enrollment-weighted basis, over 70% of MA enrollees are in contracts with 4+ Stars, a nearly 11% increase year over year.

But below the water line, at the metric level, the news was mixed and cautionary:

  • The good news: Average Star Ratings increased for 10 Part C measures and 5 Part D measures. We saw significant improvements in several challenging, longitudinal Health Outcomes Survey (HOS) measures: Improving/Maintaining Mental Health, Monitoring Physical Activity, Part D Appeals Autoforwards, and High Risk Medications. There were smaller improvements on many other measures, where removal of the 4-Star thresholds helped plans improve ratings.
  • The bad news: Average Star Ratings DROPPED for 16 Part C measures and 6 Part D measures. We saw significant decreases in several screening measures (colorectal cancer screening, diabetes kidney disease monitoring) and the HOS measure of improving/maintaining physical health.  And there was a big drop on the Medicare Plan Finder (MPF) Price Accuracy measure, where the cut points have gotten so small that 97% accuracy only gets 3 Stars, 99% results in 4 Stars, and it literally takes a perfect 100% to earn 5 Stars.

We knew the removal of the 4-Star thresholds would produce a tremendous amount of fluctuation in the measure cut points, and that's exactly what happened.  It's like playing "Pin the Tail on the Donkey" during an earthquake, making it really hard for health plan leaders to predict where their ratings will ultimately land while they still have time to influence them.  For example:

  • The average rating on the Diabetic A1c Control measure increased from 3.3 in 2015 to 3.9 in 2016.  But there was no change whatsoever in the average performance rate for this measure — in both 2015 and 2016, the average compliance rate was 76%.  The improvement on this measure can be entirely attributed to CMS relaxing the cut points once the predetermined threshold was removed.
  • In contrast, the Controlling Blood Pressure measure rating dropped from 3.7 in 2015 to 3.4 in 2016.  The compliance rate actually increased from 65% in 2015 to 71% in 2016.  This is an example of where the removal of the predetermined thresholds tightened the pressure on this measure — in fact, the 4-Star threshold increased 12% upon removal of the predetermined thresholds.

The Star Ratings data for 2016 pretty much emasculated industry arguments for relaxing metrics for Special Needs Plans (SNPs).  SNPs saw improvement in their quality scores roughly equal to that of HMOs and PPOs: MA plans operating SNPs averaged a 3.61 rating in 2016 (up from 3.47 in 2015), while plans with HMO/PPO-only contracts averaged 3.87 in 2016 (up from 3.79 in 2015).

Non-profit MA plans are pounding for-profits into the sidewalk on quality. About 70% of non-profit MA plans received 4+ Stars vs. 39% of the for-profits. Much of that discrepancy is due to culture. Non-profits tend to be far more focused on the all-important member experience measures and are more collaborative with their provider networks.

Methodological changes by CMS ensure the Star Ratings bar will continue to rise.  2016 is the first year plans with 500-999 members were rated. Only 369 Medicare Advantage Prescription Drug Plans (MA-PDs) were rated in 2016. 188 more plans weren't rated, but may be in 2017 — and this dilution will warp the bell curve plans are graded on, especially when considering most of those 188 are provider-sponsored, and strong performers will emerge. 4+-Star plans have the most to lose in this environment, and no one can afford to get comfortable.

Some takeaways:

  • Stars must be managed as a program and a corporate priority, not as a group of measures.  The effort must be directed by dedicated executive leadership and support.  No plan improves Star Ratings doing it off the side of their desks.
  • The removal of the remaining predetermined thresholds means there is no way for plans to "pick and choose" a subset of measures to focus on.  It has to be improvement across the board.
  • The bar continues to rise fast among Part C Star Ratings measures.  The "low hanging fruit" has been eaten. Part C Star Ratings success is no longer easily influenced by slick reports provided to physicians. Plans need to help providers execute on gaps in care plans and eliminate barriers to care for the vulnerable. There's a reason the 5-Star plans are mostly provider-sponsored, vertically integrated, collaborative, and member-centric by nature.
  • Star Ratings measures need to be woven into every department's work streams.  This includes not only quality, care management, health services, and pharmacy, but also risk adjustment, network operations, and compliance.
  • Lagging SNPs need to work harder and smarter and assume no CMS help on the measures for the low-income and disabled.  To the contrary, recent draft measures for dual eligibles from the National Quality Forum focus on mental and behavioral health and will prove an enormous challenge.

