CY 2019 PROPOSED POLICY & TECHNICAL CHANGES FOR MEDICARE ADVANTAGE & PART D
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CY 2019 PROPOSED POLICY & TECHNICAL CHANGES FOR
MEDICARE ADVANTAGE & PART D
JOHN GORMAN JEAN LEMASURIER
Founder & Chairman Sr. Vice President, Public Policy
DAVID SAYEN OLGA WALTHER
Sr. Vice President, Client Relations Sr. Legislative & Policy Advisor
WHO IS GORMAN HEALTH GROUP?
Gorman Health Group is the leading solutions and consulting firm
for government-sponsored health programs
Government Programs
Leading enterprise of national consulting services and software solutions for payers and providers
Our Mission
Our mission, as the industry’s most active professional services consultancy and provider of technology-
based solutions, is to empower health plans and providers to deliver higher quality care to beneficiaries at
lower costs while serving as valued, trusted partners to government health agencies
Washington, DC
Headquartered in Washington, DC, with more than 200 staff and contractors nationwide with over 2,000
combined years of Government Programs experience
Leadership
Deep payer and provider knowledge coupled with Centers for Medicare & Medicaid Services (CMS)
regulatory expertise
2 Copyright © 2017 Gorman Health Group
BROAD SERVICES
Our clients have one-stop access to expert advice, guidance, and support,
in every strategic and operational area for government-sponsored programs, across seven verticals
CLINICAL COMPLIANCE
Pairing clinical teams with innovation to provide patient- Offering guidance and support in every strategic and
centered care operational area to ensure alignment with CMS
.
PHARMACY OPERATIONS
Leading experts in Part D, Pharmacy Benefit Manager, Bringing excellence to every aspect of your
formulary, and pharmacy programs implementation — from enrollment to claims payment
HEALTHCARE ANALYTICS & STAR RATINGS & QUALITY INNOVATIONS
RISK ADJUSTMENT SOLUTIONS Strategic innovations to drive quality and improve
Implementing cross-functional risk adjustment programs for performance
medical trend management and quality improvement
SALES, MARKETING & STRATEGY
PROVIDER STRATEGIES
Driving profitable growth and member retention through
Supporting network design and medical cost control strategic marketing, sales, and product development
implementation
3 Copyright © 2017 Gorman Health Group
CURRENT STATE OF MEDICARE ADVANTAGE
Advance Rate Preview: Projected Growth of
4.29% for FFS
MA-VBID Memo Expanded to 25 States,
Additional Flexibilities
Larger than ever bipartisan support
Proposed Regulation focuses on deregulation
and additional flexibilities
4 Copyright © 2017 Gorman Health Group
ITEMS TO WATCH IN 2018
Tax Bill:
• Possible Sequester of 4%
Administration and GOP leadership
signaling Medicare Reform as top
agenda for 2018
SNP Reauthorization and CHIP
Funding
5 Copyright © 2017 Gorman Health Group
AGENDA – MEDICARE ADVANTAGE
Medical Loss Ratio
Other paperwork reduction initiatives
New Benefit Design Flexibilities
Marketing & Enrollment Changes
Star Ratings Updates
Compliance Updates
Request for Comments: Provider Burden
Physician Incentive Plans: Stop Loss Protection
Requirements
6 Copyright © 2017 Gorman Health Group
AGENDA: PART D CHANGES
Implementation of CARA
Expedited Substitutions of Generics
RFI on POS Rebates and Price Concessions
Any Willing Pharmacy Standards
Part D Tiering Exceptions
Other Part D Proposals
7 Copyright © 2017 Gorman Health Group
MARKETING & ENROLLMENT CHANGES
Marketing vs. Communications
CMS proposes to narrow what
constitutes marketing as materials
and activities that influence a
beneficiary’s enrollment decision
New category of materials and
activities known as
“communications” that would be
subject to less oversight
Communications: “activities and use
of materials to provide information
to current and prospective enrollees”
8 Copyright © 2017 Gorman Health Group
MARKETING & ENROLLMENT CHANGES
New Open Enrollment Period
Return of additional Open Enrollment Period
• Old OEP allowed for one enrollment change between January 1 and March 31
• Permitted new enrollment into an MA plan for original Medicare, changes between MA
