Yet, while CMS won’t require QHPs to submit this data for another year, beta testing will being in 2015, meaning health plans have only a few short weeks to prepare.

This program will closely resemble the Medicare Advantage (MA) Five-Star Quality Rating System, which rates MA plans based on their performance in a number of key measures. Similarly, through the QRS, all QHPs in the exchanges will be subject to such measures as access to care, access to information, plan administration and overall rating of the health plan.

This may come as a shock to commercial health plans, as many have not dealt with the challenges that MA plans have faced in achieving acceptable ratings in the similar Five-Star system.

Yet, success in the QRS program is vital to plans’ success in the exchanges.

During the 2016 exchange enrollment period, health plan ratings will appear on exchanges for all to see. Poor performance in any of these areas could be potentially damaging to a carrier’s enrollment numbers or ability to offer coverage.

Insurers must get their ducks in a row now, especially if they plan to have any level of success during the 2015 beta test.

To properly prepare, plans must:

• Understand key measures as it pertains to their business
• Identify which areas of patient care and/or satisfaction influence these measures
• Determine a game plan for collecting and monitoring data
• Proactively address any issues that may arise

Doing so will ensure that plans are proactively addressing any issues that may affect their quality ratings in 2016, and in turn, enrollment numbers.

If you are unsure of how to address these changes, contact Cody Consulting today.

Thankfully, yesterday’s challenges can be learning opportunities that help us improve in the future. The following are four lessons learned leading up to the 2015 AEP that will help health plans better prepare for creating ANOCs and EOCs next year:

Lesson #1: A comprehensive timeline is key to success

One challenge some MA and PDP plans faced this year was the absence of a formalized timeline for developing and distributing materials. With little time to collect information and create documents after The Centers for Medicare & Medicaid Services (CMS) releases its ANOC and EOC model documents, developing a comprehensive timeline well in advance is key to staying on schedule and distributing materials on time.

It’s also important that this timeline be flexible, as delays from CMS may push back schedules and require that health plans hurry up and then wait, or worse, vice versa. Next year, make sure you have a timeline that has enough padding to adjust for delays.

Lesson #2: Key contributors should be identified early

When developing their ANOC and EOC documents for the 2015 AEP, many plans neglected to proactively identify the cross-functional team needed to ensure that materials were accurate, on schedule and in compliance. As a result, identifying and gaining the commitment of subject matter experts (SMEs) to review documents for accuracy and compliance came as a bit of a challenge.

When not all departments are adequately involved in this process, plans risk distributing materials containing mistakes or errors. To alleviate this problem, plans should identify key contributors and build a cross-functional team early on in the process. This should include SMEs from all relevant areas of the organization who can provide timely review of content and ensure accuracy of information.

Lesson #3: Clear leadership should be established

While establishing a cross-departmental team is an important part of success for the AEP document creation process, every team needs a leader. Health plans that did not have a dedicated individual responsible for guiding the materials creation process and all its players may have risked wasting both time and money, and increased their risk of non-compliance.

Additionally, if this individual did not have cross-departmental authority, precious time was wasted on gaining cooperation from individuals not within the project leader’s reporting structure.

Next year, prior to selecting a team or establishing a timeline, a leader within the organization should be appointed to manage the ANOC and EOC materials creation process from beginning to end. Ideally, this person will have limited work commitments aside from this project to ensure a dedicated focus. They must also have the authority to push the process forward, make decisions and obtain content and approvals from other team members.

Lesson #4: Software should be used to increase efficiency and compliance

During the 2015 AEP prep season, health plans that used a software tool to help manage the materials creation process had an easier time coordinating all the different moving parts involved. In addition, they likely reduced their risk of document errors, costly errata mailings, and late project completion – not to mention dramatically decreased the stress levels of project participants.

Tools are available that help health plans manage all aspects of development, tracking and distribution of these required materials, and many successful plans integrate these software solutions into their materials creation process. If they have not already, plans should start exploring tools that facilitate a comprehensive approach to marketing collateral needs.

A powerful tool will include modules that manage scheduling, compliance, document creation, as well as overall project management. And don’t forget, individuals on the materials creation team must be fully trained to use these tools. After all, what good is a solution that streamlines processes if those within the organization do not use it properly or to the full extent of its capabilities?

