It’s Product, Benefit, and Premium Time for 2018
Whether you are just updating your current product benefits, are offering a new plan benefit package (PBP), new product, or service area, or are new to Medicare Advantage altogether, now is the time to start planning for the 2018 bid submission.
It is best practice in the bid process to utilize a working team approach, with one clear leader. The team should include representatives from the following areas to ensure the best product is brought to market, and, when it is offered, that the implementation of the product is seamlessly implemented. Some of the members who should be included are:
- Sales/Marketing
- Finance/Actuary
- Network
- Pharmacy
- Medical and Health Management
- Operations
- Compliance
GHG believes, at the beginning of the bid process, it is important to level-set the team on the marketplace. Some of the analyses we typically like to present include:
- Service area demographics
- Medicare penetration
- Current membership analysis
- Enrollment trend analysis
- Results of the Annual Election Period (AEP): Who are the winners and losers this AEP, and why?
- Product analysis
- Benefit analysis
- Competitive analysis
Strong planning is key in the bid process. You want to understand the goals upfront and make sure your product and benefits can deliver. We have found weekly meetings, a detailed project plan with strong leadership, and project management skills are critical if you want to limit the number of iterations and last-minute back and forth that brings along the increased risk of errors.
Having a strong operations component incorporated in the process helps identify the planning needed to seamlessly implement benefit changes and pinpoint impacts on customer service. The Sales and Marketing team are key in characterizing product differentials and how the benefits will be sold, and not only how the sales team will sell, but if the Sales team can sell the benefits.
We could go on, but you get the importance of every department working together and pulling their weight. GHG has seen the success of plans who get the need for a deliberate process, as well as those plans in nail biting situations – hoping it all comes together at the end. Let me tell you, the first way is always preferable! So get your analysis started, put your project plan together, and start putting together your team if you haven’t already!
Resources
Don’t miss our webinar on Tuesday, January 31, at 1:00 PM EST, where we will provide an informative session on how to conduct a feasibility study to develop a successful growth strategy for your organization. Register now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year's event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Reflections on the Basics of Delegation Oversight
Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.
With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.
As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:
- Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
- Understand how your delegate will demonstrate effective, compliant activities on your behalf.
- Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.
We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.
“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.
Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:
- Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
- Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
- Complete robust testing prior to new benefit implementation.
- Partner as a team (Compliance and Operations) to ensure success together.
- Maintain a dedicated unit focused on delegation oversight.
- Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.
Bonne chance!
Resources
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Plan Now for Performance
As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has to be vigilant about identifying any weaknesses that could mean high costs or low expectations relative to budget. Parent companies have to be aware of line of business similarities and differences as Exchange and Medicaid business become more like Medicare Advantage in terms of programs and benchmarks. A recent article from Kaiser on retention makes great points about the line of business impact on retention and how it is a simple metric that encompasses many operational issues.
GHG is constantly improving its tools to identify outliers as well as relationships between different metrics that cross department lines. Finding root causes and quantifying them for the organization are more impactful than just handling them on an ad hoc basis. Just like compliance is everyone's responsibility, so is financial performance. Identifying weaknesses AND leveraging strengths combine to form a more complete business model for sustained growth.
GHG can prepare a tailored snapshot of your market and your company's performance. Contact us here.
Resources
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Hot Takes on Medicare Advantage and Part D in 2017
The Centers for Medicare & Medicaid Services (CMS) released its annual Medicare Advantage (MA) and Part D "landscape files" with data on plans and bids for 2017. It's a picture of programs that are rock-solid and driving insurers' revenues and earnings, offering better supplemental benefits for no increase in price for two-thirds of beneficiaries. Interestingly, CMS appears to be sandbagging its enrollment projections and assumed no growth for MA in 2017. We think we're heading to 4.2-4.5% enrollment growth, continuing a steady, winning drumbeat for the industry.
By the numbers, the landscape files showed the following:
- While the number of contracts with CMS dropped by 8%, the number of Plan Benefit Packages (PBPs) is virtually the same.
- The number of PBPs with $0 premium is virtually the same. Although the number of $0 premium Preferred Provider Organizations (PPOs) with prescription drugs has increased by 21 PBPs, the number of Health Maintenance Organizations (HMOs) with drugs has decreased.
