CMS final rule for Medicare Advantage and Part D prioritizes member experience and expands telehealth access

CMS final rule for Medicare Advantage and Part D prioritizes member experience and expands telehealth access

The Centers for Medicare & Medicaid Services (CMS) issued a final rule last week that increases the weight of member experience measures, expands access to telehealth, and increases some chronic disease supplemental benefits, among other changes.

Increased weight of patient experience measures

CMS refined the Medicare Advantage Star Ratings system (and Part D Star Ratings) by giving member experience measures more weight in determining ratings. Specifically, CMS increased measure weights for CAHPS patient experience and access measures from 2 to 4. This change takes effect for the 2021 measurement year and will be reflected in the 2023 Star Ratings.

Given this change, which CMS hinted at earlier this year, improving member satisfaction and the overall experience has become a top priority for leading MA plans nationwide.

Telehealth flexibility

As part of what it called “larger efforts to advance telehealth,” CMS encouraged MA plans to increase their telehealth benefits and gave plans more flexibility to count telehealth providers across several specialties toward meeting CMS network adequacy standards.

CMS has been strongly encouraging plans to leverage telehealth as a way to safely get care to members who need it, without waiting for all in-person visits to resume. For example, earlier this year CMS said clinicians can conduct Annual Wellness Visits and other preventative or chronic condition monitoring virtually. Mental health services and substance abuse counseling are now covered through telehealth as well.

MLR expansion

The final rule also expands medical loss ratio (MLR) regulations, allowing MA plans to include all amounts that an MA organization pays for covered services in the incurred claims portion of the MLR numerator. “Incurred claims,” now include payments to individuals and entities that previously did not meet the traditional definition of provider in the MLR statute.

This move is intended to incorporate costs associated with supplemental benefits MA organizations now may offer their members. Supplemental benefits can include items and services that fall well outside the definition of “provider.” This change may also be helpful to plans that have leveraged the flexibilities provided by CMS during COVID-19.

Pandemic accommodations

To address the COVID-related challenges plans are facing, CMS adjusted the 2021 and 2022 Star Ratings calculations, acknowledging that data collection and measure scores will likely be affected by the pandemic.

Finally, CMS retired measure C16: Rheumatoid Arthritis Management, although it’s an area plans may still want to keep an eye on. In addition, the rule makes all Medicare beneficiaries with End Stage Renal Disease (ESRD) eligible for Medicare Advantage, beginning Jan. 1. And it eases rural healthcare policies in order to make more Medicare Advantage options available to rural residents.

About NovuHealth

NovuHealth is the leading healthcare consumer engagement company, driven to improve consumer health and health plan performance. NovuHealth motivates consumers to complete high-value healthcare activities by leveraging its sophisticated engagement platform, proven loyalty and behavioral science strategies, and deep industry and regulatory expertise. Headquartered in Minneapolis, NovuHealth has worked with nearly 40 health plans and served nearly 15 million consumers across all 50 states. Learn more at novu.com.

Read more
New J.D. Power study reveals members want to hear more from their health plans, and CMS provides a new tool to help

New J.D. Power study reveals members want to hear more from their health plans, and CMS provides a new tool to help

A new J.D. Power study reveals a gap between how health plans communicate with members and what members expect, especially during the pandemic. In its 2020 analysis of consumer attitudes toward health plans, the customer research firm found that:

  • 60% of plan members say they were never contacted by their plan with COVID-19 information; and
  • 48% said they feel their plan has not shown concern for their health since the pandemic reached the U.S.

The research illustrates that members expect more communication from their plans. But for many plans, effective member engagement remains elusive.

New CMS guidance could help plans increase member engagement

Last week, CMS released new guidance that gives health plans a powerful new tool to engage Medicare Advantage (MA) members and get them the care they need.

CMS now allows plans to add new rewards and incentive (R&I) programs in 2020 in response to COVID-19. Plans typically include these programs in their bids submitted the prior year. And if you currently have an R&I program, but want to expand it or increase the budget in response to the pandemic, CMS is providing the flexibility to do so.

This new guidance illustrates CMS’s willingness to provide plans more flexibility to engage members and motivate them to seek the care they need. And it paves the way for plans to significantly ramp up their member engagement efforts for the remainder of 2020.

