The health-care overhaul bill stipulates targets of 80% for small-business plans and 85% for large-company plans, but the industry had lobbied to make it easier in various ways for insurers to hit those benchmarks. (If they don’t, they’ll have to pay rebates to policyholders.)

As expected, the regs weren’t changed from those recommended by the National Association of Insurance Commissioners.

Here’s a quick MLR wrap-up from Kaiser Health News.

http://www.cms.gov/MAPDHelpDesk/02_Plan_Communications_User_Guide.asp

What is not detailed in the memo are the restrictions of the new SEP.  Are these members allowed to only move to a plan with a higher STAR rating?  Can they only move to a plan with a 5 rating or back to original Medicare?  I guess these details will be communicated at a later date.  In short, this is a game changer for the 2012 bids!  Good luck.

HPMS MEMO: SEP to Enroll in 5-star plans

• Vendor should be independent of the MAO and not involved in the submission process
• Vendor should have previous experience in MA reporting requirements and technical specifications
• HIPAA compliant
• Prior experience in completing project of similar scope and size
• Staff must complete CMS web-based CMS Data Validation Training

See the attached document for further details of the standards:

Standards for Selecting a DV Contractor 20101012

• Implementing provisions of the Affordable Care Act;
• Clarifying various program participation requirements;
• Strengthening beneficiary protections;
• Strengthening Medicare’s ability to distinguish stronger health plans for participation in Medicare Parts C and D and to remove consistently poor performers; and
• Implementing other clarifications and technical changes.

One of the most notable changes is to the rule governing the 2012 Medicare Advantage Quality Bonus Payment Demonstration program.  The current ACA legislation only provides bonus to plans who receive an overall rating score of 4 or 5 stars (The average of the Part C and D scores).  Leaving no bonus to plans who score a 1,2, or 3 rating (See chart).

The rule change is intended to test if providing additional bounce opportunities at the 3 and 3.5 star level accelerate the progression of improvement of plans to higher STAR rating levels.  The demonstration program will run for 3 years from CY 2012 through 2014.

Based on the 2011 Star ratings, this change in bonus methodology significantly changes the number of plans who qualify for a bonus.  Under the original rules only 16 plans would have received a bonus.  Under the demo rules an additional 39 plans will receive a bonus totaling 55 plans.

In short the April 2011 timeline was already known, however the signal that there will be required changes for January 2011 is new.  We look forward to receiving the details of these changes to help plans stay with in compliance requirements.

The memo is attached below.

Advance_Announcement_of_April_2011_Software_Release

1) Call Medicare to request a copy: 1‑800‑MEDICARE (1‑800‑633‑4227)

2) Download a copy at the following link:  http://www.medicare.gov/publications/pubs/pdf/10050.pdf

Happy 2011 Annual Enrollment Period!

Summary of Changes:

1. PLAN BID TABLE – New table that contains abbreviated plan bid information including the plan’s ICL, and application for supplemental benefit coverage
2. MANUFACTURER AGREEMENT TABLE  - This will be the same information that CMS will publish that lists labeler codes for manufacturers that signed the Medicare Coverage Gap Discount Program Agreement.
3. FDA BRAND / GENERIC TABLE – document New Drug Application (NDA) and Biologic License Application (BLA) marketing status as reported by the FDA

In addition to the new DDPS tables there are significant changes to the edit codes that CMS will be providing in the PDE Reply files.  I suggest your review these changes with your PBM and internal monitoring departments to ensure accurate reporting and monitoring of PDE data to CMS.

CMS’ focus to monitor all data submitted will include a focus on accurate and timely PDE reporting.

See the memo here: Prescription Drug Event (PDE) Edit Guidance Effective 1.1.2011 9.24

Each organization is allowed an attendee and additional web seats.  Mark Friday, Oct 29, 2010 at 10am-4:30P Eastern Time on your calendar.  The in person meetings will be at the CMS building in  Baltimore.

Go to their website for details and registration information.