- The number of PBPs with a $0 drug deductible has decreased 11% from last year.
- Approximately two-thirds of all beneficiaries on an enrollment-weighted basis will see no premium increase, and most will see additional supplemental benefits in 2017, such as vision, hearing, and dental care. The average enrollment-weighted premium is actually $1.19 less than 2016.
- Humana will offer the cheapest Prescription Drug Plan (PDP) in 22 of 34 regions. EnvisionRx, which was acquired by RiteAid last year, is the lowest bidder in 11 regions.
- WellCare and United showed improvement in Part D bidding and are now eligible for low-income auto-assigns in 8 and 27 regions, respectively.
- MA enrollment is up almost 60% since the passage of the Affordable Care Act (ACA) in 2010, smashing expectations of an exodus.
- Strangely, CMS implied in its announcement that MA growth would be flat in 2017. We're projecting year-over-year growth of 4.2-4.5% in 2017.
- Centene (which acquired Health Net), United, and Aetna expanded their service areas in several states.
By every measure, 2017 should be another good year for Medicare plans. Let's hope whoever wins this Presidential election doesn't screw it up.
Resources
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
The MA 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. Visit our website to learn more about how we can help you >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
An "October Surprise" in Medicare Advantage Star Ratings
Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year's includes an "October Surprise:" a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought bonuses and rebates.
Roughly 370 MA plans are currently scored under the Star Ratings system, which we all know by now is graded on a curve. Plans above 4 Stars get substantial bonus payments and bid rebates from CMS and above 5 Stars can market and sell their products year-round. In this sense, plans below 4 Stars are circling the toilet bowl as there is only so long they can compete against the better benefits of 4+ Star plans. The Star Ratings for 2017 will likely knock many 4+ Star plans off their pedestals. Here's why: for 2017, for the first time, 188 new plans could be scored under Star Ratings.
- 64 of the 188 are Medicare-Medicaid Plans (MMPs), which CMS announced in June will be moved into their own separate Star Ratings program this fall. This is a bit of bad news for most MA plans, since their inclusion in the MA Star Ratings program would likely have helped fill the lowest end of the curve.
- The 124 that are left still represent enough mathematical volume that their performance will shift the bell curve. Most will likely earn an overall rating of 3 or 3.5 stars, which will cause rating dilution for those at 4+ Stars. If those plans have the same level of performance as the previous year, they will likely dip below 4 Stars. This is a looming disaster for those companies because they've already booked the bonus money and predicated their benefit designs and 2017 campaigns on receiving the rebate.
- Regarding the 6 "dead men walking" plans below 3 Stars for 3+ years and slated for termination: a "hospital improvement" bill, which passed the House and is still in the Senate, includes a provision to delay CMS' authority to terminate MA contracts based on poor Star Ratings for 3 years. It's possible these 6 plans may continue to fill the very lowest end of the Star Ratings bell curve, thus helping other low-performing plans by padding the lowest end of the bell curve.
Many plans are going to get a nasty shock when they dig into CMS' latest news. It's another stark reminder Star Ratings management is a constant campaign, and plans cannot afford to get comfortable when it comes to their quality performance.
Resources
CMS recently notified plans of the first preview period for the 2017 initial Star Ratings data. It is critical for plans to begin the annual re-evaluation of Star Ratings performance now to pinpoint new problem areas, implement tactical actions, and identify improvement opportunities to raise ratings. Read full analysis >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Retail Healthcare - An opportunity for success
Are you providing your members and potential members the opportunity to speak with you in person?
In the age of technology, we are forgetting how to serve our customers without them having to pick up the phone or log into a website. For some, this way of doing business fits the population they serve. It's fast and convenient, but in the Medicare world, we still have customers who want to speak with us in person, who need help navigating the complexity of healthcare, and sometimes it just can't be solved by pushing a button on a phone or computer.
So how do health plans continue to evolve in the technology world and still provide a personal touch while remaining profitable?
If providing quality healthcare and outstanding customer service is the objective of a health plan, and members and potential members want services on their time, in their neighborhood, then a brick and mortar location can solve for both.