plans, and disenrollment from MA plan to original Medicare
• Could not make changes to Part D Coverage
Affordable Care Act
• Eliminated old OEP
• Instead allowed for 45 day period to disenroll from MA into Original Medicare, and enroll
in part D coverage
CMS proposes to bring OEP back, with a few changes:
• Organizations may not market during this second OEP
• Organizations will be allowed to make changes to Part D Coverage
9 Copyright © 2017 Gorman Health Group
MARKETING & ENROLLMENT CHANGES
Default Enrollment Changes
Currently, CMS allows for an optional enrollment mechanism that allows
MAOs to provide default enrollment to a newly MA-eligible individual
enrolled in another health plan offered by the MAO (such as commercial
or Medicaid)
CMS proposes to limit this enrollment mechanism to beneficiaries
enrolled in a Medicaid managed care plan offered by the same
organization
CMS proposes a “simplified election process” for those converting
coverage from other non-MA plans to an MA plan by allowing these
MAOs to accept enrollment requests throughout an individual’s Initial
Coverage Election Period (ICEP)
10 Copyright © 2017 Gorman Health GroupMARKETING & ENROLLMENT CHANGES
Passive Enrollment of Dual Eligibles
Current passive enrollment authority limits the use of passive enrollment
to:
• Instances where there is an immediate termination of an MA contract
• When CMS determines remaining in a plan poses harm to beneficiaries
CMS proposes to expand this authority, to allow passive enrollment for
full-benefit dually eligible beneficiaries from a non-renewing integrated D-
SNP to another comparable plan to preserve care integration under
certain circumstances
11 Copyright © 2017 Gorman Health GroupMEDICAL LOSS RATIO
CMS Proposes MA & PD sponsors would only report the “MLR
percentage and any remittance owed to CMS for each contract”
• CMS still retains audit and sanctions authority
• Plans must still retain MLR data for 10 years
• Substantial decline in MLR data required to be reported
CMS also proposes to revise the MLR calculation so that it would
include fraud reduction activities in the MLR numerator
• Fraud prevention, fraud detection, fraud recovery, Medication Therapy
Management Programs
• Would eliminate provision allowing recovered claim payments to remain in
incurred claims
12 Copyright © 2017 Gorman Health GroupOTHER PAPERWORK BURDEN REDUCTION
PROPOSALS
Electronic submission of beneficiary
paperwork
• CMS is proposing to permit MA and Part
D sponsors to provide certain notices,
such as the EOC electronically
Removal of Quality Improvement
Project
• CMS proposes to remove QIP, as CMS
deems this information not beneficial and
duplicative of Stars efforts
13 Copyright © 2017 Gorman Health GroupMEANINGFUL DIFFERENCE CHANGES
Currently, CMS will only approve a bid if the plan benefit package is
substantially different from other plans offered by the organization in the
area, in respect to premiums, cost sharing, and benefits
CMS proposes to remove these “meaningful difference” requirements
beginning in 2019
CMS retains authority to disapprove a bid if the proposed benefit design
substantially discourages enrollment in that plan by certain Medicare
eligible beneficiaries, and allow to non-renew if a plan fails to attract a
sufficient number of enrollees
• CMS expects plans to have differences in: Part D coverage, provider network, Part B
and plan premiums, unique populations served
14 Copyright © 2017 Gorman Health GroupMA UNIFORMITY REQUIREMENTS
Currently, CMS interprets that MA
plans must offer all enrollees
access to the same benefits at the
same cost sharing
CMS proposes to permit plans to:
• reduce cost-sharing for certain
benefits,
• offer specific tailored supplemental
benefits, and
• offer lower deductibles for enrollees
that meet specific medical criteria
15 Copyright © 2017 Gorman Health GroupREQUEST FOR COMMENTS: PROVIDER BURDEN
CMS is exploring ways to reduce
provider burden arising from
requests for medical record
documentation by MA organizations
Particularly interested in solo
providers
Specifically seeking comment on the
nature and extent of medical record
