Medicare Advantage 2020 Proposed Rule

It’s been a long wait since the passage of the Bipartisan Budget Act in February, but the 2020 Medicare Advantage (MA) proposed rule is finally here. Perhaps the biggest opportunity for plans is the shift that makes telehealth a basic benefit, which means the digital revolution that brought us things like ATMs on every corner, iPhones, and Teslas is finally seeping into Medicare. Plans can decide which benefits to provide via telemedicine in any geography. What is really exciting is the service can be delivered to the patient in the home. This is a tremendous opportunity to bring continuity to episodes of care that will really impact outcomes. It will also be possible for plans to offer telehealth services as a supplemental benefit. Additionally, it’s an opportunity for MA to offer new advantages over Original Medicare where telemedicine is still restricted to rural areas and the patient must be in a health facility to partake in the services.

Star Ratings are in for some changes, too. Measures with proposed changes will include Medicare Plan Finder price accuracy, all-cause readmission, and controlling high blood pressure.  Additional enhancements will be made to CMS’ methodology to adjustments will be made to handle unusual situations beyond a plan’s control like the fires and hurricanes that seem to be less unusual as of late.

The Centers for Medicare & Medicaid Services (CMS) gives, but, unfortunately, it also takes. On the program integrity side, the agency proposes using extrapolation in the Risk Adjustment Data Validation audits. That is a definite cloud on the horizon for plans as the regulation predicts a return to the program of $4.5 billion for the government over 10 years. Since 2012, CMS has held extrapolation from a valid sample of records was coming, and now there is an opportunity to comment on the specific methodology that might be used. Comments on the proposed rule are due 12/31. Happy New Year.



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

Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan’s investment. Click here

Bundled Payments Report Issued

Bundled payments capitate medical care at the episode level. It is one of the few “value-based” approaches the Centers for Medicare & Medicaid Services (CMS) and the Innovation Center have fielded that works. But it doesn’t work for the taxpayers, at least not yet. If you stop and think about it, the whole Prospective Payment System (PPS) is basically a bundle approach. It tied together a lot of individual hospital services that used to be separately billed and gave hospitals an incentive to be efficient. And were they ever: the average length of stay dropped 17%! The newer approach expands the bundle, in some cases to every part of the episode, including physicians, hospital, post-acute, and home health. Before the Affordable Care Act (ACA), CMS ran some demonstrations that proved the concept, yielding savings a bonus for doctors, and savings for the government and the patient, too, with reduced copayments. A further expansion under the ACA was promising, so the Obama Administration jumped ahead with a mandatory program for hip and knee replacement in 66 localities. The hospitals cried foul, but many had success and enjoyed bonuses. After the 2016 election when Tom Price became Health and Human Services (HHS) Secretary, he pared back that program just as results showed it was successful.


Keep in mind Medicare spends between $16,500 and $33,000 on knee or hip cases. Average charges in total approach $50,000 in the U.S. If you are mobile, you can get it done for less than $10,000 in India!


The Lewin Group delivered a report to CMS this week on the fifth year of the voluntary bundled payment initiative that was started under the ACA's Innovation Center in 2012. As in earlier years, the great majority of activity was in joint replacement episodes, and while there was little impact on quality for better or for worse, there were savings in spending on the services. Those savings were generated by reductions in post-acute care, both inpatient and home health. Unfortunately, the government didn't get any benefit, and the providers did because it was an upside-only risk approach. The newer “advanced” Bundled Payments for Care Improvement (BPCI) initiative, which is getting started now, will put providers at risk. Sophisticated providers are ready to play in this new space. This is where health reform is happening – initiatives that align providers’ incentives with the goals of public programs. Health plans and provider groups that stay focused on CMS’ strategy will be the winners going forward.



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

Three Reasons to Invest in the Open Enrollment Period

The Open Enrollment Period (OEP) is back with some new rules. Starting January 1, 2019, Medicare Advantage (MA) enrollees have a one-time opportunity to switch their plan, similar to a grace period. This opportunity ends March 31. Both new MA enrollees and existing enrollees have the opportunity to switch plans. This is a new opportunity for MA plans to both win and lose enrollment! To make sure you are not on the losing enrollment side, here are a few ideas in which to invest resources and budget before the upcoming OEP.

