Dealing with Change in the Medicare World

The healthcare world and Medicare health coverage are in a state of rapid and uncertain change. What can health plans and those serving health plans, such as pharmacy benefit managers and even consultants, do to be ready for both anticipated and unanticipated changes?

Here are some of the issues facing the industry in today’s turbulent environment, and some suggested solutions to these difficult, change-driven dilemmas:

Changes in the Medicare Landscape:

Possible changes from political decisions:

  • On July 7, the Trump administration announced that it will temporarily halt billions of dollars in payments under the Affordable Care Act’s risk adjustment program. The announcement came as insurers were awaiting an annual report informing them whether they owe money into the risk adjustment program or will be paid out for the previous year. Insurers say the sudden halting of those payments creates uncertainty at a critical time, as they are currently developing their premiums for 2019.
  • The current administration has suggested expanding access to inexpensive short-term health insurance offerings with fewer benefits and less coverage by extending the limit on how long these policies can last from three months to 364 days. While this initiative might open new markets for some health plans, it might also curtail or diminish current plan offerings.
  • The entire future of entitlements is in question, as the current administration and congressional majority propose huge shifts in the way these programs are administered. These changes might include privatization of Medicare, caps or reductions in benefits, adjustments in the age at which Medicare members can obtain benefits, and so forth. For instance, House Republicans unveiled a budget resolution in June that would institute a voucher program, limit eligibility and cut more than $500 billion from the Medicare program over the next decade.

Possible changes from CMS:

  • Every year, the Centers for Medicare & Medicaid Services (CMS) issues revised model templates for the government-mandated member documents the Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC), as well as guidance and sample templates for the Summary of Benefits (SB.) In the recent past these changes have been relatively minimal, but each year brings the possibility that CMS will make radical and wholesale changes to these documents, requiring health plans to revamp their deliverables in major ways.
  • The Medicare Marketing Guidelines (MMG) is CMS’s guidebook for health plans marketing in the Medicare space. The MMG covers everything from rules around how to conduct informational, educational, and sales meetings for current and potential Medicare members, to specifications for design, to required disclaimers for marketing materials, such as newspaper ads, banners, posters, flyers, and so forth. As with the model templates for ANOCs and EOCs, changes to the MMG have been light in the past few years; however, sweeping changes in these rules, which could come any year, would force health plans to undertake significant changes in their processes.
  • CMS is responsible for other regulatory changes in areas such as benefits, costs, payments, enrollment practices, privacy requirements, and health exchange rules. All potential future changes in these areas would affect how health plans do business.

Changes in society as a whole:

  • The demographics of the population of America are changing. Most notably, Baby Boomers are aging into Medicare. This factor alone could cause large and important changes in the way Medicare and Medicaid programs are funded and administered.
  • Actuarial tables indicate that both Medicare and Medicaid are running out of money and may need to be altered to allow for continued payments to current members. One suggestion that has been discussed is to extend the age at which people qualify for Medicare from 65 to 67. This change would not affect current Medicare members, but would require future prospective Medicare members to extend their working careers or make other changes to accommodate the change in Medicare eligibility. The effect of these changes on health plans is unclear, but certainly would be impactful.

Possible Solutions for Health Plans and Others in the Industry:

Stay abreast of change:

  • It is vital that all Medicare staff at health insurers participate in obtaining knowledge of the current and future Medicare rules, regulations, guidelines, model documents and other relevant information. Here are several steps plans can take to ensure that this knowledge transfer occurs:
  • Read Health Plan Management System (HPMS) HPMS sends out a steady stream of memos, some to the whole industry and some directed to individual health plans. Medicare managers should make sure that all appropriate employees read these memos. Tools exists to simplify this process.
  • Read health care newsletters like:
    • Medicare Advantage News
    • Health Plan Daily
    • AIS Health Daily
  • Follow political and regulatory changes in newspapers, radio, and television, and on social media like Twitter and Instagram

Be prepared:

  • Construct your systems to be flexible in the face of change. Move from legacy systems to web-based, agilely developed software. Prepare in advance for scalability in either direction.
  • Don’t be too late (or too soon!) in dealing with change. Timing is critical. For example, if you make changes based on preliminary CMS information that sometimes comes in the form of “seeking comment on proposed,” you be too early and must back out changes later. On the other hand, if you wait to start your Medicare project until you see where proposed legislation or regulatory change lands, you run the risk of failing to meet project deadlines.
  • Be ready to change and change again. Change is often an iterative process. CMS issues a corrections memo in August on its ANOCs and EOCs. This memo requires late changes in projects on these Medicare documents.

Utilize other resources to deal with change:

  • Consider hiring a Compliance officer or other manager who is tasked specifically with managing change
  • Examine your systems and replace any that are out of date, slow, or not 100% accurate with newer, faster, zero-tolerance systems. These changes might include moving to a cloud-based data storage model, upgrading operating systems, making sure that you are on the latest version of common software applications like Microsoft Office, and so forth.
  • Consider using a third party for document creation, including ANOCs, EOCs, SB, and other marketing materials.

For more information on how CODY can help your health plan navigate the ever-changing healthcare landscape, contact us today.