The good news is the 2015 ANOC and EOC mailing project is done – you’ve made it through. Now, let’s use the lessons learned and make next year even better.

by Al Valenti and Kelly Altmann

In addition, it also touched on the major issues surrounding state Medicaid plan programs, specifically:

The inability to assess standards and success among states

Even though the federal government requires states to establish quality standards for Medicaid programs and monitor quality and reporting compliance, there is practically no uniformity for these standards across the states. Shortfalls in contract requirements and data collection make it difficult to compare state-to-state data and assess whether beneficiary health has actually improved throughout the country.

Staff cuts and questions of accountability

Some states have cut back on staffing of their Medicaid offices. This not only raises concerns about the states’ ability to hold health plans accountable, but also has resulted in the federal government being criticized for failing to ensure the states properly oversee the plans.

Inconsistencies in practices

States are required to set rates, monitor contracts and enrollment practices, and oversee operational functions and compliance programs of their Medicaid plans, but how each state complies differs. This, unfortunately, leads to operational and reporting inconsistencies and prevents the ability to share and compare best practices, data and other important information.

Lack of CMS state oversight

Each state is required to audit health plans providing Medicaid services. CMS monitors that state oversight. However, CMS has been accused of having problems with such oversight, according to reports from the Department of Health and Human Services Inspector General’s office and the U.S. Government Accountability Office.

To alleviate these challenges, CMS is moving to exert more direct control and oversight of these programs, which will ultimately benefit Medicaid plans. However, preparing compliance efforts will be key. To find out how Medicaid plans can prepare for increased CMS oversight, see our previous blog post on this topic.

We excel in providing consulting and software solutions to help government-sponsored health plans significantly mitigate compliance risk. If you’d like to learn more, please contact us today.

At this stage of the game, tension is running high. By now, many health plans have likely discovered the way they were planning on creating the documents won’t work, have encountered issues with vendors, or any other number of challenges that put tasks and timelines into a tailspin.

This follow-up piece provides advice for how to push through bottlenecks, solve last-minute challenges and get compliant AEP materials out accurately and on time.

1.     Address Critical Timeline Challenges Immediately

If any tasks on your timeline are slipping, focus on addressing the critical missed deadlines as quickly as possible. If your team was having meetings once a week, now is the time to increase meeting frequency to twice a week, or as often as necessary. In addition, the marketing communications team should communicate daily, keep management abreast of the status of projects, and stay alert for possible roadblocks that may delay progress.

2.     Effectively Manage Subject Matter Experts

When working with a health plan’s internal subject matter experts (SMEs), marketing communications directors should clearly express their needs and anticipate what would be helpful for SMEs to know in advance. For example, educating SMEs on potential compliance issues that may arise while they are preparing content for the documents will help increase the likelihood that they provide usable content the first time around. Giving SMEs explicit deadlines when you request information will also ensure timelines are maintained.

3.   Keep Notes to Document the Good, Bad and Ugly

Inevitably, you will have moments during the AEP materials creation process when you have ideas for how to do things differently next year. Even though it may be difficult, try to keep notes about what’s working and what’s not working that you can reference later, with the ultimate goal being to make your life easier the next time around. After the AEP season concludes, review your notes, identify your weak spots, and consider what tools and resources – such as CodySoft – may be worthwhile to improve the AEP materials creation process for 2016.

Medicare plans must create, print and deliver AEP materials, specifically, Annual Notification of Change (ANOCs) and Evidence of Coverage (EOCs), to members by September 30. Preparing AEP materials can be a time-consuming, labor-intensive process and wrought with compliance risk.

1. Create a Comprehensive Task List and Timeline

Numerous tasks and various departments and people are involved in creating AEP materials from start to finish. Having a well-thought-out production timeline will help ensure your materials are completed on time and are compliant. Consider using a program, such as CodySoft, that allows you to assign tasks, people and deadlines to ensure streamlined project management, as this can make the job infinitely easier.

2. Use the 2015 Model Documents

Some health plans may be tempted to create their 2015 AEP materials by making updates to their 2014 templates. However, if one data point of the thousands you update is missed, your health plan is out of compliance. Using the 2015 model documents provided by CMS – which only requires a 10-day file and use approval period – is the least risky and most expeditious way to prepare your AEP materials.

