Uncategorized | GHG Advisors

Senate passes bill repealing major provisions of Affordable Care Act

Last week, the Senate passed an Affordable Care Act (ACA) repeal bill, with a vote of 52-47. Although largely symbolic, this marks the first time the Senate has been able to pass such a bill.

The Senate voted on a bill previously passed by the House, however, because of the large number of amendments made by the Senate, the legislation now goes back to the House, where it is all but certain to pass. The White House already stated the President will veto any ACA repeal legislation, and because the Republicans do not have enough votes to override such a veto, this will be the end of the movement. Nonetheless, the Republicans will see this as a major step in their attempt to repeal the ACA, as it is the first time Congress will be able to get such a bill to the President's desk.

What's more interesting is the parts of the bill which gained some bipartisan support. For example, the "Cadillac tax" repeal amendment was overwhelmingly approved with a vote of 90-10. Although this amendment will not become law this time around, its repeal is already scheduled in talks in tax packages expected to be voted on before the end of the year. It is also unclear how the anticipated funding expected from the Cadillac tax would be replaced. It is estimated such a repeal would remove about $90 billion from the ACA over 10 years, however, the Senate's tax repeal would not go into effect until 2015.

The passage of the bill also gives a glimpse into the Republican's ACA repeal agenda should they win the White House bid next year. Some of the major provisions include:

Defunding of Planned Parenthood
Repeal of the Medicaid expansion
Elimination of reinsurance, risk corridors, and risk adjustment programs set up under ACA
Repeal of Cadillac tax
End premium subsidies for insurance purchased through the Marketplace and small business tax credits
Repeal of individual and employer mandates by lowering the penalties for non-compliance to $0
End of healthcare.gov

Despite the Republican Party's fulfillment of the promise to get an ACA repeal to the White House, conservatives have yet to offer a replacement plan. The vote on the Medicaid repeal could also create some problems for senators up for re-election in states that have expanded Medicaid, such as Pennsylvania, Illinois, and Wisconsin. At the same time, Medicaid expansion continues to gain more interest from the remaining states yet to expand. Louisiana's new governor vowed to expand Medicaid on his first day in office. Virginia Hospital and Healthcare Association recently announced their change in position to support a bed tax, which would allow the state to expand Medicaid under ACA without any additional state funding. Utah and Wyoming continue talks to come up with a plan to expand Medicaid in the next year. And although Idaho remains opposed to expanding, the legislature is discussing a plan for the state to cover basic primary care for those who do not qualify for Medicaid but earn too little for subsidies under healthcare.gov, at a cost of $32 per month.

Resources

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by GHG Advisors

CMS Clarifies Key Audit Terminology

Immediate Corrective Action Required (ICAR), Corrective Action Required (CAR), and Observation. These terms have become part of the vocabulary for Compliance specialists, auditors, analysts, managers, directors, and Compliance Officers who so often field questions from Operations. Let's consider the following scenario: Compliance has just completed an internal audit of Claims Operations and has identified findings. This leads the Ops team to ask, "Are these findings CARs or ICARs?"

Last week, the Centers for Medicare & Medicaid Services (CMS) issued a memo clarifying certain definitions which apply to their Program Audit process. This clarification was released in response to Sponsors who have provided feedback stating they feel the process for determining CARs, ICARs and Observations is not transparent, and they lack the ability to determine how audit conditions will ultimately be classified. CMS has posted clarified definitions for these terms, as well as the term Invalid Data Submission (IDS) here on their CMS Program Audit website. While I will not re-write the memo, CMS hopes these key term definitions provide the industry with the transparency it sought. In short:

ICAR: These are items CMS identifies during an audit as systemic deficiencies so severe they require immediate correction. CMS cites lack of access to medication and/or services as well as immediate threats to enrollee health and safety. ICARs count as two points in the scoring methodology.
CAR: These are items CMS identifies during an audit as systemic and requiring correction, but the correction can wait until the audit report is issued. (This does not mean wait until the audit report is issued!) CMS clarifies that CARs may affect beneficiaries but not in a way immediately impacting their health and safety, and count as one point in the scoring.
Observation: These are non-systemic, typically one-off issues of non-compliance identified during the audit. No points are assigned in the scoring methodology for Observations.
IDS: This is cited when a Sponsor fails to produce an accurate universe within three attempts. This will be cited in 2016 for each element which cannot be tested, and counts as one point in the scoring.