Let Your Data Do the Talking

Recognize the power of the data available to you, and utilize that data to develop communications to new and existing enrollees, make organizational and/or operational changes to your operations, and allow this data to eventually feed into your product development process. Utilize leading indicators such as grievances, customer service complaints, rejected claims, and similar data to identify issues. Lagging indicators such as disenrollment surveys, especially if they are “real time,” provide valuable information. Continual analysis of both leading and lagging indicators can fix potential problems, identify members at greatest risk for disenrollment, and provide the basis of building an attrition model to predict members most likely to leave going forward.


Member Services and Communications need to be the Stars of OEP!

Member communication interactions (either verbal, written, or in person) could either break or win you the OEP. You still have time to review your welcome interactions with new members and your existing member communications and interactions with current members to ensure they are best in class. You may want to have member events this year so they understand the 2019 benefits – and if you have great news for them, you want to make sure they hear it. The goal is to ensure every new member knows what to do January 1 and to have multiple touches that educate, welcome, and engage members about their new MA plan. You do not want buyer’s remorse occurring at any point from the sale through the end of OEP. Existing members need to be educated about any changes in benefits, and if your data is talking to you, you will have a list of members who need “real” hands-on member service touch points. In addition, when was the last time you really looked at the communications going to your members? Are you communicating too much or not enough? Do the communications have the same tone and messaging throughout? Or are they just recycled from year to year? Has the Member Services team received training lately to make sure they are reinforcing the tone and messaging you want your members to hear and feel? Do they know the 2019 benefits and what benefits to make sure members know about? Do you listen to Member Services calls to ensure you are providing the member experience you portray in your advertising and communications?  Now is the time to reassess how you are communicating with your members and make certain you are maximizing your opportunity.

Marketing Cannot Be Forgotten

Health plans are unable to market the OEP opportunity but do have the ability to market the following:

  • Branding
  • New to Medicare
  • Education
  • Medicare Supplement

Although you may not have much of a budget for marketing during the first quarter, you can utilize it effectively. Make sure you are advertising in January and the last few weeks of March. If you have educational events, advertising them digitally or though radio will help bring additional awareness to what your organization does for its members. Most plans have a very robust “New to Medicare” budget already, but you may want to invest in some free-standing inserts in January or March and/or advertise on TV. Utilize branding during this time since it puts your brand in the market during the OEP. Whatever you have the resources to do, make sure you are strategic in your efforts to make it worthwhile.

It’s Not All about Winning Enrollment

At Gorman Health Group, we are hearing many clients talk about gaining enrollment during the OEP but not so much about the possibility of losing membership. Your goal should be to ensure you have everything in place for this OEP to make certain you are on the winning side of OEP and are not giving up your membership to another MA plan that made sure they strategically invested in this opportunity!

For more information about the OEP opportunity and ways you can set up your team for success, contact me at




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

Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan's investment. Click here



Why Investing in Your Staff Will Benefit Your Members

I started my career working in social services. I wanted to change the world, as many of us do in our youth. When my family needed health insurance, I applied for a job with a health insurance company. It was an unexpected career change, but I was fortunate as I had an amazing mentor who taught me a different view point of my job. She expanded my view and taught me to see the big picture of making our members’ lives better. Was I in case management? Maybe a social worker interacting with members? No, I was a customer service representative and then an enrollment supervisor. But she gave me vision of how my job touched our members and made a difference.

Mentoring is a fine art. As the talented poet Robert Frost said, “I’m not a teacher but an awakener.” Ask yourself this, no matter your position or role, can you say that? Are you a teacher or an awakener?

It is that vision and passion that makes the difference. I learned from a few key people in my career what that looks like, and it changed my world. Today, in many ways, that skill is lacking, and it is time to bring it back. As you consider your role, and that of those on your team, what can you do to awaken those on your team to be part of the bigger change to your culture and member experience?

Some suggestions that guide me are:

Always Remember: “It’s All About the Member.” I remember very early in my career a call that impacts me still today. A member called in distraught. His wife, also a member, was dying. She was in a nursing home and didn’t have long to live. Her family had made a blanket for her, and it had disappeared. Aside from it being a participating facility, it had nothing to do with our insurance. But it had a world of impact to them. I worked for a company that valued that and allowed me to follow up to make sure the blanket was found and returned to the member. I also had the freedom to take this man’s calls as much as needed.

