2021 CMS Application Season: 133 Days

Now that October first is behind us, and everyone has had time to evaluate all the new benefits being offered for 2020 (Just kidding – reviewing what’s out there is an enormous task!), it is time to think about the 2021 plan year.  There is no rest in the field of Medicare Advantage and Part D.

Some folks have already started with their 2021 application and expansion planning. Network providers might be in negotiations, state licensure filings are being drafted, and perhaps organizations are conducting feasibility studies to determine how to put their best foot forward in this market.

Other organizations might be taking a more cautious approach, and perhaps may not have gotten the head start that others have. If this sounds familiar, don’t worry, this is pretty common, but it’s time to make some decisions.

CMS has released the draft applications for both Medicare Advantage and Part D for industry comment. There were no major changes, but drafts are always worth a look as this is your opportunity to give the agency valuable feedback.

If you have not submitted a new application or a service area expansion request in a while, it is important to understand how the process has evolved. Document requests have changed, time frames may be different, and the CMS review process can be a challenge if you do not know what to expect. If you have never submitted an application, be assured that the agency releases templates, instructions, and training. However, not everything is straightforward, and I say this having worked with many experienced plans who on an annual basis still struggle to understand the requirements or the review process.

Review the applications and if you have questions about the process or the requirements, start working them out now. You have 133 days until applications are due on February 12.

CMS Scales Back 2020 Program Audit Changes

With current program audit protocols set to expire on April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) have decided to scale back the sweeping proposed changes published in 2018, as reflected in their recent notice posted on August 16.

According to CMS’ supporting statement, over 700 comments were received by the agency in response to the proposed changes, which covered not only program audit protocol but also timeliness monitoring data requests. It was acknowledged most commenters supported the goal to simplify data collection for audits, but many were concerned about the time needed to reprogram systems to accommodate the changes.

CMS has had the authority to extend the current documents, which is how the agency is proceeding, with some minor updates. The package including supporting statement may be reviewed here.

Updates: Timeliness Test tables in Coverage Determinations, Appeals and Grievances (CDAG) and Organization Determinations, Appeals and Grievances (ODAG) regulatory references; increase of grievance samples from 10 to 20; edits to Compliance Program Effectiveness (CPE) questionnaires, and various table edits affecting each program audit data request tool.

Removed: Medication Therapy Management (MTM) materials (protocol suspended); CPE self-assessment questionnaire; CDAG questionnaire; ODAG questionnaire (reducing duplication and burden); CDAG Tables 9, 10, and 16, addressing Standard IRE Auto-forwarded Coverage Determinations and Redeterminations, Expedited IRE Auto-forwarded Coverage Determinations and Redeterminations, and Part D Call Logs, respectively; ODAG Table 14, Part C Call Logs; Website Review of Formulary Administration protocol; Enrollment Verification of the Special Needs Plan Model of Care protocol.

For the organizations responsible for supporting Medicare Advantage and Part D functions subject to program audits, the scaling back of revisions should be a welcome change, as it reduces the amount of re-programming to be done. One of the most impactful initial proposals was to consolidate certain CDAG and ODAG universes. On the other hand, while CMS had proposed to eliminate the impact analysis (IA) excel documents and instead leverage universe record layouts for requesting data, the IA documents remain.

CMS’ next step is to publish a new data collection request under a separate Office of Management and Budget (OMB) control number. Expect this request to reflect recent regulatory changes (think of the new appeals chapter), the simplification of tools, and to allow for more time to implement system changes.

Comments from the public are due October 15, 2019.

Any Day Now: Waiting for the 2020 Marketing Guidelines

Hello August! New and established health plans are waiting for the 2020 Medicare Communications and Marketing Guidelines (MCMG) to come out. Over the past few years, the final MCMG, formerly known as the Medicare Marketing Guidelines, were dated as follows:

  • 2019 MCMG dated July 20, 2018
  • 2018 MMG dated July 20, 2017
  • 2017 MMG dated June 10, 2016
  • 2016 MMG dated July 2, 2015
  • 2015 MMG dated June 17, 2014
  • 2014 MMG dated June 28, 2013

See a pattern? I could go on, but the history shows more of the same. The industry has come to expect these guidelines be released around June or July, and health plans often schedule their marketing material initiatives around this time. With additional dependencies on third party reviews (such as state agency reviews or outside consultant reviews) and print vendors, this important sub-regulatory reference is necessary to finalize materials for submission (if needed), printing, and finalization.

I outlined some key changes in my post regarding the draft 2020 MCMG. Industry comments were due to the Centers for Medicare & Medicaid Services (CMS) by April 4. Like most of my colleagues, I’ll be hitting refresh on CMS’ MMG webpage until I see that magic term “CY2020” on a document!


New Guidance on Evaluating Compliance Programs

While most everyone I speak with these days relies on the Centers for Medicare & Medicaid Services (CMS) Program Audit Protocol to review their compliance program effectiveness (CPE), it is imperative to review a compliance program through another lens.

The United States Department of Justice (DOJ) recently updated their guidance for prosecutors on the evaluation of a compliance program’s effectiveness. The three fundamental questions are as follows:

  1. Is the corporation’s compliance program well designed?
  2. Is the program being applied earnestly and in good faith (implemented effectively)?
  3. Does the corporation’s compliance program work in practice?

For anyone new to reviewing a compliance program, or if you are a compliance professional performing a self evaluation, the DOJ provides key considerations and questions to ask in order to make solid determinations on these questions. Tracer samples are one way to identify patterns, and that is core to CMS’ current methodology. However, I have discussed many of these DOJ-identified additional factors with clients recently:

  • Risk Assessment: are resources devoted disproportionately to low-risk issues?
  • Third Party Management: What are the actions and consequences of third party (vendor or delegate) misconduct?
  • Culture: Do top leaders set the tone to encourage compliance? Does Compliance have sufficient seniority and autonomy to perform their duties, and has the organization allocated sufficient funds for the function?

I mentioned in a previous post that “we are most comfortable in roads we’ve traveled over and over, and therefore might be more susceptible to distraction.” If you are using the CMS CPE protocol every year, consider revising your methodology with some frequency. The industry’s methods and recommendations are evolving; make sure you change with the times.  Enforcement actions will tell a story soon enough – do not become part of that story.

Communications Accessibility: Best Practices Released by CMS

On April 26, 2019, the Centers for Medicare & Medicaid Services (CMS) released Communications Accessibility for Individuals with Disabilities – Best Practices for Medicare Health and Part D Prescription Drug Programs. This document was submitted to the agency by IMPAQ International, LLC. The report focuses on auxiliary aids and services addressing communication-related accessibility needs, as those cover typical beneficiary interactions.

About a year and a half ago, some colleagues and I authored a white paper titled Accessible Communications: Standing Tall in Service. We realized the importance of this topic as the agency had released frequently-asked questions related to Section 504 of the Rehabilitation Act of 1973 (Section 504) and Section 1557 of the Affordable Care Act (Section 1557). I’m happy to report many of our recommendations and best practice concepts are also found in the IMPAQ piece, such as cultural competency training, leveraging qualified readers, tracking/maintaining beneficiary requests, analysis of complaint data, and auditing/monitoring of vendors. IMPAQ covers more in the arena of web accessibility, whereas I respectfully believe we covered more from a delegation oversight standpoint.

The reason we wrote this piece was because our number one priority was beneficiary access to care and service. I know for a fact the piece was not as popular as anything related to CMS program audits or marketing materials. Now that CMS has released these best practices, plans and delegates should sit up and take more notice of this topic. This could be a harbinger of things to come.