Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.
By James Gutman, Managing Editor
May 23, 2013 Volume 19 Issue 10
The long road to CMS-backed initiatives to coordinate care for Medicare-Medicaid dual eligibles finally is entering its operational phase, at least for the initial participants. And many of the marketing, formulary and enrollment requirements CMS has outlined so far will look familiar to Medicare Advantage and Part D plans since they seem to be built on the same base of rules, albeit with some differences reflecting both state involvement and the unique characteristics of the duals population.
It now appears that only three states — Massachusetts, Ohio and Illinois — will begin federally funded capitated duals demonstration programs this year, since California recently opted to delay its start until at least next January (MAN 5/9/13, p. 8). But CMS is working with nine other states — Idaho, Michigan, New York, Rhode Island, South Carolina, Texas, Vermont, Virginia and Washington state (which already has been approved for a managed fee-for-service demo) — on capitated demos to start in 2014, Vanessa Duran, senior technical advisor in CMS’s Medicare-Medicaid coordination office, told a session of CMS’s MA and Part D spring conference May 6. CMS on May 21 gave Virginia the actual go-ahead for its initiative, which would begin early in 2014.
In 2014, Duran explained, while voluntary, opt-in enrollment may start at any time after all approvals are in, the first wave of a chosen state’s passive enrollment of dual eligibles may begin only on the following dates: Jan. 1, April 1, July 1 and Sept. 1. CMS is readying final enrollment guidance on other aspects, but it already has determined that states will have the lead role in enrollment issues and can delegate some or all of those functions to the health plans they pick to serve the duals, she said.
On the marketing side, CMS and the states jointly will set the rules, according to Duran, who added that they must be at least as stringent as those applicable to MA and Part D plans. She said the final marketing guidance from CMS will be based on the Medicare marketing guidelines, the Memorandum of Understanding (MOU) between the agency and the state, and contracts between the state and health plans. Draft marketing guidance for Massachusetts, which figures to be the first state running with its CMS duals initiative, came out March 29.
In marketing training materials CMS released April 24, the agency emphasized that plans serving duals under the demo will be held responsible for all marketing materials used by their subcontractors and that the plans must submit subcontractor marketing materials for review and approval.
Duals Programs Have Additional Requirements
The requirements outlined in these materials generally parallel those for MA plans, but there also are some rules specific to the demo. They include a requirement to maintain a separate section of the plan’s website for the duals initiative. Moreover, in addition to its current market-surveillance activities, “CMS will implement state-specific surveillance plans,” including “secret shopping of formal marketing events,” in duals demo service areas, the training materials noted.
And Duran said the agency is in the process of finalizing demo-specific models for such required documents as the Annual Notice of Change (ANOC), Evidence of Coverage (EOC)/member handbook, Summary of Benefits (SB) and comprehensive formulary. Each state will further customize these documents, she said.
Since state translation and multi-language insert requirements often are more stringent than those of Medicare, the state standards will apply in that subject area, the training materials explained.
There also are specific standards pertaining to the drug formularies and medication therapy management (MTM) programs of plans in the duals initiatives, pointed out Marla Rothouse, an attorney who is another senior technical advisor in the CMS duals office. MTM programs are mandatory for all duals plans in the CMS demo and were due May 6, while the mandatory formularies are due May 31, Rothouse said. The required Plan Benefit Package for the demo is due June 3, the same due date as for MA and stand-alone Prescription Drug Plan (PDP) bids for 2014.
The marketing training materials also outlined some of the requirements regarding enrollment in the duals demos. In the states starting initiatives in 2013, for instance, according to the materials, there will be an “independent state enrollment broker handling enrollment/disenrollment actions,” and “in general,” the plans themselves will not send enrollment/disenrollment notices. The exception to that is a “Welcome Letter” the plans send to passively enrolled duals. Enrollment brokers will use state-specific enrollment notices, the training materials said.
Unlike in MA, there is no outbound eligibility verification (OEV) requirement in states that don’t permit enrollments by independent or plan-employed agents/brokers. And plans serving duals under the demo may not begin marketing sooner than 90 days prior to enrollment, although there could be exceptions “on a state-by-state basis,” the CMS materials noted.
Before the effective date of enrollment, the plans must give opt-in enrollees the formulary, a combined provider and pharmacy directory, an identification card and a member handbook. Passively enrolled duals must get all of those plus the Welcome Letter and SB. CMS said it will translate some key materials, such as the ANOC, EOC, SB, directory and formulary into Spanish for use by the plans.
The agency said in the training materials that its star quality ratings will not apply to the new duals plans in 2013 or 2014 since the plans are too new to measure.
View CMS materials on marketing and enrollment in the duals initiatives at http://tinyurl.com/c2fabfu; go to the section called Marketing Guidance and Model Materials for Medicare-Medicaid plans.
http://aishealth.com/archive/nman052313-04
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