CMS directs plans to send any questions to their mailbox at part_c_part_d_audit@cms.hhs.gov. Take it from me, the CMS team is responsive to posed questions. An informed and more prepared industry will hopefully make for a smooth 2016 audit season for CMS and for Sponsors.

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In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Let us help you create a culture of compliance. Contact us today to get started >>

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by GHG Advisors

AEP Is Winding Down, But Your Work Is Not Over!

As the Annual Election Period (AEP) begins to wind down, you have a pretty good idea of where you will end up this AEP. Whether you knocked the socks off your competition or missed your goals, now is the best time to assess your marketing and sales strategies in preparation for 2017!

Typically, we all have to perform an analysis for senior management showing where the leads and sales came from and what the costs per lead and sale were. Based on that information, we want to understand what changes need to be made or tested for next AEP to increase lead generation and decrease the cost per lead or sale.

But that shouldn't be the end of the analysis — now is the time to do the following:

Conduct an AEP Process Analysis — From an operational perspective, what went right and what didn't go as well as expected? Were there reprints? What were the call center stats — were they better or worse than last year? From an operational perspective, what would we like to change from this year to the next? What do we have to do internally/externally to accomplish that?
Vendor Assessment — What vendors over-performed or performed as expected? Do vendors need to be replaced? If so, the Request for Proposal (RFP) process should probably be completed by the end of the first quarter.
Review Competitive Creative — There is nothing wrong with understanding what competitors are doing and seeing where you might need to strengthen your own creative in the next year.
Review the sales distribution strategy to understand where the sales opportunities may have been missed and where they were most successful.
Deep-dive Evaluation of Lead Generation to Member Onboarding — Since now is the time when we really remember all of the pain points and accomplishments, we want to document them to ensure we make changes where needed and expand the successes.
Look back at the work plan/tactical execution plan to understand where more time is needed next year for a better execution come AEP.

Based on our experience, now is the time to conduct the assessment — before everyone has forgotten what needs to change and before the frustration of a missed date or opportunity becomes a distant memory. Gorman Health Group (GHG) has helped several organizations with this type of assessment — to provide that outside-in perspective which is honest and non-partisan.

Have questions? Contact GHG at ghg@ghgadvisors.com.

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Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans. We will position you for the challenges â€” and opportunities â€” posed by health reform, designing a strategy that takes into account your service area, market environment, core competencies, and vision of the future. Visit our website to learn more >>

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by GHG Advisors

Evolution of Validation: Selecting an Independent Auditor

The Centers for Medicare & Medicaid Services (CMS) audit validation process has evolved over the past few years. Here is what you should know about the changes and how to best prepare to contract with an Independent Auditor, or IA.

Let's go back to 2012. CMS was conducting the validation of audited Sponsors' corrective action plans (CAPs) by retesting areas found to be problematic. While the terminology has changed, the charge was led at that time by the Regional Office. In 2013, validation became an activity conducted by the Medicare Parts C & D Oversight and Enforcement Group (MOEG) at Central Office and Regional Office staff. Any items that resulted in a Corrective Action Required (CAR) or an Immediate Corrective Action Required (ICAR) were subject to validation.

As part of the 2013 validation timeline, the Sponsor had seven days from the issuance of the final audit report to submit a CAP for each condition. If we reference the 2014 Part C and Part D Program Audit and Enforcement Report, CMS outlined the average number of days which elapsed after an audit notice was issued.

If we take a look at the average days elapsed from the Exit Conference to the Final Report Issued date, the number of days elapsed has decreased, from 241 days in 2011 to 99 days in 2014. Based on the last year of reported data, plans still had a healthy three months from the verbal acknowledgement of CARs and ICARs (that is, the Exit Conference) to the issuance of the final report in order to implement corrections. In theory, by the time the final report was issued, some issues could have been corrected and, therefore, could have been ready for validation. However, time had to elapse for CMS to approve the CAPs, and after that point, CMS allowed Sponsors another 90 calendar days from that approval to implement and test the results of those CAPs. That's a lot of time when you look at it from the beneficiary perspective.