Brick and mortar locations — or storefronts — can be used as a multi-purpose space for health plan staff, agents/brokers, and the surrounding community. These stores can be strategically designed for year-round activity or be used as a pop-up location during open enrollment and provide numerous advantages that online cannot:
Year-Round Opportunity:
- Utilizing a variety of healthcare professionals such as medical groups and providers, senior associations, and ancillary community interaction at the store location.
- Provide informational seminars for both educational and sales purposes, health and wellness information, engagement with the local community, age-in seminars, and Medicaid eligibility clinics to help the low-income population apply for Medicaid/Low Income Subsidy (LIS).
Seasonal Opportunity:
- Facilitate sales seminars, lead agent appointments, walk-ins, and seasonal health fairs to drive Annual Election Period (AEP) awareness and educational seminars to bring awareness to the products and services offered by your health plan.
Achieving a measurable return on valuable marketing dollars goes a long way toward meeting growth objectives and improves profitability. With marketing budgets challenged by today's economic conditions, and the added pressure of Medicare Advantage rate reductions on health plan's cost structure and a shortened AEP, finding ways to maximize enrollment and spend less gets tougher and more challenging.
So whether your health plan is considering a year-round opportunity or seasonal location, this can bring your members and potential members a comfortable setting to gather, a place for the community to learn more about Medicare/Medicaid services, answer member questions, and troubleshoot issues pertaining to enrollment right in the heart of community — no dialing, no waiting — just fast and convenient.
Potential success with storefronts can be what your market needs, but careful design of a robust strategy is required to maximize your return on investment. Don't delay — Gorman Health Group can help you navigate the complexities and provide you with a plan that will surely satisfy your members, potential members, and your stakeholders.
Resources
At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. 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 >>
Meeting CMS Halfway: The 2016 Audit and Enforcement Conference
On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements, upcoming developments, and more.
While the agency has not given everyone the keys to the kingdom, the transparency of process improvements and changes can be likened to someone meeting you halfway. If you expect CMS to meet you where you are, you'll be waiting a long time. Sponsors need to do the rest: digest the free information provided, distribute to all affected parties, and implement. Practice until each step of an audit runs like a well-oiled machine. Sound cliché? It should. The core focus of this audit model has not changed in years. You may argue that you've had staff turnover or have switched delegates for a certain function. None of it matters. The requirements are still the same, and they are in line with many items your organization attested to upon application.
My summary and analysis of the conference can be downloaded here, however, it is no replacement for watching the webcast recordings on your own and making necessary changes to your program.
Resources
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Is Your Sales Distribution Strategy Up for the Challenge?
It's already July, and time is ticking! Do you have your sales distribution strategy completed and management staff in place? With the Annual Election Period (AEP) just a few months away, finalizing your distribution channel, creating sales training, developing telemarketing scripts, and hiring management to oversee all these tasks must be completed now. In addition, making sure you have compliant marketing materials and a compliant website is more important than ever.
Make sure you have done the following:
- Develop sales recruitment strategies that align with your sales and retention goals
- Identify Field Marketing Organizations that fit your culture and believe in your value proposition
- Identify obstacles or gaps within your Sales team
- Develop sales goals that promote year-over-year growth
- Confirm the proper number of agents are in place to meet sales goals
- Verify you have a sales oversight program that will hold up to the Centers for Medicare & Medicaid Services (CMS) standards
- Create trainings that help your sales staff:
- Sell against the competition
- Develop key alliances in the community
- Navigate the dos and don'ts of marketing
- Conduct community meetings
- Self-generate leads and community outreach
- Telemarketing implementation plan — whether internal or external resources are being utilized
- Sales scripts for Telemarketing team that are ready to be submitted to CMS' Health Plan Management System for review
• Have strong call center staff development scheduled
• Update policies and procedures for Sales and Member Services based upon internal goals and 2017 Medicare Marketing Guidelines (MMG)
• Review marketing materials and your website to make sure they are compliant
If you feel overwhelmed by this list, don't worry — our Sales and Marketing subject matter experts can help you maneuver through the overwhelming task of hiring, training, and implementing strategies while navigating your Sales management staff through the newly released 2017 MMG. We can even provide you with proven interim staff to get you on track for the 2017 AEP.