Systems Are Tools. Automation is great. It allows us to be efficient and focus on the things that need our attention. Auto-adjudication for claims or enrollment gives us the ability to focus on the fallout that can’t auto process. What happens often is that systems replace training and knowledge. Staff no longer know “why” the system is doing something. It makes problem resolution and oversight far more challenging as often issues are not identified quickly. Process improvement and automation are amazing tools, but don’t let them replace a knowledge and training about the behind-the-scenes requirements.

Our Staff Need Us. Management is in meetings and often behind closed doors. That leaves a gap. Where does your staff go when they need help? Is it counted against them to ask for help? Does your staff feel like you understand their barriers and are working to eliminate them? Do you give them the opportunity to grow and be challenged in a supportive environment, or is it more “sink or swim”? If we really want member-focused staff, we need to be staff-focused managers.

First Call Resolution Is Only Valuable When It Is the Right Resolution. Is first call resolution more important than the right resolution? More and more I am hearing plans say they are not giving their members homework. What a refreshing philosophy. You may not be able to fully resolve an issue on the first call because more research or activity is needed to prevent that “homework.” Sometimes that is what excellent service requires.

My team includes some of the most talented, engaged people in the industry. They understand mentoring and strive to bring that to each project. A recent example is a colleague of mine. She recently worked with a client and had a location called “Katie’s Learning Lab.” Operations staff could stop in and ask questions and get clarifications when they didn’t know what to do. It gave a sense of security; there was a place to get help without judgement. Katie invested time with the staff. She gets it. She knows that until staff have a mentor to show them their place in our members’ world, it’s just a job when, in reality, it’s people’s lives. And we have the amazing ability to positively impact them.

We understand enrollment and customer service representatives as well as analysts well-versed in MA (and engagement with seniors) are in short supply in most markets.

If interim staffing to support your front line staff is what you need to ensure a successful enrollment season, GHG can enhance your team with our own mentors, providing knowledgeable, effective assistance and an eye for detail from staff with decades of experience.

Here are suggestions to ensure your team is effectively trained to make every member touch count.


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

Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan’s investment. Click here

Taking Advantage of Reimbursement Increases & New Benefit Opportunities for MA?

The Centers for Medicare & Medicaid Services (CMS) has provided increases in reimbursement to plans, and Gorman Health Group believes this trend will continue for Medicare Advantage (MA) for the immediate future. So how are you taking advantage of this?

  1. Are you increasing your service area?
  2. Are you entering MA for the first time?
  3. Are you increasing your benefits and lowering premiums in existing plans?
  4. Are you introducing new products that will be more competitive in the market?

If you answered “yes” to any of these questions, the time to start planning for 2020 is now.

The Notice of Intent is due to CMS on November 12 of this year. You now have less than two months to ensure you have a clear strategy in place if you plan on increasing your service area or are entering MA for the first time. If you answered “yes” to either question #1 or #2, now is the time to do the following:

  • Market analysis of proposed new counties you are planning to enter
  • Three-year enrollment opportunity analysis
  • Development of a scorecard to understand which counties have the best opportunity
  • Feasibility study to provide guidance on how long it will take to be profitable


For existing plans that are not expanding their service area, now is the time to do the following:

  • Membership analysis by plan including:
    o Age
    o Geography
    o Length of time with plan
    o Chronic conditions and how they affect the MLR
    o Disenrollment findings
    o Plus other data based on the story it tells
  • Competitive product and benefit analysis utilizing 2019 plans and benefits
  • Market analysis

Now is the time to develop your strategy so by 1st quarter 2019 you are ready to start implementing your strategy for new plans and more competitive benefits for 2020. CMS have now given plans enormous leeway in developing benefits—now is the time to take advantage of this opportunity. Today, some benefits will need to have returns on investment, and others will need to be researched to find new vendors to actually provide the benefits. In addition, you need to ensure operational limitations are not hindering you from finding the right set of benefits for your plans.

If you need help, please don’t hesitate to contact me. We at Gorman Health Group are happy to assist in any way.