Fast forward to today — CMS is exercising their authority to require a Sponsor to hire an IA in order to validate if deficiencies found during a CMS program audit have been corrected. In a memo released on November 12, 2015, CMS confirms they will not provide recommendations on IA firms. Instead, they require the Sponsor to attest to both the independence of the IA as well as an absence of conflicts of interest. They point to the 2010 guidance for the selection of a Data Validation auditor for examples of relationships not meeting the standard for organization independence.

We are united with CMS' recommendation that Sponsors solicit proposals to select an IA early in the post-audit phase. Speaking from the auditor standpoint, it is much better for all parties involved to plan early, so exceed CMS' expectations and seek proposals as soon as possible. It's better to have that agreement in place ahead of time, rather than waiting until CMS sends you their instruction to hire an IA. This will give you the time to evaluate your options, so you can best determine their experience and subject matter expertise. When you are accountable to CMS to validate corrections, it is particularly important to partner with someone you can trust to apply a skilled eye to the validation activities. Otherwise, you may be subject to further scrutiny by CMS, which is the last thing any Sponsor needs when coming to the close of their audit process.

Resources

Determining conflict of interest is the responsibility of the Plan Sponsor and can be subject to interpretation. Not every auditor that a Plan Sponsor has used in the past is necessarily a conflict of interest. Contact us for further questions >>

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by GHG Advisors

2015-2016 CMS Program Audit Protocols Update

It's Christmas in October (and Hanukkah, too) if you've been waiting for the revised 2015-2016 Program Audit process and protocols. Let's get right down to it!

You'll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?

Overall Process

If the Sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in an audit report. After the third failed attempt, the Centers for Medicare & Medicaid Services (CMS) will classify this as an Invalid Data Submission, or IDS. There is NO reason a universe should be submitted late. Some of our Sponsor partners have required additional time for certain submissions, and they requested that time from CMS and got it. Nothing should irk senior leadership more than a universe being submitted a few minutes late, especially considering data issues in program audits directly impact Star Ratings.
CMS Account Managers will be playing a greater role in the validation of pre-audit issue summaries, which are made up of disclosed and self-identified issues. CMS also clarifies if CMS identified an issue during the course of routine monitoring and brought it to the Sponsor's attention, it would be classified as a self-identified issue. There are specific timing issues CMS will consider in determining whether an issue is corrected or uncorrected. It is best practice for Compliance departments to incorporate a log similar to what CMS has provided in the management of disclosed and self-identified issues.

CPE

Reduction of employee interviews, with addition of interview(s) of those responsible for managing accountability for FDR oversight. Not a surprise seeing as this has been a consistent finding for CMS throughout 2015 and previous years. Sponsors should coordinate and start mock interviews now with those who are responsible. CMS is seeing gaps in FDR oversight compliance whether or not you have three FDRs or three dozen.
By the numbers:
1. Tracer templates narrowed down from 2 to 1;
2. Tracer samples increasing from 5 to 6, all to be conducted in week 2, so Compliance staff can participate in week 1 activities;
3. There are 3 options for providing supporting documentation for tracers: embed into your Tracer, upload via SFTP, or have it immediately available onsite.
CMS has incorporated a documentation request list to help them review the effectiveness of a compliance program. These documents will need to be submitted along with the 5 universes for this audit area. CMS has also provided a template for the Sponsor to demonstrate organizational structure and governance. This template includes a number of questions and data requests, and should help auditors compare apples to apples.

CDAG and ODAG

Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) universe time periods will be determined by the Sponsor's enrollment size. In addition to numerous data layout clarifications and updates, CMS also details which universes may be combined with others to determine effectuation and notification scores.
As previously announced in 2016, Part C and Part D grievances should be submitted based on date of resolution notification. They include a reminder not to include Complaints Tracking Module (CTM) cases in grievance universes. (Who is still including CTM cases in grievance universes? Please call us, whoever you are, and let us help!)

