Readiness Checklist Outlines Key Operational Requirements

The Centers for Medicare & Medicaid Services (CMS) published its annual Readiness Checklist via HPMS memo on 10/2/2018. As in prior years, the checklist provides a high-level overview of key operational requirements for the coming plan year. Plan Sponsors must communicate any at-risk requirements to their CMS Account Managers. Here we summarize important things to consider as the 2019 plan year approaches:

  • CMS is phasing out the Social Security and Health Insurance Claim Numbers and moving to a Medicare Beneficiary Identifier (MBI) by April 2019. Plans must ensure all systems are ready for the transition, including any “home-grown” data repositories (e.g., appeal and grievance databases).
  • CMS will be providing Medicare Advantage (MA) and Part D Sponsors access to a precluded providers list after eliminating the provider/prescriber enrollment requirement. Claims from those identified in the precluded provider list must be denied.
  • The reinstituted Open Enrollment Period (OEP) not only changes enrollment time frames, it also expands customer service extended hours for 7 days a week, 8:00 am to 8:00 pm, through March 31, starting in 2019.
  • Update systems, processes, and training to the new guidelines for Special Election Period (SEP) changes for dual-eligible (DE) and other low-income subsidy (LIS) eligible individuals. Beginning 1/1/2019, DE and LIS individuals will only be able to change plans one time per quarter for the first three quarters with no SEP in the fourth quarter. Many systems are automated to allow these elections to process when received, as through 2018, they are unlimited.
  • Health plans should be sure to include customer service, enrollment, and appeals and grievances in their drug utilization controls for opioid management. Staff will need to have scripts and processes in place when members are placed in drug management programs that may impact their access to medication and impact potential disenrollment restrictions.

Ensure your employees are familiar with new guidance from CMS, including the Call Letter; Final Rule and Medicare Communications and Marketing Guidelines. The Readiness Checklist does not convey all guidance changes, and understanding the new rules is critical for Plan Sponsor readiness and compliance.


Gorman Health Group conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. This is especially important for plans new to the market in 2019. Contact us today for additional information.



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Tina Bailey
Tina Bailey

Vice President, Compliance Solutions

Tina Bailey began her tenure at GHG in 2011 and was appointed Vice President, Compliance Solutions in August 2018. In this capacity Tina leads the Compliance Solutions team and its engagements to ensure optimum solutions. Tina brings GHG clients more than 25 years of experience, providing them a knowledgeable resource in Medicare Advantage and Part D with an emphasis on Special Needs Plans (SNPs). Her areas of expertise include compliance, applications, audits, readiness, delegation oversight, marketing materials, bid development, new plan implementation as well as appeal and grievance expertise. Prior to her role at GHG, Tina held a management position with a SNP where she was responsible for the organization's day-to-day Medicare operational compliance. Tina has also held management positions with several MAOs in the greater Los Angeles and Orange County markets. In her previous roles, Tina was responsible for compliance interpretation and implementation, member/marketing material review and submission, bid development and submission, internal audits and CMS audit preparation, implementing internal corrective action plans, and creating detailed trainings. Tina is certified in Compliance and Ethics from the Health Care Compliance Association.

1 Comment
  1. Ms. Bailey,
    Do you know if Chapter 18 Medicare d appeals and grievances has been updated to reflect the changes in the 2018 Call letter.
    I am trying to get clarification on tier exceptions and keep looking for the update but have not been able to find anything yet.


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