The Bridge – Volume 8

Highlights of Medicare Advantage Chapter 2 (Enroll & Disenroll) Updates

Wanda Blakely, Senior Consultant

Updates for Chapter 2 of the Medicare Managed Care Manual have been posted to the CMS website–and be aware that the amount of changes are more than we typically see. Plans must be responsive and alert to these updates to ensure enrollment and operations processes continue to run efficiently and effectively.

If you have any challenges interpreting or applying the updates, reach out to Madena’s skilled team for help.

CMS released the HPMS Memo on 8/11/2020 regarding guidance updates for CY2021. Updated Chapters 2 and 17D of the Medicare Managed Care Manual were posted to CMS’ website on 8/12/2020.

Essential Chapter 2 Updates to Note:

  • For Plan Year 2021, ESRD beneficiaries may join an MA plan during a valid election period
  • Provides information regarding the use of Electronic Signatures
  • §30.4.4 – SEPs for Exceptional Conditions
    • Contains updated language for several of the SEPs and #7 SEP for Individuals with ESRD Whose Entitlement Determination Made Retroactively is no longer available after 12/31/2020.
    • Three new Exceptional Conditions SEPs
      • #19 SEP for Individuals Enrolled in a Plan Placed in Receivership
      • #20 SEP for Individuals Enrolled in a Plan that has been identified by CMS as a Consistent Poor Performer
      • #21 SEP for Other Exceptional Circumstances
  • §30.4.6 – SEP for Significant Change in Provider Network contains updated language
  • §40.1.1 – Enrollment Request Mechanisms contains updated language
  • §40.2 – Processing the Enrollment Request contains updated language
  • Appendix 2 Summary of Data Elements Required for Plan Enrollment Mechanisms and Completed Enrollment Requests – Updated to remove ESRD reference
  • Chapter 2 Exhibit 1 New Model Individual Enrollment Request Form for enrollment into an MA plan with cover page
    • Expected to use for AEP which starts on 10/15
    • OMB No. 0938-1378
    • The OMB-approved enrollment form is considered a “model” for purposes of CMS review and approval of plan marketing materials; plans can choose to customize the form as needed.
  • Chapter 2 Exhibits 1b & 1c Model MSA and Model PFFS Enrollment Forms include minor updates
  • Chapter 2 Exhibit 2 Model EGHP Enrollment Form includes minor updates
  • Chapter 2 Exhibit 4 and 4c Model Acknowledgement Notices – Removed ESRD reference
  • Chapter 2 Exhibit 7 Model Notice for MA Organization Denial of Enrollment – Removed ESRD denial reason
    • Note: The numbering of denial reasons skips #9 (goes from 8 to 10) and #9 is still referenced in the “Insert” instructions.
  • Chapter 2 Exhibit 8 Model Notice for CMS Rejection of Enrollment – Removed ESRD reason
  • Chapter 2 Exhibit 22 Model Notice on Failure to Pay Optional Supplemental Benefit Premiums – Notice of Reduction in Coverage of Optional Supplemental Benefit(s) Within the Same Plan (PBP) – Removed information regarding the option to disenroll. An individual would be able to disenroll only if he/she is eligible for one of the existing SEPs.

Don’t hesitate to reach out if your team is overwhelmed by all the changes! Madena has the staffing solutions and expertise to help you apply the updates.

July HPMS Memo Summary

Sara King, Senior Business Analyst

The end of July brought crucial updates to Program Audit Activities, OEC record layouts, and Model Notice Corrections. Sara King, one of our Senior Business Analysts, provides the updates for you below.

Resuming Calendar Year 2020 Medicare Parts C and D Program Audit Activities
CMS has finalized its plan for resuming routine Parts C and D program audit activities.
All of the engagement letters for the scheduled calendar year 2020 Parts C and D
program audits have been sent as of July 27, 2020.
Resuming Calendar Year 2020 Medicare Parts C and D Program Audit Activities

Contract Year (CY) 2021 Online Enrollment Center (OEC) Record Layout Changes
This memo provides advanced notice of the upcoming changes to the CY 2021 OEC record layout used by the
Health Plan Management System (HPMS) OEC Management module.