Our goal is to help you succeed and achieve your 2017 AEP sales goals. Let us weather the storm for you while you watch your membership grow. Don't let time run out — contact us today!
My favorite quote:
"Sometimes I wish I could just fast forward the time just to see if in the end it's all WORTH IT!"
— Author Unknown
Resources
Impact of the 2017 Medicare Marketing Guidelines. On June 10, CMS announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors. In a new article, our teams of Compliance and Sales & Marketing experts outline the top changes to the guidelines that we believe will have an impact on your organization. Read now >>
Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions. Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Request a demo today >>
Health Plans Need to Start Talking About Disparities in Care
On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services' Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It's a game-changer in advancing health equity and reducing disparities.
The new regs, implementing Section 1557 (the nondiscrimination provision) of the Affordable Care Act, prohibit discrimination, marketing practices, or benefit designs that discriminate on the basis of race, color, national origin, sex, age, or disability. This will escalate disparities from simply being a "quality improvement need" to being a huge compliance issue. It goes without saying that an investigation of your plan by the civil rights cops splashed across local news would be devastating. As the Centers for Medicare & Medicaid Services (CMS) has begun more aggressively using their data to identify these disparities, health plans certainly should begin doing the same.
The final rule prohibits sex discrimination in healthcare, including by:
- Individuals cannot be denied healthcare or health coverage based on their sex, including their gender identity and sex stereotyping. These last two items are of particular importance given transgender policy enforcement is relatively new. OCR has prosecuted cases recently where transgender patients were discriminated against in hospital admissions and room assignments, denying mammograms to transgender females, denial of gender reassignment surgery as "cosmetic," and harassment by medical transport drivers.
- Women must be treated equally with men in the healthcare they receive and the insurance they obtain. OCR has prosecuted several cases recently where hospitals assigned male guarantors when a wife obtained services but not the other way around.
- Categorical coverage exclusions or limitations for all healthcare services related to gender transition are discriminatory.
- Individuals must be treated consistent with their gender identity, including in access to facilities.
- Sex-specific health programs or activities are permissible only if the entity can demonstrate an exceedingly persuasive justification.
The regs also include important protections for individuals with disabilities and those with limited English proficiency by:
- Requiring covered entities to take appropriate steps to ensure communications with individuals with disabilities are as effective as communication with others.
- Covered entities must post a notice of individuals' rights, providing information about communication assistance, among other information.
- Covered entities are required to make all programs and activities provided through electronic and information technology accessible to individuals with disabilities, unless doing so would impose undue financial or administrative burdens.
- Covered entities cannot use marketing practices or benefit designs that discriminate on the basis of disability.
- Covered entities must make reasonable changes to policies, practices, and procedures, where necessary, to provide equal access for individuals with disabilities.
- Requiring covered entities to make electronic information and newly constructed or altered facilities accessible to individuals with disabilities and to provide appropriate auxiliary aids and services for individuals with disabilities.
- Requiring covered entities to take reasonable steps to provide meaningful access to individuals with limited English proficiency. Covered entities are also encouraged to develop language access plans.
Resources
CMS recently announced the release of the 2017 Medicare Marketing Guidelines for Medicare Advantage Organizations and Part D Sponsors, which include added language, clarifications, and new requirements. Join Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Carrie Barker-Settles, Director of Sales and Marketing Services, on Tuesday, June 28, from 1-2 pm ET, to discuss what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
AEP Marketing and Sales Readiness — Do You Pass the Quiz?
The following are questions Gorman Health Group would ask when conducting an assessment on marketing and sales strategies and execution plans for our Medicare Advantage clients. Take the quiz today and see if you are on track for a successful Annual Election Period (AEP).
If you have answered "no" to any of these questions and you feel you are behind the eight ball — contact us, and we can get you on the right track. AEP is just around the corner!
Resources
Understanding what's working and what's not within your sales and marketing plan is a must in the ever changing competitive Medicare market.Our seasoned veterans will work with your team to redefine sales and marketing strategies that will pay big dividends short and long-term at your plan. Visit our website to learn more >>
Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions. Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Contact us today to set up a demo >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>