Formulary Administration (FA) and Special Needs Plan Model of Care (SNP-MOC)

Thankfully, there were no significant changes noted in the core processes for these audit areas. Plans will note CMS has added the Cardholder ID to the SNP Enrollees (SNPE) record layout, and, more importantly, they request separate record layouts be submitted for each unique MOC rather than per contract.

Pilot Protocols

CMS commits to releasing the pilot protocols for Medication Therapy Management (MTM) and Provider Network Adequacy later this year.

They describe one of their objectives for the MTM review to "initiate enforcement actions and/or identify possible performance measures for sponsors to implement." Technically, CMS can refer a Sponsor for enforcement action for any aspect of the audit. Why highlight it in MTM? Get busy making sure your program is in order.
No surprises in network adequacy — CMS has emphasized they will be evaluating networks for adequacy by also evaluating whether or not participating providers' practices are open to treat enrollees. Some of our partner clients have already started their own internal evaluations to ensure this important beneficiary protection is met.

This year's audit season was a whirlwind of many things. For Sponsors and auditors alike, it's fair to say the industry struggled with the earlier-published protocol. Now that this document set has been released for 2015 and 2016, this should allow some breathing room for all to start implementing changes in tools, reports, and monitoring efforts. Unfortunately, that breathing room overlaps the upcoming holiday season, so perseverance is key! There is truly no rest for the weary.

Resources

If your organization is interested in a mock audit utilizing the latest protocols. We can help! The Online Monitoring Tool™ is our compliance software designed to help organizations operating in Medicare, Medicaid and the Health Insurance Marketplace track the compliance of their operations. 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

MA-VBID Request for Applications Released

The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications for the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, which is an opportunity for MA plans to offer supplemental benefits or reduced cost sharing to enrollees with CMS-specified chronic conditions, focused on the services that are of highest clinical value to them. Applications are due by January 8, 2016.

CMS will tentatively select plans by April 2016. The application document repeats most of the information CMS released in the original announcement and webinar. However, the application will be submitted via a web portal which will be released in the near future. The process is much like the MA contract application process. CMS does provide information about the questions which will appear in the template.

Applicants will be required to present narrative explanations about their proposed interventions. First, there is the general overview of the proposed interventions describing the overall approach and understanding. This section must convey specific enough information tracking to details about interventions in later sections of the template. It will act to set the stage of an application.

Next, applicants must describe each separate VBID intervention. This will include each combination of plan and enrollee group so every target population is described with repetitive plan information and interventions. CMS describes the target population according to the eight qualifying diseases/conditions listed in the VBID demonstration.

Applicants must list specific benefits for each target population. CMS lists the various combinations of benefits:

Reduction or Elimination of Cost Sharing (not conditional)
Reduction or Elimination of Cost Sharing for High Value Provider
Reduction or Elimination of Cost Sharing Conditioned on Participation
Supplemental Non-Covered Benefits

CMS asks for "clear descriptions" in each of the four options and provides a number of elements applicants must discuss in their narratives.

While applicants must upload actuarial and financial documentation in this template, there are no specifications about the types of information for which CMS will ask. Notably, there is a statement that such information may not be required.

Health plans must also discuss their compliance history extending to January 1, 2010. Finally, an official of the applicant must certify their applications, their understanding about the conditions including marketing limitations, and bid requirements.

Data analysis is the key first step to identifying target populations and subsequent benefits which will become the focus of the demonstration. 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. Contact us to learn more >>

Resources

Download a copy of the recording from the October 5 webinar titled "Medicare Advantage Value-Based Insurance Design Model (MA-VBID)", hosted by John Gorman.

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by GHG Advisors

ACO vs. Value-Based

Earlier this year, the U.S. Department of Health & Human Services (HHS) set a goal of moving 30 percent of payment for traditional Medicare benefits to value-based payment models by the end of 2016 and 50 percent by the end of 2018. The Center for Medicare & Medicaid Innovation's (CMMI's) Accountable Care Organizations (ACOs) have been the largest movement toward that goal to date, yet the most recent financial results highlight some flaws, and organizations should carefully analyze whether an ACO or a Medicare Advantage (MA) structure is a better fit for them.