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

Top 10 Changes – NEW Medicare Communications and Marketing Guidelines (MCMG)

Gorman Health Group will conduct a webinar on the new guidelines in the next couple of weeks, but we wanted to get this out right away as the Centers for Medicare & Medicaid Services (CMS) has rewritten the Medicare Marketing Guidelines (MMG) for 2019. A lot of information is the same but just condensed – there are a lot changes! Here is the top 10 list of 2019 CMS MCMG changes:

  1. CMS has grouped activities and materials into Communications and Marketing that are distinguished based on intent and content. It will be important to understand the differences and educate your staff since interactions with beneficiaries can start out as a communication and end up as a marketing communication – with different compliance requirements.
  2. Plans/Sponsors may compare their plan to another plan/sponsor provided they can support the comparison through studies or statistical data and the comparisons are factually based. CMS does not provide any detail on the scope of studies or time periods required for statistical data, so proceed with caution if considering publishing plan comparisons.
  3. Plans cannot market during the Open Enrollment Period (OEP) or engage or promote agent/broker activities to target the OEP as an additional marketing opportunity but can do the following:
    1. Market to beneficiaries who are new to Medicare, also known as “age-ins,” who have not yet made an enrollment decision
    2. 5-star plans can continue the Special Enrollment Period (SEP)
    3. Market to dual-eligible and low-income subsidy (LIS) beneficiaries
    4. Send marketing materials and have meetings with those who request the information/meeting, and provide OEP information via the call center
  4. CMS has provided detailed guidance on activities in the healthcare setting with an emphasis on differentiating between activities a provider (or pharmacist!) performs as a matter of a course of treatment versus activities a plan or provider performs aimed at influencing an enrollment decision. If you recall, this was one of the specific topics for consideration for which the agency sought feedback in its April 12, 2018, request for input on this guidance.
  5. There is a new Material ID process – plans must use a “C” for communication materials or “M” for marketing materials at the end of the Material ID. Here is an example: H1234_abc567_C.
  6. Documents such as the Summary of Benefits (SB), Evidence of Coverage (EOC), Annual Notice of Changes (ANOC), directories, and formularies need to be posted by October 15. CMS has listed each required document in a chart that describes to whom required, timing, method of delivery, Health Plan Management System (HPMS) timing, format, additional guidance, and translation requirements. This is very helpful.
  7. Plans no longer have to mail the EOC to existing enrollees, but the ANOC must be mailed. If a new member enrolling throughout the year (for example, for a June 1 effective date) requests hard copy materials to be mailed to him/her, the hard copy request must be fulfilled within three business days, and the request remains in effect until the member leaves the plan or requests that hard copies be stopped.
  8. Plans must keep their call centers open 7 days a week, from 8 a.m. to 8 p.m., for an additional 6 weeks – from February 14 to March 31. These additional costs need to be factored into next year’s budget, and sponsors should be having conversations with any call center vendors supporting this line of business.
  9. The rules for disclaimers have changed again, but now it’s easier! Make sure you read each disclaimer since parts of some disclaimers are still needed or if you mention 10 or more benefits.
  10. Plans must submit website marketing content for review, including contracted third-party websites. Plans do not need to submit web pages with or containing CMS-required content for review. This is a 45-day review! This means almost every website needs to be reviewed now. Website content that has not been reviewed/approved cannot be viewable to the public. This is a significant change as sponsors were previously permitted to post websites that were pending review.

This is not a year to skim through the guidelines—we are still reading and re-reading the document to make sure we understand the implications. Good luck, and watch for our webinar in the upcoming weeks!




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

Prep for the 2019 Medicare Communications and Marketing Guidelines

I am shocked the 2019 Medicare Marketing Guidelines (MMG) did not come out last Friday since that is when I started vacation. But no… a week later, we are still waiting, and now the wait really starts to impact the development of our marketing strategies and tactics.

In reviewing the April 12, 2018, Centers for Medicare & Medicaid Services (CMS) memo asking for request for input on the 2019 Medicare Communications and Marketing Guidelines, our Marketing team at GHG got together to think about what we would do right now not knowing what the changes are and not being 100% sure if these changes are going into effect. Here are a few suggestions to get your marketing team ready for what we are expecting:

#1 Disclaimers: There is a good chance many of the current disclaimers will be modified and/or deleted. This should not stop you from developing creative materials, although you should have some alternative copy ready to be utilized if the majority of disclaimers go away. Some ideas to consider:

  • Laundry list of most important benefits
  • Additional “call to action” copy to get prospects to either call you or go to your website
  • Copy that clearly states your differential in the market – and it doesn’t matter if this is a repeat of copy. Repeating the most important points you want a prospect to remember is an important strategy!

