How to Make Your Next MA-PD Plan Implementation a Success

By John Gorman

Friends of mine built a house. They indicated it was the most stressful event, full of decisions they didn’t know they needed to make, and struggled to agree. The timeline they hoped for was not reality and had to be reworked. While they said they were stronger having gone through the process and they love their house now, it wasn’t the fun event they thought it would be, and they never want to build a house again.

I have never built a house, but having worked through many Medicare Advantage Prescription Drug (MA-PD) plan implementations and expansions, I know those feelings. So many decisions to be made, processes to be designed, timelines to be managed. The advantage I have is, having gone through the process many times, I know what to expect and how to manage the experience. Because of that, the thought of another implementation is exciting rather than dreadful.

Here are four actions I learned that can make your 2019 or 2020 implementation more productive and less stressful:

Know the Timeline. There are many steps to a successful implementation, starting with feasibility, network, application, vendors, and materials then moving on to individual components. Some components’ end dates are clearly outlined by the Centers for Medicare & Medicaid Services (CMS) such as application and bid submission dates. Others are a bit more obscure such as connectivity with CMS and data testing. Identifying all these components and backing into the final due date is necessary and should be done very early in the process. We often encounter clients who are not aware critical documents should have been submitted months ago to CMS for 45-day approval in order to have them ready for 10/1, and provider contracting should be well under way for 2019 expansions and implementations. Those providers should be contracted and credentialed before your application is filed with CMS in mid-February. It is difficult enough to complete everything when you know it is coming. Being unaware of required elements and their timelines can result, at its worst, a failed implementation or negative first impression with CMS.

Choose the Right Vendors for Your Organization. “What vendor should we use?” is probably my second most asked question on an implementation. It seems like an easy question to answer, but it’s not. There are many factors that impact your organization’s decision on vendors. For most processes, we encourage the use of Requests for Proposals (RFPs) to look for the best vendor that meets your organization’s particular needs. Some questions that should be considered are:

  • Do you just need software for processes, or are you planning on business process outsourcing (BPO) for some functions?
  • Might you start with a BPO then plan on assuming the functions in year 2 or 3? If so, is there a vendor that will start with BPO services but then transfer their platform to your staff?
  • What is your IT support like? Can you host software and manage upgrades? What about file integration between vendors?
  • How serious is the vendor about compliance? Are they proactive while still allowing your input? Are they hands off? Do they leave it all up to your organization? Do they make the decisions, and you have to pay for any other interpretation?
  • What is your price point? If needed, will a vendor work with you to move some of the implementation costs into a higher per member per month (PMPM)?
  • What are current and recent past clients saying about the vendor? Are there struggles that may impact your organization?

Manage Impacts on Staff. If you are an existing health plan, your staff all have “day jobs.” If you are a new organization just setting up your health plan, you probably have minimal staff wearing many hats. Either way, an implementation is a marathon and not a sprint. Having exhausted staff who are unable to focus means lost productivity and potentially staff turnover. Additionally MA and Prescription Drug Plan (PDP) implementations are highly regulated and totally different from commercial, Health Insurance Marketplace, and even Medicaid. We often get calls six to nine months before an implementation start date by organizations that didn’t bring in any MA or PDP experience. High-quality competent staff are at their wits end trying to learn a totally new product line and implement a new program at the same time. They are not only exhausted but feel a sense of failure that wouldn’t be there if the organization had included experienced people who have implemented a program as part of the project from the start.

Make Timely and Informed Decisions. An implementation is full of decisions, many of which have multiple considerations that can lead to disagreements within the organization. Small decisions such as what day to send out premium invoices to large decisions such as whether to utilize independent brokers and agents or where to put particular functions can linger for weeks, holding up processes. Setting up a steering committee that will make decisions when there is disagreement can keep your implementation on schedule. There are a lot of moving pieces, and delays due to decision-making can have far-reaching impact. A failure to decide on whether to use independent agents and brokers, which resulted in an inability to contract with brokers or hire internal sales people in time to be trained and tested for the Annual Election Period, could have far-reaching impact on the success of your program. Expect disagreements, and set up processes to make timely, informed decisions up front. The investment will be well worth it.

Implementations, like building a house, are not for the faint of heart. It is an amazing adventure to build something that wasn’t there before, but it is a lot of hard work and a long-term effort. Investing in some solid upfront planning won’t make the process painless, but it will make it sustainable and put your organization in good standing for success. When your staff tells their “remember when” stories in the conference room, do you want it to be with a “never again” attitude, or do you want them to say, “Let’s go build something!”?

At Gorman Health Group, we have been part of many service area expansions and implementations. Regardless of where you are in the process, we can help your organization cross the finish line. If you would like more information about expanding your service area or implementing an MA plan or PDP, please contact us here or by emailing me directly at

Let’s go build something together!