3. Use a “Central Source of Truth” Data Grid for All Plan Benefit Information

Plan benefit information that must be included in members’ ANOCs, EOCs and Summary of Benefits (SB) could have variables that number in the tens of thousands. With such a large number of data elements to manage, plans must use one “central source of truth” for benefit information if they expect to meet CMS’s requirements. A tool like CodySoft will help automate this process and ensure CMS compliance.

Driving the Shift

As of mid-June, 8 million Americans have enrolled for health coverage in the health insurance marketplace (also known as the “exchanges”), a program born of the ACA. Some of those 8 million people did not previously have health coverage at all; others had previously been covered by their employers but sought coverage through the exchanges when they lost their company-sponsored health insurance. Where did their employer-sponsored coverage go?

Many companies – including behemoths Walmart, McDonald’s and Starbuck – are laying off employees or reducing their hours in order to avoid the directive to buy insurance or pay the fine for failing to do so. In fact, a Congressional Budget Office (CBO) report issued in February estimated that by 2017, the American workforce will be reduced by the equivalent of 2 million full-time jobs, because of the ACA. To take this a step further, prominent bioethicist Dr. Ezekiel Emanuel recently predicted most employers will discontinue providing health coverage entirely by 2025.

In addition, some people are voluntarily leaving their jobs, now that affordable health coverage is available. This is particularly true for older employees who are not yet eligible for Medicare. No longer do these individuals need to continue working solely to retain their company-sponsored health insurance, because enrolling in the exchanges does not require a health screening nor does it exclude for pre-existing conditions. In fact, with the ability to enroll in the exchanges, a person of any age is now no longer tied to their employer to keep their health coverage – creating a fundamental shift in how healthcare is provided in our country.

Pros and Cons of a Portable Workforce

Americans who enroll in the exchanges can take their health insurance with them wherever they go, whether it’s to a different company, into retirement, or being self-employed. A portable workforce that doesn’t have to rely on an employer for health coverage creates an independence that promotes self-employment, creation of start-ups and a capitalist society with greater innovation.

However, individuals enrolled in the exchanges cannot deduct their health insurance premiums from their annual tax returns. And while companies that provide group health insurance can deduct those premiums, employers who avoid paying for group health insurance by pushing employees to the exchanges will face a mandate to pay a penalty with after-tax dollars. This can be seen in the recent IRS ruling that bars employers from pushing workers into exchanges, which the The New York Times covered in an article on May 25. We predict that once the exchanges become more fully developed, future legislation will be introduced to allow employers of all sizes to move employees freely into the exchanges without penalty.

As the demand for coverage through the state exchanges increase, the ACA’s health insurance marketplace will improve its products and options. And as more people enroll in the exchanges and no longer rely on their employers for health coverage, America will see a more portable and innovative workforce take shape.

When CMS establishes greater control and oversight of Medicaid at the state level, government-sponsored health plans will have a new set of issues to work through in order to comply with the new regulatory guidance. The good news is these new regulations will most certainly mirror those already in effect for Medicare. Therefore, mirroring best practices in Medicare compliance today will better position health plans in the future.

Based on Medicare compliance programs, Medicaid plans can expect CMS to require increased operational reporting and increased compliance within the risk management function. To best prepare for rigorous compliance changes, Medicaid plans should:

Streamline process workflow

Conformity with CMS compliance guidance requires highly efficient communication and effective collaboration between a number of operative departments throughout a health plan. Marketing communications, compliance, IT, operations and medical management will need to coordinate their functional activities and reporting in order to comply with CMS standards. An effective process workflow that keeps everything running smoothly, on-time and in compliance is critical.

Enhance project management

Health plan member communications directors have the tough job of guiding collateral through a creation cycle that includes tracking multiple versions, pushing through numerous bottlenecks, dealing with multiple subject matter experts, ensuring regulatory compliance and setting up printing and delivery. An effective project management tool specifically designed for health plans can make things infinitely simpler and ensure materials are in compliance with CMS. This will also enable easier reporting when CMS audits are required.

Improve risk management

A robust risk management function will be essential for Medicaid plans required to detect, mitigate and alleviate risk throughout an organization. An organization’s risk management tool is key to compliance management as federal and state guidance evolves at a brisk pace.