#2 Font Size: If CMS no longer mandates that all marketing materials have at least a Times New Roman 12-point font type, it will be much easier for the Marketing teams to fit in additional copy points. You may want to develop materials in 11-point and 12-point font to see what extra space you may gain. You may be able to utilize some of the ideas above to help increase marketing points, especially on postcards. Although remember – those whose eyes are over age 65 are not able to read very small type, and if you reverse out the type, it may become illegible, so we would not recommend anything smaller than 11 point font.

#3 Referrals: If CMS allows you to announce that you can offer a gift for a referral and you can request email addresses when asking for referrals in addition to the mailing address – start planning for a mailing now! What free gift could you provide for a referral? Think about allowing members to send referrals to the plan by email, phone, as well as mail so you can utilize these leads quickly for the Annual Election Period (AEP).

#4 Business Reply Cards (BRCs): BRCs that do not mention plan-specific benefits do not need to be submitted into the Health Plan Management System (HPMS). Make sure now that your BRCs do not mention benefits. This is an easy fix—make it now.

#5 Provider Communications: CMS is expected to clarify it is not a violation of CMS marketing requirements if contracted providers notify their patients that the contract status between the provider and the plan/Part D sponsor is changing. We have seen many plans this year developing benefits and products with their providers. Utilizing providers to communicate this relationship during AEP is important. You don’t have to wait for the guidelines to be released on this one – it is already allowed!




Benefits are Submitted. What’s Top of Mind for 2019 Marketing and Sales? Learn more

Whether you need help establishing an effective member experience or member communication strategy, cataloging and evaluating existing member communications, or identifying opportunities to streamline and strengthen your member engagement tactics or interventions, we can help. Read more here

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

Benefits are Submitted. What’s Top of Mind for 2019 Marketing & Sales?

Now that benefits have been submitted, the emphasis is turning to Sales and Marketing. When speaking with different Medicare Advantage plans across the country, you start to hear different things about what is going to be important for Marketing and Sales this Annual Election Period (AEP) and Open Enrollment Period (OEP). Here is some of the top “buzz” we have been hearing from plans:

  1. Bigger marketing budgets for 2019! Many MA plans are happy with their 2019 MA products and want to take advantage of this opportunity to grab market share. We see increased spending in New-to-Medicare programs, AEP direct mail, and social media especially.
  2. More diverse sales distribution strategies are coming into play this year. We have seen many MA plans really diversify their sales strategies and do the following:
    1. Increase Field Marketing Organization (FMO) arrangements and number of contracted agents.
    2. Pay attention to the metrics of the telesales team and either decide to outsource this function or develop much stronger training internally, plus build a more solid process to get leads to the proper sales channel quickly instead of just sending out sales packages and delaying the sales opportunity by several weeks.
    3. Build web strategies to increase online sales, especially to the New-to-Medicare segment.
  3. OEP is back! We have spoken to several MA plans about this new/old enrollment period, and here is what we are hearing from the marketplace:
    1. Make sure onboarding is perfect since you no longer have nine months to change a bad first impression. Make sure prospects understand what to expect when they enroll, and meet that expectation.
    2. Show the love to both your new members and those you have determined are most likely to leave in the first quarter. Member meetings with food help drive attendance as well as welcome calls.
    3. Although MA marketing is not allowed during the OEP, there are a few different ways to ensure your name is reinforced during the OEP:
      1. New-to-Medicare programs – running a few free-standing inserts might be helpful
      2. Brand marketing TV in the first quarter
      3. Medicare Supplement marketing, especially in January if you have Medicare Supplement
    4. Ensure your agents (both internal and external) understand the OEP rules and make the most of bringing you sales during this time



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


The 2019 Model Marketing Materials Are Posted. Ready for What's Next?