Increasing backlog of deferred care carries risk for members and plans

That’s imperative, because the amount of health care that Americans have deferred due to the pandemic is growing at an alarming rate. According to NPR, more than half of Americans 70 or older put off medical treatment in the first month of the pandemic alone—everything from vaccinations to cancer screenings to even emergency care.

All those deferred services not only mean that members aren’t getting the care they need, it could also create medical loss ratio (MLR) challenges for plans later this year. Medicare Advantage and Medicaid MCO plans are required to spend 85% of revenue on medical expenses. But with so many services deferred, some plans are reporting unexpectedly high profits. The good news is that many plans are already waiving co-pays and paying premium rebates in anticipation of being upside down on their MLR. But those waivers are dependent on getting members the care they need.

Engaging members proactively and strategically

Proactively engaging members—and offering rewards and incentives to motivate them to get needed care—can also help plans balance out the MLR. As you know, R&I programs for Medicare Advantage members qualify as part of clinical spend, not administrative spend, so R&I investments go toward your MLR.

What’s more, with recently relaxed CMS and NCQA regulations making telehealth a viable option for more than 80 health care services, plans don’t have to wait for stay-at-home orders to be lifted—they can encourage members to get the care they need now. Yet based on the J.D. Power study, plans need to focus more on telehealth: 75% of consumers are aware of telehealth, but 54% don’t understand if their plan covers such benefits.

Several of NovuHealth’s leading health plan clients have initiated proactive member engagement programs, and we’re helping them do so strategically. For example, our engagement programs promote telehealth as a viable option for many services including annual wellness visits, musculoskeletal condition management and remote monitoring of physiologic markers like BMI, blood pressure and HbA1c. We’re also helping plans prioritize the most critical health care activities for members who are most at risk, such as mom and baby populations and those with chronic conditions. Those members can’t wait behind the wave of people who will soon be seeking appointments.

In the end, these leading plans recognize that reengaging their members now is in the best interest of both the plan and the members. Plans can create a competitive advantage by moving quickly and thoughtfully, and they can ensure their members get the care they need.

Want to learn more about how NovuHealth can help you thoughtfully engage your members and get them the care they need?

Want to learn more about how NovuHealth can help you thoughtfully engage your members and get them the care they need?

About NovuHealth

NovuHealth is the leading healthcare consumer engagement company, driven to improve consumer health and health plan performance. NovuHealth motivates consumers to complete high-value healthcare activities by leveraging its sophisticated engagement platform, proven loyalty and behavioral science strategies, and deep industry and regulatory expertise. Headquartered in Minneapolis, NovuHealth has worked with nearly 40 health plans and served nearly 15 million consumers across all 50 states. Learn more at novu.com.

Read more
2021 Medicare Advantage bids are due June 1! Here’s how (and why) to include rewards & incentives

2021 Medicare Advantage bids are due June 1! Here’s how (and why) to include rewards & incentives

Despite all the changes and upheaval currently facing the Medicare Advantage (MA) market, the MA bid process is still underway and bids are still due June 1.

Which means now is the time to plan for a 2021 rewards & incentives (R&I) program—and get it in your bid.

While members may be deferring care in light of COVID-19, and CMS has relaxed administrative burdens on plans—including nixing the requirement to submit HEDIS and CAHPS data this year—it’s still as important as ever to focus on member engagement. Members need your plan’s guidance, resources and motivation to stay healthy during this time and beyond—and R&I can be a big part of that.

So don’t delay. Because if you miss including an R&I program in this year’s bid, you may have to wait a full year before adding one. With CMS’ new proposed rule, plans may no longer have the option to add a rewards and incentives program mid-year.

Ready to start planning for an R&I program that supports your members’ health and your plan’s business goals?

Download our essential guide for including rewards & incentives in your 2021 MA bid, including how to correctly account for costs, comply with CMS regulations, and optimize your R&I investment this year and the years to come.