Model Notice Corrections and Updates
This memorandum provides corrections to model templates for the Contract Year 2021 Annual Notice of Change;
Evidence of Coverage; Part D Explanation of Benefits; Part D Formulary Abridged and Comprehensive; Model
Transition Letter; and Pharmacy Directory

  • Correction to the July 29, 2020, HPMS memo, “Model Notice Corrections and Updates”
    • The Centers for Medicare & Medicaid Services (CMS) is issuing a correction to the July 29, 2020 HPMS Memorandum entitled, “Model Notice Corrections and Updates.” The Formulary (Abridgedand Comprehensive) Model, was incorrectly identified in item 17 as one of the model documents requiring an updated footer.
  • Language in July 29, 2020 HPMS Memo:
    • 17. Part D Formulary Abridged and Comprehensive, Pharmacy Directory, Model Transition Letter
    • Summary of issue: Update needs to be made to the footer.
    • Issue location: Footer
    • Action required: Update the language as follows: [Insert print date] [June 2020]
  • Correction Needed:
    • The title for Item 17 should instead read: “Part D Pharmacy Directory and Model Transition Letter”
    • This correction is necessary because, as in prior years, the model formulary must include the footer indicating the date of the last update made to the formulary, as this will provide beneficiaries with the most current information of their benefit structure. The footer in the model formulary should read as: [Insert date of last update].
    • This version is available here.

Coming soon! Our Newly Redesigned Membership SuiteTM User Interface

Caroline Rufino, Program Manager

We have redesigned our User-Interface (UI) with our clients in mind.

The primary goals of our UI redesign focused around providing a more efficient experience
for users, improving navigation, and modernizing the look and feel of the system. While the
changes are focused on our Reconciliation tool, we are also integrating these enhanced
features in our Membership SuiteTM Enrollment module.

In addition to the layout changes, new key features will be implemented:

  • Dashboard – Our dashboard now provides quick links to all of the Reconciliation WorkSync Queues, a new section highlighting ‘Assigned to Me’ work packets for easy access, and a report view for at-a-glance perusal of the overall inventory of open packets.
  • Top Navigation Bar – Changes to the navigation bar now allow you to get anywhere within Membership SuiteTM while on any page.
  • WorkSync Queues – We have improved the WorkSync Queues page to allow increased filtering options, sorting of inventory items by any column, and the ability for supervisors to assign work right from the WorkSync Queues page.
  • Our product development team has utilized the latest web technologies to upgrade our design framework, thereby allowing for better debugging, more flexibility, and shortened development time. The new user interface will launch in phases with completion expected in early 2021.

First, Do No Harm

Do you have the right partner and tools in place to minimize or identify reporting issues that may create beneficiary harm? Madena’s Executive Vice President, Jennifer Young, shares a recent example of the efficacy of our Membership SuiteTM tool.

Jennifer Young
Jennifer Young, Executive Vice President

Madena is a delegated service vendor for MSP and COB for several local and national health plans. Internal collaboration is key to our staffing model, and our Membership SuiteTM MSP and COB modules provide extensive visibility and transparency into data files.

Using our state-of-the-art tool and Madena’s expert team, we were able to uncover an issue with a national PBM that submitted a Section 111 file to CMS and the Benefits Coordination & Recovery Center (BCRC) showing individuals – who had no direct affiliation with the PBM – actively working for the PBM. Telling the BCRC that a beneficiary is actively working with large group employer coverage will immediately set an MSP flag.

Madena leadership escalated the issue to the PBM’s Compliance department within two days of receiving the invalid files. The total impact to Madena’s clients was over 80,000 ‘other coverage’ primacy flags being set, which would have caused rejections at point of sale and extensive increases in phone calls to Pharmacy Help Desks, Health Plans, and possibly CTMs. The PBM was unaware of the problem, but quickly worked with Madena to understand and resolve the issue.

In parallel, Madena sent out an immediate advisory notice to all clients notifying them of the error. We were able to create system work-arounds within one day. Staff could continue to process the non-impacted ‘other coverage’ records, keeping clients compliant with CMS regulations and minimizing the impact to beneficiaries at point of sale.

Contact us for a free evaluation on how Madena can help your organization.

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