Change is Coming to Medicare Advantage Operations

“Adaptability is about the powerful difference between adapting to cope and adapting to win” is an insightful quote from Max McKeown, an English researcher on innovation strategy. The Centers for Medicare & Medicaid Services (CMS) is instituting some changes for 2019, starting in the Annual Election Period (AEP). Health plans have an opportunity to implement changes to cope or come up with winning strategies as they adapt to the new environment for Medicare Advantage. How we adapt to these changes will impact our member experience. As 2019 allows greater opportunity for members to change plans during the Open Enrollment Period (OEP), it is important plans don’t just cope but implement member-focused strategies to use these changes to the health plan’s and the member’s advantage.

Have you considered your strategies for these critical changes in 2019?

  1. The OEP is from January 1 to March 31. This is one of those zombie requirements as those of us in the industry years ago will recall this annual event. Members are allowed to change plans one time after the AEP. Many Operations teams know January and February are the time frames when issues arise as beneficiaries weren’t educated well enough on benefits, or systems testing missed an issue, or unintended consequences to a change become apparent. It is more critical than ever to mitigate these risks – and any member impact – before the new year. If a member is dissatisfied, you no longer have time to “win them back” before the next AEP. We all have to be on top of our game from the start to keep members happy and enrolled. Each team should have a defined strategy on 2019 Day 1 services and activities.
  2. Special Election Period (SEP) Changes for Dual Eligibles and Low Income Subsidy (LIS) Individuals. This change seems to be sneaking up on many health plans’ Operations, Sales, and Marketing teams, possibly due to the delay in the release of updated enrollment and disenrollment guidance. On April 2, 2018, CMS released some updated policy changes for 2019. This included a limitation on the SEP to one change per quarter. In the past, if dual eligibles or members receiving LIS were dissatisfied, they could disenroll and enroll in another plan. Going forward, it will be important to review your methods for dealing with member complaints to validate the processes are adequate and member friendly. Otherwise, members may escalate concerns to CMS or 1-800-MEDICARE. Additionally, systems that were set up to pass through all LIS and dual-eligible member enrollments and disenrollments will now need to be reconfigured to verify the SEP for the quarter has not been used.
  3. Expansion of Call Center Hours through March 31. Most call centers have a party around February 14, but not for Valentine’s Day. Instead, they are celebrating the end of weekend phone coverage. Starting in 2019, that weekend coverage is extended until March 31 to coincide with the OEP time period. Health plans now have a full six months of the year with phone coverage seven days a week. Managing staffing levels and expectations for this additional six weeks may seem simple, but it will be an added expense to health plans.
  4. CMS Update of Marketing vs. Communication Material. The 2019 Medicare Communications and Marketing Guidelines (MCMG) provide excellent guidance on what is now considered Marketing versus Communication. Many materials health plans submitted to CMS in the past no longer require that formal process. Documents that were almost always model in the past can now be modified. This is liberating for health plans but administratively difficult. The standardization of Medicare Advantage has allowed for streamlined processes. Now health plans need to implement processes to have even greater oversight of their member communication library and how each document meets CMS requirements. Health plans have processes in place to review for the use of models and compliant changes. This review needs to be modified to validate all critical components are included and the intent of the updated document is clear to members. With freedom comes great responsibility.
  5. Greater Use of Electronic Communication. The 2019 MCMG highlight CMS’ allowance for more documentation to be sent electronically. Operationally, many plans are just starting to consider electronic communication. This raises some interesting questions such as:
    • Where do you store your members’ emails?
    • Do you have a process to ask for and manage their requests to obtain information electronically?
    • How are you storing your delivery dates and times and managing undeliverable email?

As health plans receive more age-in members, this option will become more popular. Developing functionality to effectively manage electronic communication is a must.

As we gear up for another AEP and a new benefit year, now is the time to make sure we’ve set up all our processes. The time for coping with process changes and updates has passed. Now is the time to create your strategy for 2019 and utilize the changes to make your program a winning one. Pauline R. Kezer stated, “Continuity gives us roots; change gives us branches, letting us stretch and grow and reach new heights.” Now is the time to embrace changes and reach high.

Gorman Health Group has a full spectrum of subject matter experts for Medicare Advantage and Prescription Drug Plans. We work with health plans on a daily basis—on everything from change management to program assessments and audit support and remediation. This keeps us current and relevant. Our experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations as you implement or grow your Medicare line of business. Contact us via this link to our website, or you can email me at to help you create your winning strategy.




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The new Chapter 2 Medicare Advantage Enrollment and Disenrollment guidance was released this week for enrollments effective January 1, 2019. As you ramp up for the Annual Election Period, see which changes are required for October 15 processing. Download now

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