As we await the Medicare Communications and Marketing Guidelines (MCMG), The Centers for Medicare & Medicaid Services (CMS) released the 2019 Model Marketing Materials which includes standardized outreach and educational materials for Medicare Advantage Plans, Medicare Advantage Prescription Drug Plans, Prescription Drug Plans, and 1876 Cost Plans.

Bids are due in a little over a week. You probably have an audit or two going on, and also your day-to-day work needs to be accomplished. CMS will continue to issue enforcement actions for reasons such as delayed and inaccurate materials. Don’t let other activities impact your attention to this area.

Here are three pieces of advice while we wait for the chapter:

  • Do not reduce your internal quality control and compliance reviews of materials. While certain pieces will no longer be considered “marketing” and therefore will not require submission to the agency, you should anticipate that CMS (and your competitors) will be on the lookout for misleading and confusing communications.
  • Formulate your questions after the release of the MCMG. If something is unclear, ask before you do. I am a huge fan of the adage, “it’s better to say sorry later than to ask permission now,” but I generally save that for when I am encouraging my precocious nephews. I do not recommend employing that strategy when working with Government Programs. The agency often releases FAQs, so get your questions in.
  • Continue to plan for your review season. The deadline for plans to provide the ANOC/EOC, formularies, LIS rider and directories is September 30. That means it needs to be in their hands by that time so they can make informed decisions.

Once you have your Plan Benefit Packages in place (we are actively helping with that, too), Gorman Health Group's experienced staff can review your sales collateral to ensure your content is compliant. Our marketing material review service includes:

  • Staff members with over 10 years of experience in CMS marketing material review
  • A compliance review to ensure model instructions and MCMG are followed
  • A benefit review to ensure accuracy of approved Part C and Part D services
  • A structured process with quality checkpoints and full project management support

Contact me directly at for more information.



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

In a recent HPMS memo, CMS confirmed the Medicare Marketing Guidelines will be renamed the “Medicare Communication and Marketing Guidelines.” Read more here.

Blending Network Strategy and Product Strategy

As more and more health systems and provider organizations successfully manage the shift from patient care to population health management, long-term health plan strategic planning should be blending network strategy with product strategy as a key indicator of the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay for performance and upside risk arrangements, and as providers have seen the margins narrow and plateau, plans have had to adapt and move beyond simple incentivizing for behavior change. We heard from the Centers for Medicare & Medicaid Services (CMS) the Accountable Care Organizations (ACOs) with upside-only risk have not performed as well or increased savings in comparison to those ACOs with downside risk and skin in the game. Systems that have ventured into managing downside risk and percent of premium arrangements and that have been successful have an appetite for more. Certainly moving up the food chain from a provider to a payer has been a topic of conversation among CEO’s of large integrated delivery systems. They have worked hard to align physician trust and referral networks, build a strong name brand in their local communities, and negotiated contracts with health plans that have met and exceeded care and cost containment goals, and the question of where do we go from here is top of mind.

As we have met and strategized with provider systems from baby steps to pay for performance to negotiating their first risk deal, there has been and still is, in some cases, a strong reliance on health plans to set clinical pathways and benchmarks. From the provider perspective, the reporting and transparency with the plan partners has been a key consideration in whom to collaborate with and how they have set internal benchmarks. However, systems are starting to realize and explore the administrative support organizations available and stepping out on their own to become a Provider-Sponsored Organization (PSO), which doesn’t seem as scary as it may have five years ago. Still, in meeting with providers, the biggest misconceptions have been what does it mean to be and how do the requirements differ from a PSO versus a Provider-Specific Plan (PSP-Narrow Network), do we meet the requirements, and what is the best option for us?

The answers to those questions spark the first steps when we begin to traverse the local healthcare landscape and blend the network and product offerings. Diane Hollie, our Senior Director of Sales, Marketing and Strategy states “Brand is very important when blending two organizations.  Will members be buying the Plan for its reputation and benefits or will the Hospital System attract a member base the Plan is currently not attracting and why?”

When plans and providers consider entering into a co-branding PSP (aka Narrow Network) options, a few key considerations are:

  1. The majority of Narrow Network PSPs are Health Maintenance Organization (HMO) products and have risk-sharing contracts.
  2. Increase in volume – Can the health system handle the influx of new patients? If the primary care system is at capacity, what is the strategy to ensure new Medicare members are seen timely?



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