Including rewards & incentives in your 2021 Medicare Advantage bid: the essential guide

Including rewards & incentives in your 2021 Medicare Advantage bid: the essential guide

About NovuHealth

NovuHealth is the leading healthcare consumer engagement company, driven to improve consumer health and health plan performance. NovuHealth motivates consumers to complete high-value healthcare activities by leveraging its sophisticated engagement platform, proven loyalty and behavioral science strategies, and deep industry and regulatory expertise. Headquartered in Minneapolis, NovuHealth has worked with nearly 40 health plans and served nearly 15 million consumers across all 50 states. Learn more at novu.com.

Read more
The Trough and the Tidal Wave: How COVID-19 Will Swamp Your Health Plan (And What You Should Do About It)

The Trough and the Tidal Wave: How COVID-19 Will Swamp Your Health Plan (And What You Should Do About It)

Author: Cory Busse, Vice President, Performance Strategy at NovuHealth

The uncertainty surrounding the COVID-19 pandemic has hit all sectors of our economy, but perhaps none so hard as healthcare. Take health insurers, for example. Instead of encouraging members to get to the doctor for the care they need, health plans have pulled back (like most other industries) on their communication with members. In fact, the RISE Association recently published a survey that indicated 46% of all non-COVID communications had been suspended over the past weeks. This member engagement dry spell has had some unintended consequences for members:

1. Members cancelled their screenings and routine visits

NPR reported that in just the first month of this pandemic, more than half of Americans 70 or older put off medical treatment. Much of that was out of necessity. As states braced for an overwhelming number of COVID cases, elective surgeries and non-essential office visits were put on hold:

  • Cancer screenings – According to Epic, a leading electronic medical record (EMR) vendor, breast and cervical cancer screenings fell by 94% in March, and colorectal cancer screenings were down 86% when compared to 2017-2019 averages. 
  • Diabetes screeningsThe same study showed that HbA1c testing was down by 65%, and cholesterol and lipid panels fell by 67%. For both the cancer and diabetes screenings, the numbers were drastically higher in COVID-19 hotspots like New York and Massachusetts.
  • Annual wellness visitsA Hill-HarrisX poll recently found that 30% of respondents had already skipped an annual visit. Not only are these visits important to getting members the care they need, they’re also required for proper coding of hierarchical condition codes that go into a plan’s risk adjustment payments.

This extreme downturn in utilization should have health plans worried. As a health plan leader, you already know that cancer is two to four times less expensive to treat when caught early compared to advanced stages.  And members who are screened for diabetes cost $1,100 less per year to manage than those who are not screened.

2. Members are skipping urgent and emergency care

Even more alarming is the fact that members are forgoing emergency care, too. Kaiser Permanente reported that emergency visits have dropped by more than half, and state officials in California report that patient transports by ambulance have fallen by 20-30%. That’s not just because traffic is light and there are fewer accidents. Distressing stories abound about members having strokes and heart attacks and not seeking care. Fear of the virus and confusion about when and where to be seen for such conditions is leading your members to hold off on care that could save their lives.

3. Well-child checkups and immunizations are way down

As the scientific and healthcare communities race against the clock to find treatments and, ultimately, a vaccine for COVID-19, it’s ironic that vaccination rates for diseases we can control have plummeted. The New York Times recently reported, “As parents around the country cancel well-child checkups to avoid potential coronavirus exposure, public health experts fear they are inadvertently sowing the seeds of another health crisis.” Data collected from 1,000 independent pediatricians around the country found that during the week of April 5, measles, mumps and rubella shots dropped by 50%, diphtheria and whooping cough shots by 42%, and HPV vaccines by 73%. These are frightening numbers that could put millions of children and hard-fought gains for herd immunity at risk.

4. Your physician networks are at risk of going out of business

Much of the above has had the unintended consequence of putting additional financial strain on your provider networks. We’re not just talking about elective surgeries, which can make up 75% of a hospital’s surgical schedule. The deprioritization and outright prohibition of routine office visits has resulted in revenues for some providers dropping 50-90%. Health plans should care because the effects are disproportionately hitting small and independent practices. That means that the work you’ve done to build and maintain your carefully cultivated physician networks is in serious trouble. If even more of the smaller players give way to additional consolidation or outright closure, plans will find themselves negotiating with larger and more powerful health systems next year.