requests
16 Copyright © 2017 Gorman Health GroupCOMPLIANCE REQUIREMENT CHANGES
Reduction in first tier, downstream, and related entity compliance training
requirements
• CMS proposes to eliminate the requirement that MAOs provide compliance training for
FDRs and
• Eliminate the requirement that FDRs complete the CMS web based training
• CMS believes the MAOs and Part D Sponsors sophisticated compliance programs and
ultimate accountability make this requirement unnecessary
17 Copyright © 2017 Gorman Health GroupPHYSICIAN INCENTIVE PLANS – STOP LOSS
REQUIREMENTS
Currently, an MAO that operates a Physician Incentive Plan (PIP) must
provide stop loss protection for 90th percentage of actual costs of referral
services that exceed the per patient deductible limit. CMS is proposing to:
• Update the stop loss deductible requirements to account for changes in medical cost
and utilization, and be more narrowly tailored to the risk of substantial loss
• Codify this methodology to update stop-loss deductible limits in the future
• CMS will allow MAOs to use other actuarially equivalent stop-loss protection
arrangements
18 Copyright © 2017 Gorman Health GroupCODIFYING STAR RATINGS & NEW PROPOSALS
CMS proposes to codify key aspects of the Part C and D Star Ratings
methodology, for the 2019 performance period and first payment year of 2022
• Codifying principles for adding, updating, retiring measures, and methodology for
calculating and weighting measures
CMS also proposes to:
• Codify existing data integrity policy of reducing certain measures to one star if data used
for that measure is inaccurate, incomplete, or biased
• A new “scaled reduction, rather than immediate one star reduction for data integrity issues
relating to Part C & Part D appeal measures
• Changing its contract consolidation measurement, by applying an enrollment-weighted
average of the surviving and consumer contracts
19 Copyright © 2017 Gorman Health GroupCODIFYING STAR RATINGS & NEW PROPOSALS
CMS requests comments on:
• Whether CMS should include a survey measure for physician experience with a plan
• How cut points for various measures should be calculated
• Whether rating should be measured at plan level rather than contract level
20 Copyright © 2017 Gorman Health GroupCOMPLIANCE REQUIREMENT CHANGES
Preclusion List – CMS proposes to eliminate requirement that providers and
suppliers be enrolled in Medicare in order to provide healthcare items or
services to an MA beneficiary.
• CMS instead proposes to create a “preclusion list”, under which an MA organization
would not be permitted to make payment for any item or service furnished by an
individual or entity on this list.
21 Copyright © 2017 Gorman Health GroupPART D CHANGES 22 Copyright © 2017 Gorman Health Group
CARA – NEW OPIOID ABUSE PREVENTION
PROPOSALS
CARA provides CMS with authority to establish Part D Drug management
programs for beneficiaries at risk for drug abuse
CMS proposes to establish such a program, on a voluntary basis
• Program would allow Part D sponsors to limit “at risk” beneficiaries’ access to
“frequently abused drugs”, as identified by CMS
• CMS will tie definition of at risk beneficiaries to existing Part D Opioid Drug Utilization
(DUR) Policy and Overutilization Monitoring System (OMS).
CMS also proposes to limit the Special Enrollment Period (SEP) for dual
eligible or other low income subsidy eligible beneficiaries identified as “at
risk”
23 Copyright © 2017 Gorman Health GroupEXPEDITED SUBSTITUTIONS OF GENERICS
Part D Plans may immediately add a newly approved generic to a
formulary without advance CMS approval
Changes notice to general statement of potential changes followed by a
specific notice
Reduces direct notice for removal of drug or change in cost sharing from
60 to 30 days
24 Copyright © 2017 Gorman Health GroupRFI ON POS REBATES AND PRICE CONCESSIONS
CMS included a Request for
Information (RFI) in which it seeks
comments on requiring sponsors to
include a minimum percentage of
manufacturer rebates and all
pharmacy price concessions received
for covered Part D drugs in the
drug’s negotiated price at the point
of sale (POS).
