Potential Changes in Part C Reporting
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. To follow are Part C highlights that merit your attention.
Organization determinations/reconsiderations, Special Needs Plans care management, and enrollments/disenrollments, were updated to include additional data elements, and two new reporting sections were added: Rewards and Incentives Program and Mid-Year Network Changes.
For most data elements with a due date of February 28, the data due date was changed to a couple of different Mondays in February, and the due date for enrollment/disenrollment was changed to the last Monday in August and February. These timing changes are proposed so the reporting load would be more manageable in 2016 than it was in 2015 for the Centers for Medicare & Medicaid Services (CMS)/Health Plan Management System (HPMS), and hopefully it will be more manageable for Plan Sponsors as well.
Two new data elements for Section 6 include the reporting of dismissals for organization determinations and reconsiderations to be more aligned with Part D reporting requirements.
Special Needs Plans (SNPs) will now also report four new pieces of data:
- the enrollee initial health risk assessment (HRA) refusals,
- the annual reassessment refusals
- the HRAs where the SNP was unable to reach new enrollees, and
- the annual reassessments where the SNP was unable to reach enrollees.
Excluded from this reporting are the HRAs that were not done where no refusal is documented and the HRA simply did not happen.
A few new disenrollment data points will now be requested:
- The total number of involuntary disenrollments for failure to pay plan premium in the specified time period.
- Of the total reported in the above, the number of disenrolled individuals who submitted a timely request for reinstatement for good cause.
- Of the total reported in the above, the number of favorable good cause determinations.
- Of the total reported in the above, the number of individuals reinstated.
A new reporting section is proposed for rewards and incentives programs. Plan Sponsors who respond in the affirmative will be required to explain which health-related services and/or activities are included in the program, which rewards enrollees may earn for participation, and how the value of the reward is calculated. They will also need to describe how enrollee participation is tracked, how many enrollees are currently enrolled, and how many rewards have been awarded so far.
Not surprising, CMS’ increased oversight over network adequacy is making its way into Part C reporting. The new reporting section, Mid-Year Network Changes, will provide CMS with visibility into how often Plan Sponsors undergo mid-year network changes and how many enrollees are affected by this type of change. CMS states, based on 60-day comments, CMS increased the data elements from 13 to 53. Fun! CMS also states, “Collecting this data will help to inform CMS in determining how broadly to use the new Network Management Module (NMM) in HPMS to verify that plans’ networks meet CMS network adequacy standards.” If you recall from CMS’ 2015 Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast, presenters specifically addressed this module and said Medicare Advantage Organization (MAO)-initiated submissions will not be viewable or evaluated by CMS. However, the NMM also allows for CMS-initiated requests of Health Service Delivery (HSD) tables “in support of various processes,” which certainly you can presume will be viewable and evaluated. I don’t know about you, but if it is in HPMS, it’s viewable to CMS.
For all Plan Sponsors who currently do not have mechanisms for capturing this information, we encourage you to nail down a process. Operational areas may want to get a head start on determining how this information is captured today. CMS is using data now more than ever to determine outliers and to identify candidates for program audits, both of which can lead to enforcement actions. Remember: what they are asking Plan Sponsors to report on are not new requirements — so we anticipate CMS to have little patience for those who demonstrate non-compliance with items agreed to upon initial application.
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