The results show these ACOs are important building blocks for many organizations and will continue to generate success coupled with tweaks made by the Centers for Medicare & Medicaid Services (CMS) to generate more positive numbers. Organizations having already proven their success in generating savings could easily graduate to MA and be successful. Plans not as successful, or plans not currently possessing the infrastructure needed to succeed in MA, should look to CMS' Next Generation model to alleviate some of the concerns of the previous demonstrations.

CMS applauded the most recent financial and quality results, stating Medicare ACOs continue to improve quality of care while slowing down healthcare costs. Ninety-seven ACOs qualified to share in savings by meeting quality and cost benchmarks. CMS stated the ACOs generated net savings of $411 million in 2014 and improved in most quality measures. CMS also noted additional ACOs are inquiring about participating next year.

Yet these numbers represent one in four generating enough savings to qualify for bonuses. Only 11 Pioneer ACOs earned savings payments of $82 million. Five generated losses, with three owing CMS shared losses of $9 million. Despite CMS reporting Pioneer ACOs improving an average of 3.6 percent compared to 2013 on 28 of the 33 quality measures, most did not see any rewards. Only 27 percent of Medicare Shared Savings Program (MSSP) ACOs earned shared savings payments.

The results indicate ACOs need time to adjust to the model and show improvement over time. Thirty-seven percent of the MSSP ACOs launching in 2012 generated savings in the third performance year, compared to 27 percent of MSSPs beginning in 2013 and 19 percent beginning in 2014. However, these numbers do not account for the ACOs dropping out of the program, potentially skewing the earlier success rates. The results also highlight the complexity of participating in CMS' alternative payment models. Many ACOs not as successful initially likely lacked or underestimated the investment needed for new infrastructure and systems. Plans and providers need to understand the need to set up more sophisticated information technology (IT) infrastructure and how to successfully utilize data. As potential ACOs evaluate whether to participate, they should consider how much of an investment is needed in order to succeed.

The major concern over CMS' use of benchmarks is also still evident. In order for an ACO to qualify for shared savings, the ACO must beat a benchmark calculated by CMS. The year-to-year trend in this benchmark is a mix of the national percentage growth rate in Medicare and the absolute dollar value of the annual per member per month (PMPM) increase in the average Fee-for-Service (FFS) per capita costs. Because of this, ACOs in high-cost areas consistently achieving lower costs are not rewarded because their improvements in financial and quality performance are not accurately captured. The current program also lacks a full and up-to-date risk adjustment to accurately account for beneficiaries' health status. Thus, ACOs that may generate savings for CMS still miss the benchmark.

Despite concerns with methodology, there are now approximately 7 million beneficiaries served by more than 400 ACOs. At the same time, CMS has shown it is focused on issues that develop and is working on options which will tweak the program to better fit future participants (the Next Generation ACO, for example). Despite the challenges, ACOs are currently the biggest initiative succeeding in enticing and exposing large numbers of providers and beneficiaries in its effort to coordinate services. The program is still receiving strong interest from both new applicants and existing ACOs seeking to continue the program, and CMS plans to announce new and retiring ACOs by the end of the year.

Resources

We understand Medicare ACOs: We have helped launch eight over the past two years. But we also understand that this is just a first step toward taking greater control over the Medicare revenue stream by "moving up the food chain." Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. 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 >>

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by GHG Advisors

Healthcare Implications Post Boehner Exit

House Speaker John Boehner announced last Friday he will resign his seat at the end of October. Following this announcement, House and Senate members immediately announced plans to pass a spending bill preventing a government shutdown by scrapping plans to block Planned Parenthood funding for the time being. Boehner's resignation makes this move possible because he no longer faces the threat of being ousted by the House Republicans if the bill he brings forward to the floor does not have Republican majority.

While the most imminent government shutdown has currently been averted, the threat of everything coming to a halt mid-December, at which point the spending bill funding would run out, is much more likely to materialize. The next funding bill will need to work out the funding levels for the rest of budget year 2016 in order to prevent a government shutdown. In an attempt to put the continual nightmare of annual shutdown threats off until the next administration, Senator McConnell just announced potential talks with President Obama to negotiate a 2-year budget, and cover fiscal year 2016 and 2017.

