CMS Fall Conference: Looking Ahead to 2020

The Centers for Medicare & Medicaid Services held their Medicare Advantage and Prescription Drug Plan Fall Conference & Webcast yesterday in the pleasantly comfortable city of Baltimore, MD. Collaboration and transparency seemed to be themes in the various sessions, covering topics such as the enhancement of Independent Review Entity data reporting, integration policies for 2021 Dual Eligible Special Needs Plans, and one-third financial audits. Currently, all session information is in the Upcoming/Current Events section of CMS’ website but it is anticipated it will move to Event Archives, along with video recordings of each session to follow in the future.

A blended panel of CMS and health plan representatives provided advice and specific practices on accessible communications. The speakers were well-prepared and provided many suggestions and examples during their allotted time, such as: interpreters via video, centralized database for member communications preferences, listening to live calls to ensure call center representatives are capturing communication requests, quarterly regression testing on websites, and hosting an inclusion and diversity week. One panelist effectively summed up the spirit of the session suggesting not to only think about the requirement, but to put the consumer first.

While not explicitly stated, accessible communications practices can and should be leveraged by sponsor partners such as delegates, providers, and community agencies participating in the MA-PD program. As I mentioned in a previous post, CMS released best practices regarding communications accessibility. No, these requirements may not be in the ever-present program audit protocol, but this is just as important of a focus area. If a member is not able to interact with their plan, how can they effectively access their benefits and services? My advice: assign one of your most creative employees to think of innovative ways to ensure equal access regardless of abilities.

The keynote delivered by Demetrios Kouzoukas, Principal Deputy Administrator and Director of the Center for Medicare, included glowing statistics regarding the state of Medicare Advantage and Part D. He acknowledged even with the many improvements completed (such as broadening benefits, streamlining the materials process, and implementing new legislation), the agency is not resting on laurels. He said the administration will continue to protect the program and build on elements that work well. Based on the messaging, this next year looks to be a continuation of collaboration and transparency for CMS.

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 maybe 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.

2020 Medicare Communications and Marketing Guidelines and Updates

Today, the Centers for Medicare & Medicaid Services (CMS) posted a memo regarding the Medicare Communications and Marketing Guidelines (MCMG), and yesterday, CMS published two memos: HPMS Marketing Module Updates and Model Notice Corrections and Updates. I’ll address today’s memo first.

In an interesting turn, CMS is instructing plans to refer to the 2019 MCMG guidance in conjunction with the updated guidance provided in today’s memo. Changes are designed to clarify scope and minimize burden. There are a number of clarifications that will affect your 2020 material review initiatives. It is also important to note CMS releases this noting it is “pending issuance of updated guidance,” which could be indicative of a delayed 2020 MCMG document.

Regarding the marketing module updates, the agency provides a comprehensive list of retired codes and provides new codes for benefit highlights and CMS-requested communications. CMS also provides additional operational clarifications and updates which should be incorporated into plan processes.

As it happens every year, the agency has published a list of corrections and updates to their model notices released in May. Some changes are run-of-the-mill clarifications to language. However, there are quite a few changes to support changes to the handling of Part B drug requests. In 2020, plans may start applying step therapy to Part B drugs, so additional instructions have been added to plans to disclosed a complete list of Part B drugs subject to these requirements. Furthermore, CMS modified Part C adjudication timeframes for organization determinations and appeals for Part B drugs as part of their Final Rule, so additional language was added to clarify the Part B prescription drug coverage decision and appeals decision timeframes. Since new models have not been posted, it is imperative for plans to ensure all materials take these changes into account.

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!