25 Copyright © 2017 Gorman Health GroupRFI ON POS REBATES AND PRICE CONCESSIONS
Manufacturer rebates – minimum level; definition of applicable average
rebates
• E.g. category or class, weighting, all drugs or only rebated drugs, targeted drugs, plan
level
Definition of pharmacy price concessions
• Lowest possible reimbursement, exclude some or all performance incentive payments
26 Copyright © 2017 Gorman Health GroupANY WILLING PHARMACY STANDARDS
CMS seeks to update AWP requirements by:
• Clarifying that policy applies to all pharmacies no matter how they are organized
• Revising the definition of “retail pharmacy” and adding definition for “mail order”
• Establishes a deadline of September 15 for providing standard terms and conditions
27 Copyright © 2017 Gorman Health GroupPART D TIERING EXCEPTIONS
CMS proposing to eliminate allowing plans to exclude a dedicated generic
tier from the tiering exceptions process and;
Establish a framework based on the type of drug (brand, generic,
biological product) requested and the cost-sharing of applicable
alternative drugs, and;
Clarify appropriate cost-sharing is based on the lowest cost tier when
alternatives are available
28 Copyright © 2017 Gorman Health GroupOTHER PART D CHANGES
Change to Days’ Supply Required by Part D Transition Process: CMS proposes to shorten
the required transition supply in the Long Term Care (LTC) setting from 90 to 30 days
Electronic Transaction Standard Used by Part D Plans: Update to the current electronic
prescribing standard for the Part D e-Prescribing Program to the latest version, Version
2017071
Treatment of biological Products: CMS proposes to amend the definition of generic drug
to include follow-on biological products for LIS cost sharing and Non-LIS catastrophic
cost sharing
Preclusion List: CMS will remove current prescriber and provider enrollment requirements
and instead provide plan sponsors with a preclusion list
29 Copyright © 2017 Gorman Health GroupJohn Gorman Jean LeMasurier
Founder & Chairman Senior Vice President, Public Policy
T 202-364-8283 T 202-204-6180
E jgorman@gormanhealthgroup.com E jlemasurier@gormanhealthgroup.com
Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance
Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing strategic,
operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant, member-centric
focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.
Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent
workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist
government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™
(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and
streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses
on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and
expert summaries of the most critical legislative and political activities impacting and shaping your organization.
Stay connected to industry news and gain perspective on how to navigate the latest issues by subscribing to our weekly newsletter, and follow us on LinkedIn, Facebook, and Twitter.
We are your partner in government-sponsored health programs.
30 Copyright © 2017 Gorman Health GroupDavid Sayen Olga Walther
Senior Vice President, Client Relations Senior Legislative & Policy Advisor
T 202.253.0277 T 202.794.0052
E dsayen@gormanhealthgroup.com E owalther@gormanhealthgroup.com
Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance
Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing strategic,
operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant, member-centric
focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.
Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent
workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist
government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™
(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and
streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses
on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and
expert summaries of the most critical legislative and political activities impacting and shaping your organization.
Stay connected to industry news and gain perspective on how to navigate the latest issues by subscribing to our weekly newsletter, and follow us on LinkedIn, Facebook, and Twitter.
We are your partner in government-sponsored health programs.
31 Copyright © 2017 Gorman Health GroupSave the Date – April 25-26, 2018
Red Rock, Las Vegas
Copyright © 2017 Gorman Health Group, LLCREFERENCE PROMO CODE “CAPG25” AT CHECKOUT TO SAVE 25% OFF REGISTRATION FEES.
OFFER EXPIRES 1/5/2018
April 25-26, 2018
Top Five Reasons to Attend
• Compliance professionals can earn CCB CEUs
• Expert panel discussions with Gorman Health Group divisional leaders
• Strong focus on effective compliance program management, product development, network adequacy, emerging trends in
technology solutions, Star Ratings, and risk adjustment
• Collaborate with colleagues through interactive panel discussions and multiple networking opportunities
Visit https://www.gormanhealthgroup.com/gorman-health-group-2018-forum/ for more information.
33 Copyright © 2017 Gorman Health GroupREGISTER HERE 34 Copyright © 2017 Gorman Health Group
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