So what does this all mean for healthcare and the Affordable Care Act (ACA)?

Planned Parenthood aside, Boehner was actually quite a critical opponent of Obamacare and fought it to the very end, even bringing lawsuits against the administration. His only move seen as a positive in the healthcare industry is the support to repeal the flawed Sustainable Growth Rate (SGR) formula earlier this year. Because House Republicans are likely celebrating the win of the resignation, however, we will likely see many more attacks on the ACA despite all of them being unlikely to work, just as under Boehner's leadership.

Reconciliation bills are one likely tactic — House Ways and Means Committee already approved one today — to repeal portions of the ACA, such as employer and individual mandates, medical device tax, and the Independent Payment Advisory Board. The House and Energy Committee also introduced a reconciliation bill to defund Planned Parenthood. However, although Boehner stepping down may mean such bills could make it through both the House and Senate, they will certainly meet their end on the President's desk.

Unfortunately, this also puts any potential good bipartisan agreements at bay for the time being. Bipartisan bills to repeal the "Cadillac Tax," for example, will likely see much more punting around. Repealing the tax would create an $87 million budget deficit, and, with what is shaping up to be an aggressive fight in December, such a move is unlikely.

Under the new speaker's leadership, likely a more conservative pick, the Planned Parenthood fight may also stick around until December 2015. While Boehner was more willing to work across party lines on this issue, the current Republican majority is celebrating the resignation and may be much more emboldened in their fight in December.

The big issue is, of course, the 2016 budget. While the current spending bill will deal with emergency issues such as the imminent expiration of the transportation funding, the bill in December will need to tackle the FY 2016 budget as a whole. One huge one is Part B premiums — if Social Security is not adjusted and stopgap funding is not provided, this fund could run dry, and Medicare recipients under Part B will see significant premium increases. Another example is the temporary funding created by the repeal of the SGR, for example, funding for ambulance rides and physical therapy. These programs will face cuts if funding is not agreed upon in December.

Resources

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by GHG Advisors

Do More Than Survive AEP

How quickly another Annual Election Period (AEP) is upon us. This time of year is the perfect time to review your new member onboarding activities and AEP strategy. We all know the sale doesn't end when the application is turned in and membership begins. This is where the rubber hits the road.

These are the four questions to consider going into AEP:

Are all plan resource documents updated with the 2016 plan benefits? Picture this: A friend newly eligible for Medicare recently enrolled in a Medicare Advantage plan. He experienced a benefit problem that nearly ended in a sales allegation all because a representative was relying on outdated benefit information. This would have been avoided if everyone at the plan had the new benefit designs.
Does health plan staff see the big picture? It's easy for us to focus on our individual operational components. After all, the number of regulations and processes to manage a compliant Operations Department is significant and takes our full attention, but the big picture allows for cohesive programs and the ability to see what part we play. Does Enrollment know the top issues that Reconciliation experiences? Is there a feedback loop established to catch improvement opportunities early as we move into AEP? Has Sales shared the advertising schedule and advertisements with Customer Service? Customer Service can maintain that strategy and answer member questions about the campaigns for 2016.
Are operational oversight tools in place? Not only should all operational staff know the requirements governing their processes, they should know how to tell they are meeting those requirements. The ability to oversee our own processes and know we are in compliance is empowering. Not only can corrections occur immediately, but staff can be confident and efficient, focusing on the important actions supporting new and existing members.
Is everyone focused on the goal — ensuring a positive member experience? If applications are incomplete, is the Enrollment staff focused on sending a letter to get the application off their plate or focused on reaching out to the member to complete the member enrollment? Are welcome calls in place to answer any lingering questions and ensure new members feel confident and engaged in their plan choice?

AEP was quick to arriveâ€”it will be equally quick to come to an end. Make sure it's the AEP you designed rather than the AEP you survived.

Resources

In Operations, we naturally focus on our own internal processes and efficiencies, but now is the time to invest in making sure staff knows how their contributions impact members and the health plan. Gorman Health Group's experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations. We've been in your shoes and know how to navigate through AEP. Visit our website to learn more >>

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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 forâ€¦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 onâ€”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 >>

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by GHG Advisors