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- Kristina on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Curt Black on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Margaret on What Sequestration Could Mean to Medicare Advantage Claims Payment
- Jane Wall Medicare Health Benefits Inc on Strange Bedfellows Come to Medicare Advantage’s Rescue
- Barb Housewright on What Happens to Medicare/Medicaid If There’s a Government Shutdown?
The fog has cleared. CMS sees the size of the FFE Mountain and is beginning to put its plans in place to get health plans certified to participate in the FFE by August 2013. While the partnership states have clearly indicated their intention to play a role in reviewing federal requirements for FFE applicants, other states’ governors have cited a myriad of reasons for not having an exchange. At this point, CMS has a few issues to sort through before they can give directions to applicants.
In at least 23 states, governors are allowing a “Federal takeover” in the form of a federally facilitated exchange (FFE). Now, CMS has published the first draft of the application that health plans need to complete to become a qualified health plan (QHP) in the CMS FFE. To be sure, the exchange regulation allows individual exchanges flexibility in defining rules and operations, provided they meet the basic requirements. This flexibility applies equally to how CMS interprets its role in operating exchanges in the FFE states.
As AEP comes to a close on December 7, we are well into the time that organizations need to make sure that new members receive all of their required materials, including their identification cards. Having the annual election stretch to December 31 in the past was certainly to an organization’s advantage from a sales perspective, but it was an operational challenge when it came to ensuring those late applicants had access to services on day one.
Medicare Advantage and Part D have for years been the world’s largest experiments in paying insurers more for the care of sick members while paying less for healthier members, or risk adjustment. Some two dozen states now risk-adjust Medicaid payments to health plans, and the hundreds of Accountable Care Organizations (ACOs) launching this year and next are risk-adjusted as well. Now that the election has been decided, we know that health plans operating in the insurance exchanges launching in 2014 will also be risk-adjusted based on a similar methodology to that used in MA and Part D. It’s the new core capability for health insurers in the post-reform world, and it’s examined closely by my two top experts, Bill MacBain and Dr. Jack McCallum, in this month’s Managed Healthcare Executive magazine here.
It’s hard to argue this wasn’t a decisive victory for the President and Democrats in the Senate. What remains to be seen is whether intractable Congressional Republicans will come to the table to get stuff done.
Who saw last night’s presidential debate in Denver? Certainly there is a great deal of water cooler discussion going on today. Something that irked me was the continual reference to the fact that Medicare would continue to be available for “seniors”. Anyone working in the Medicare Advantage arena (whether it’s in Medical Management, Sales, Customer Service, you name it) knows that Medicare is not just for seniors. The Marketing guidelines even prohibit targeted marketing in this regard, i.e. implying a plan is available only to seniors as opposed to all Medicare beneficiaries. In fact, the list of under-65 recipients who qualify is as long as the list of over-65 qualifications.
According to the Department of Health and Human Services (HHS), Medicare Advantage (MA) enrollment is anticipated to grow 11 percent. Regardless of the politics behind the message, more beneficiaries than ever will be enrolled in MA products. Most organizations cannot keep up with all of CMS’ requirements. As evidenced in their best practice reviews of 5-star plans, no plan is perfect. Common findings included improper formulary administration, denial of transition fills, and lack of an effective monitoring and auditing system. These findings have a high impact on MA enrollees.