1)      Do you have a method to identify complex cases and actively evaluate and modify the medication therapy plan to ensure safe and effective care

2)      Do you have a pharmacist actively involved with your case management team?

3)      Do you have a pharmacist involved with direct patient care?

Your plans ability to incorporate effective medication therapy in to your care plan and actively help your patients manage their care will have a significant impact on you plan’s STARS ratings.

AHIP ARTICLE

Further References:

Kaiser Health News

Stockton (Calif.) Record: “These sanctions will remain in effect until each of the three plans demonstrates to CMS that it has corrected the related deficiencies and that those deficiencies are not likely to recur. The actions will not impact the 1 million Medicare beneficiaries enrolled in these health and drug plans” (11/23).

The Associated Press/Bloomberg Businessweek: “Health insurer Universal American Corp. said Monday federal regulators will suspend the company from enrolling new members in its Medicare Advantage plans as an open-enrollment period for the government-subsidized health coverage gets under way. The Rye Brook, N.Y., company said the suspension by the Centers for Medicare and Medicaid Services starts Dec. 5 and is tied mainly [to] agent oversight and market conduct issues. It said it was ‘working diligently’ to resolve the issues as soon as possible” (11/22).

• Private plans are new renewing hundreds of Ma plans displacing over 700,000 lives who must find new coverage options
• Kaiser Family Foundation is predicting a 13% decline in MA plans in 2011
• The remaining plans are keeping premiums fairly flat with slightly richer benefits – mostly legislated and around preventative care services and expanded drug formularies.
• Public companies, like Humana, are predicting 2011 earnings decline of about 16%
• 2012 – Expect significant changes to both benefits and the players in the market.

ARTICLE in the WSJ

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.

• CMS’ Proposed Rule to Incentivize Practitioners
• Quality Management and Quality Improvement
• Case Study: Early Adopter, Lovlace Health Plan
• New Trends in Medical Management: Integration Strategies
• And more!

Contact www.healthcare-conferences.com for more information and how to sign up.