2021 Medicare Advantage Readiness Checklist

Every year, CMS releases an annual Readiness Checklist in an effort to remind Medicare Advantage (MA) Plan Sponsors of key contractual responsibilities in the upcoming plan year. The Readiness Checklist is not only a great reminder for existing Sponsors, but is also an excellent guide for plans that are new to the MA market.

This year, the Checklist released on October 2nd includes an assortment of existing and changed requirements to help you and CMS determine if you are ready for health plan operations in 2021.  

CMS expects that Sponsors are utilizing the Checklist for the upcoming contract year. However, the agency also conducts a teleconference with Sponsors to understand any potential challenges and obtain feedback about a plan’s process improvements to mitigate any risks or gaps in meeting obligations. CMS requires plans to report any requirements where they are at risk or where technical assistance is needed. 

Sponsors should carefully review the Checklist for regulatory changes and updates that may have occurred since the previous year. Remember, this Checklist is intended as a summary of critical requirements and it includes references for plans to locate any guidelines that they may need to understand the guidance. Plans should review all Checklist references including Health Plan Management System (HPMS) memos, Final Rules, and the Call Letter for the detailed interpretation of these CMS requirements.

A few examples of focus areas that may be new or expanded upon in 2021 include:

Systems, Data, & Connectivity: Prescriber Real Time Benefit Tool (RTBT) – Part D Sponsors
Contracting, Subcontractor Provisions, and Oversight: MAOs Offering Dual Eligible Special Needs Plans (DSNPs)
Enrollment/Disenrollment: Timing of Annual Enrollment Period (AEP) and Electronic Enrollment Mechanisms (Excluding MMPs)
  • Plans that may have implemented changes to their temporarily absent policies due to the public health emergency (PHE), allowing out-of-area members to remain enrolled, ends on 12/31/2020 or at the end of the public health emergency, whichever is earlier. These members will automatically be disenrolled on 1/1/2021 if they are still absent from the service area or 6 months after the individual left the service area, whichever is later. 
  • Plan Sponsors’ ability to accept enrollment on electronic devices or secure internet websites must follow CMS enrollment guidance, including submitting materials and web pages related to enrollment for approval prior to use and complying with CMS data security policies. Sponsors are also ultimately responsible for handling of sensitive beneficiary information including when it is processed by first tier, downstream and related entities (FDRs) and must report security and/or privacy breaches timely.
Grievances, Initial Coverage/Organization Decisions, and Appeals: Continuation of Benefits While an Appeal is Pending
  • This requirement is only for applicable integrated plans.
Where Do We Go from Here?

Outside of program audits and data reporting, the Readiness Checklist is a valuable tool in CMS’ oversight arsenal. Is your MA Plan ready for 2021? GHG conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. Contact GHG Advisors today to learn how we can help you be best prepared.

Jennifer Rogalla
Jennifer Rogalla

Jennifer Rogalla is a Senior Consultant in Compliance Solutions with Gorman Health Group. Her background includes over 25 years of experience with Medicare regulations, medical billing and health insurance programs. Jennifer has provided assistance with CMS audit preparation, audit assistance and remediation in the areas of compliance, appeals and grievances. Additionally, Jennifer is experienced with application filings, compliance program development and implementation, marketing material and provider contract review and as well as Part D operations compliance. Most recently she assisted plans with interim leadership positions to support the development of process improvements for Star ratings.

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