If you achieved 4+ Stars this year, congratulations, it's an increasingly impressive accomplishment.  Now get back to work.  There are 178 plans at 3-3.5 Stars who are close on your heels and feeling the urgency.  Now add the 188 unrated plans who will smash the bell curve in 2017.  A 4-Star plan's equal effort in 2016 only guarantees a score that starts with a 3 the next year.  Keep. Moving. Forward.

If you missed your 4th Star this year, panic a little, but then get it together. Fast. In a competitive market, you're circling the toilet bowl but aren't flushed yet.  You still have time to influence your 2017 Star Ratings and must make improvement the focus of your benefit, formulary, and network designs in the months ahead. You have big decisions to make and must invest time and resources wisely and with a sense of urgency.

Once again, the 2016 Star Ratings prove the world's biggest experiment in performance-based payment is working and forcing insurer evolution.  And evolution isn't about size, it's about continuous adaptation.

 

 

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 >>

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

The MA-VBID Model: Key Takeaways

Now that you have digested the Centers for Medicare & Medicaid Services' (CMS) announcement on the proposed demonstration for high-value benefit designs, the clock is ticking on determining an optimal set of benefits prior to the CMS deadline of November 15, 2015.

Over 37 organizations are eligible to consider this opportunity, which is based on member value and not competition.  As John Gorman, Founder & Executive Chairman at Gorman Health Group, and I discussed at length on our recent Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar on Monday, a multi-faceted approach within the health plan operation will be needed to quickly put together a review and proposal. Operational "must haves" include high-value, narrow networks which understand the eligible populations, high-quality disease management programs, solid Star Ratings programs, and predictable membership.  A strong foundation in claims processing and configuration, product design (including supplemental benefits), return on risk adjustment, efficient organization staffing, and excellent communications (electronically) with providers are needed to support the required capabilities.

Although marketing to the target populations will take place post-enrollment to limit adverse selection, the concept of a target condition is based on two key triggers.  Realistically, the target condition is marked on a claim with several months' run-out, even if a need already exists such as follow-up visits to specialists or prescription drugs.  Good Electronic Medical Record (EMR) communication can shortcut that process to activate benefits.  Fortunately, drugs can be targeted for benefits, but Pharmacy Benefit Manager (PBM) coordination is critical.

GHG has been preparing for this shift in the industry and is already working with clients to assist in the assessment of current providers, referral patterns, and populations within the eight chronic conditions (diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and various International Classification of Diseases (ICD) combinations).  Understanding the cost and utilization as well as referral patterns for these members (medical and pharmacy) will help a plan maximize the potential for success. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations.

The benefits must be approved with November submissions and certified by the plan's actuaries with the 2017 bid in June 2016, so they are binding.  Gorman Health Group is prepared to help with individual plan assessments and partner with clinically-effective benefit designs that deliver financial and quality results.


Resources

GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>

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 >>

Download a copy of the recording from Monday's Medicare Advantage Value-Based Insurance Design Model (MA-VBID) webinar, hosted by John Gorman.

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

by GHG Advisors

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

Drum roll, please…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)—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 interactions—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

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 for…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 on—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 >>

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 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

Potential Changes in Part C Reporting

The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. To follow are Part C highlights that merit your attention.

Organization determinations/reconsiderations, Special Needs Plans care management, and enrollments/disenrollments, were updated to include additional data elements, and two new reporting sections were added: Rewards and Incentives Program and Mid-Year Network Changes.

For most data elements with a due date of February 28, the data due date was changed to a couple of different Mondays in February, and the due date for enrollment/disenrollment was changed to the last Monday in August and February. These timing changes are proposed so the reporting load would be more manageable in 2016 than it was in 2015 for the Centers for Medicare & Medicaid Services (CMS)/Health Plan Management System (HPMS), and hopefully it will be more manageable for Plan Sponsors as well.

Two new data elements for Section 6 include the reporting of dismissals for organization determinations and reconsiderations to be more aligned with Part D reporting requirements.

Special Needs Plans (SNPs) will now also report four new pieces of data:

  • the enrollee initial health risk assessment (HRA) refusals,
  • the annual reassessment refusals
  • the HRAs where the SNP was unable to reach new enrollees, and
  • the annual reassessments where the SNP was unable to reach enrollees.

Excluded from this reporting are the HRAs that were not done where no refusal is documented and the HRA simply did not happen.

