This year, some of the biggest industry leaders such as Aetna and UnitedHealthcare have exited the Affordable Care Act (ACA) marketplace. The outlook for the longevity of Obamacare looked grim without some drastic changes coming down from the Department of Health and Human Services (HHS) to balance the deficits seen by health plans as they navigate this new world of healthcare.
There is some light on the horizon for the health plans that are offering ACA plans on and off of the Exchange. The struggles and concerns expressed from health plans across the country are being heard and acted upon at HHS, which is evident in the 2018 Notice of Benefit and Payment Parameters (NBPP) that was released on August 29, 2016. The 2018 NBPP displays an array of proposed changes and updates that provides clarification, detailed rules, and specific changes to address the nuances associated with the commercial market. Such proposed changes and updates include the following:
- New Standardized Plan options and requirements
- Adjustments to user fees, cost share reduction (CSR) values, and coefficients
- Eligibility, enrollment, and benefit changes that impact special enrollment periods (SEPs), direct enrollment, and binder payments
- Recalibration of the risk adjustment model to address partial year enrollments, high-cost risk pool, and pharmacy utilization
- Risk Adjustment Data Validation (RADV) process changes and addition of new auditing requirements
- Actuarial Value (AV) calculator and rating adjustments
The healthcare industry has been eager to influence the structure of Obamacare. HHS has responded to what they are hearing, but the question is, are you ready to operationalize the technical processes and business support outlined in the NBPP to be successful? The ball is in the health plan’s court now to take and run with. The approach to address the ACA is not your typical Medicare Advantage strategy. The commercial market has gotten much more complex and strategic. Being able to understand how each organizational decision impacts processes to promote a cross-functional organization and support rate setting, risk adjustment, data management, and EDGE server submissions are just a few pieces of the puzzle that should be considered.
Gorman Health Group (GHG) has a unique set of ACA expertise to assist those in the industry impacted by the ACA and the changes proposed in the 2018 NBPP navigate this new highly regulated world. Here is just a glimpse at what the industry has been asking GHG and the type of support GHG has been bringing to clients across the country:
- What are the key ACA processes health plans should be watching closely?
- Can health plans be successful with the current ACA regulations set forth?
- What impact do these proposed changes have on how plans partner with their Pharmacy Benefit Managers (PBMS’s)?
- How critical is it to apply stringent processes for data management and submissions?
- What is the best way to approach all of the core functions associated with risk adjustment from an ACA perspective?
The more precise HHS gets, the more precise health plans need to be. Having the right technical infrastructure and membership platform in place is a great start. Look for a detailed GHG analysis around the proposed 2018 NBPP industry impact in the coming weeks
This new industry brings about greater challenges than we’ve ever known in government programs while also providing immeasurable opportunities for health plans that prioritize high quality, clinical care, as well as proper coding and documentation and highly functioning enrollment and reconciliation functions. GHG has first-hand knowledge of vital plan operations and provides comprehensive strategies across a full spectrum of business needs. Visit our website to learn more >>
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