There are a number of ways health plans can cut unnecessary expenses, both before hiring a print and fulfillment vendor and during the course of the relationship. The key is knowing where to look.

This blog entry, Part 2 of 2, shares what you can do while you’re working with a print and fulfillment vendor:

Be strategic in how you handle the change order process.

Change orders can get very expensive, and unfortunately, they are going to happen. In Part 1, we covered tips on how to mitigate some potential errors, such as getting your materials in the best possible order before they go to the printer. But unexpected things are going to happen – you must plan and prepare for change orders.

Most importantly, always budget for change orders. Pull print and fulfillment orders from the past couple years and calculate the average amount you spent on change orders. Then include that amount in the budget for your next job.

Compare the vendor’s track record to the Service Level Agreement.

Presuming you followed the suggestion in Part 1 to set a Service Level Agreement that ensures the vendor has the flexibility to accommodate unpredictable timelines, regularly review the SLA to ensure the vendor is meeting your deadlines.

A vendor’s ability to meet its Service Level Agreement is a direct indication of its performance. Was the vendor able to meet your deadlines despite only having two days to complete your last print job, as outlined in the SLA? If not, the vendor may not be the best fit for your needs.

Hold Quarterly Business Reviews and challenge the vendor to add value.

Once a quarter, meet with your print and fulfillment vendor to debrief and discuss potential areas of savings. Talk about what went well and what didn’t go well during the past quarter, and what should be done differently in the future.

Don’t be afraid to ask your vendor how they can add more value. For example, pose the following question and see what kind of answer you get: “If I told you we need to reduce our spend by 10 percent, what would you do to make that happen?”

If the vendor is truly your partner, they will continually look for and suggest solutions to achieve better integration of workflows, which will translate into savings for your health plan.

There are a number of ways health plans can cut unnecessary expenses, both before hiring a print and fulfillment vendor and during the course of the relationship. The key is knowing where to look.

This blog entry, Part 1 of 2, shares what you can do before you contract a print and fulfillment vendor:

Get your process workflow in order.

If your health plan is providing its print and fulfillment vendor files that have errors, do not have all necessary approvals or are not in compliance with CMS, you have problems right out of the gate. Errors in data grids and crosswalks alone lead to costly reprints.

Make sure your marketing communications and compliance departments have the right tools to streamline workflow, track materials and ensure compliance. That way, your materials are in the best possible order before they go to the printer. This also helps set a good example for the vendor and implies you have high expectations for them, as well.

Understand the vendor’s true capabilities.

Select a vendor that matches your level of success. The larger the health plan, the greater the complexity of its printing needs – especially for government-sponsored plans with the additional risk that the Annual Notification of Change (ANOC) bring.

If you hired a local vendor when your health plan had 15,000 members and it now has 50,000 members, seriously consider investigating whether that vendor is still the best fit. A smaller vendor simply may not be able to handle the numerous checks and balances required to meet CMS regulations.

In the RFI, ask questions specifically about Medicare and Medicaid.

In your Request for Information, ask the vendor questions that allow you to confirm they understand and have the ability to handle the complexities of CMS, such as: “Can you give an example of how you have handled the ANOCs in the past, including how you addressed challenges with deadlines for these document?”

Consider hiring an unbiased, independent consultant to do the RFI for you, and ask them to use a weighted scale based on importance to find the vendor that best meets your needs.

Do a site visit before hiring the vendor.

Visit the vendor’s facility before making any hiring decisions. Observe their output and Q&A process, which is spot-checking materials for quality as they come off the press. Also, make sure the equipment can handle the size of print runs you know your health plan will require during the busy time of year. Failure to do this could result in missed sales opportunities due to materials not being available.

Ensure the vendor is flexible enough to handle delays caused by CMS.

A Service Level Agreement (SLA) is a timeline of all tasks associated with a print job. It’s especially important for government-sponsored health plans to make sure the vendor is flexible enough to handle delays and complications presented by CMS that will impact production timelines.

Your vendor must understand that they may have either 10 days or two days to produce materials, and they must be able to manage their workflow to accommodate expedited jobs. Make sure the vendor’s SLA is flexible enough to meet your deadlines.