A few new disenrollment data points will now be requested:

  • The total number of involuntary disenrollments for failure to pay plan premium in the specified time period.
  • Of the total reported in the above, the number of disenrolled individuals who submitted a timely request for reinstatement for good cause.
  • Of the total reported in the above, the number of favorable good cause determinations.
  • Of the total reported in the above, the number of individuals reinstated.

A new reporting section is proposed for rewards and incentives programs. Plan Sponsors who respond in the affirmative will be required to explain which health-related services and/or activities are included in the program, which rewards enrollees may earn for participation, and how the value of the reward is calculated. They will also need to describe how enrollee participation is tracked, how many enrollees are currently enrolled, and how many rewards have been awarded so far.

Not surprising, CMS' increased oversight over network adequacy is making its way into Part C reporting. The new reporting section, Mid-Year Network Changes, will provide CMS with visibility into how often Plan Sponsors undergo mid-year network changes and how many enrollees are affected by this type of change. CMS states, based on 60-day comments, CMS increased the data elements from 13 to 53. Fun! CMS also states, "Collecting this data will help to inform CMS in determining how broadly to use the new Network Management Module (NMM) in HPMS to verify that plans' networks meet CMS network adequacy standards." If you recall from CMS' 2015 Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast, presenters specifically addressed this module and said Medicare Advantage Organization (MAO)-initiated submissions will not be viewable or evaluated by CMS. However, the NMM also allows for CMS-initiated requests of Health Service Delivery (HSD) tables "in support of various processes," which certainly you can presume will be viewable and evaluated. I don't know about you, but if it is in HPMS, it's viewable to CMS.

For all Plan Sponsors who currently do not have mechanisms for capturing this information, we encourage you to nail down a process. Operational areas may want to get a head start on determining how this information is captured today. CMS is using data now more than ever to determine outliers and to identify candidates for program audits, both of which can lead to enforcement actions. Remember: what they are asking Plan Sponsors to report on are not new requirements — so we anticipate CMS to have little patience for those who demonstrate non-compliance with items agreed to upon initial application.

 

Resources

Compliance permeates every department, and must be supported by effective tools and rigorous oversight. Learn how we can help you create early warning systems to ensure that operational inefficiencies and threats to member satisfaction are identified immediately. 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

Changes for 2015 Part D Reporting Announced by CMS

The Centers for Medicare & Medicaid Services (CMS) recently released an updated version of the Contract Year 2015 Part D Reporting Requirements Technical Specifications.

Sponsors are required to undergo data validation to have some of their Part D data audited annually. Each Part D Sponsor is required to provide necessary data to CMS to support payment, program integrity, program management, and quality improvement activities. Additional reporting requirements are identified in separate guidance documents throughout the year.

REPORT DELETIONS

Long-Term Care (LTC) Utilization -

One notable change for 2015 reporting is the LTC Utilization section will be suspended effective immediately because similar information can be obtained using Prescription Drug Event (PDE) data. Similarly, CMS removed the LTC Utilization reporting section which reports information about the total number of beneficiaries in LTC facilities for whom Part D drugs have been provided because it is provided elsewhere in the Plan's CMS contract.

Prompt Payment -

CMS removed Prompt Payment to Part D Sponsors and Fraud, Waste, and Abuse (FWA) reporting sections and decreased hour estimates associated with these sections because CMS determined these data are no longer necessary for monitoring through these reporting requirements.

FWA Compliance Programs -

CMS has determined the reporting of these data is no longer necessary for monitoring through FWA reporting requirements. Other methods using data validation processes have replaced the need for this reporting element. Annual Data Validation Audits, informatic analysis of PDE data, and other elements reported elsewhere meet the FWA monitoring goals of CMS.

REPORTING CHANGES

Medication Therapy Management (MTM) -

The addition of a note, reporting of Line Q, "Date(s) of Comprehensive Medicare Reviews (CMRs) with written summary in CMS standardized format," has been reduced to two CMR dates, even if more have been completed. One CMR is required if the member meets eligibility requirements. After analyzing the data, CMS concluded only two dates are needed for monitoring purposes.

CMS provided clarification to Line S, "Qualified Provider who performed the initial CMR," (Physician; Registered Nurse; Licensed Practical Nurse; Nurse Practitioner; Physician's Assistant; Local Pharmacist; LTC Consultant Pharmacist; Plan Sponsor) to provide more descriptive choices.

The Technical Specifications for Part D Reporting document can be viewed in its entirety as posted on the Health Plan Management System (HPMS) Plan Reporting site and on the external CMS website by clicking this link.

 

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. 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