All of those canceled visits, missed immunizations and stress on providers are not only costing your members precious time to diagnose and treat these conditions, they’re going to cost your plan more to manage them. So, what’s a health plan to do?

Engage your members. Right now.

It’s clear that members desperately need to hear from their health plans today. Remind your members that they must still be seen for emergency conditions. Educate them about when and where to go for care that can’t wait. Encourage them to use telehealth options, now allowed by CMS, for more routine and preventive care (more below). Restart your Medicare and Medicaid Quality programs that you may have paused. Humana announced this week that they’re waiving copayments, deductibles and other out-of-pocket costs for the rest of the year for all Medicare Advantage members who see in-network primary care providers or behavioral health specialists.

You can also capture up-to-date addresses, email addresses and cellular phone numbers from members—as well as the opt-in consent—so you can use them in the future. Most of all, let them know that you’re still there and that you genuinely care about their health and wellbeing. They need to hear from you, and now is the time. Interestingly, direct mail volumes from other industries are down by up to 60% right now, so your communication to members have a high chance of making an impact.

Recommend telehealth visits where appropriate

CMS has allowed for more than 80 covered telehealth services, including many of the kinds of visits and screenings, listed above, that your members are skipping. Coverage applies both to telehealth solutions offered by your existing provider networks as well as third-party vendors. Communicating to members now that they don’t have to put off their Annual Wellness Visits, colorectal cancer screenings, diabetic screenings and immunizations will keep them healthy, and will help ensure chronic conditions are not progressing uncontrolled while they wait for the all clear.

Reward and incent positive member behavior

Many Medicare and Medicaid quality programs already use rewards and incentives to drive healthy member behavior. Now is the time to leverage these investments fully, when members may welcome such rewards in the face of unemployment and economic uncertainty. In the coming weeks and months, even your members who have historically closed their care gaps like clockwork might be uncertain about whether it’s safe to go see their doctor, or confused about how to complete activities virtually.

Conducting highly personalized outreach to members and ensuring that you’re being clear with them about what’s okay and even what’s encouraged will help head off member confusion, dissatisfaction and gaps in care during this pandemic.

To learn more about what your plan can do, schedule time to chat with one of our engagement experts

To learn more about what your plan can do, schedule time to chat with one of our engagement experts

About NovuHealth

NovuHealth is the leading healthcare consumer engagement company, driven to improve consumer health and health plan performance. NovuHealth motivates consumers to complete high-value healthcare activities by leveraging its sophisticated engagement platform, proven loyalty and behavioral science strategies, and deep industry and regulatory expertise. Headquartered in Minneapolis, NovuHealth has worked with nearly 40 health plans and served nearly 15 million consumers across all 50 states. Learn more at novu.com.

Read more
CMS’s evolving guidelines and the implications for Quality, Stars and CAHPS

CMS’s evolving guidelines and the implications for Quality, Stars and CAHPS

In response to the COVID-19 pandemic, CMS has announced several regulatory changes designed to ease the administrative burden on health plans and allow them to follow CMS’s own call to put “patients over paperwork.” 

What do all of these changes mean for your plan and your members? How can you continue to provide much-needed services and information to your members in the midst of this pandemic?

Here is NovuHealth’s informed perspective on the implications of CMS’s evolving guidelines on Quality, Stars and CAHPS.

CMS change: Plans don’t have to compile or submit HEDIS or CAHPS data for 2021 Stars

Our perspective

CMS recognizes the significant effort it takes to compile HEDIS and CAHPS data each year. By eliminating this requirement, the agency allows plans to focus on taking care of members.

However, CMS has indicated that both HEDIS and CAHPS will still be important after this crisis period. Plus, your plan is most likely still tracking that data to monitor your overall member satisfaction. That’s absolutely essential, as members may have higher expectations of you during this pandemic, and your interactions with them can greatly impact member satisfaction, retention, and overall health long term. 

CMS change: The 2020 HOS Survey is delayed until late summer

Our perspective

Although CMS has left the door open to canceling the HOS Survey altogether, at this point, the agency has moved it to late summer. This delay presents an opportunity for health plans, giving you additional time to connect with members before the survey begins. 

While you may have paused some of your programs designed to drive members to provider visits, many HOS-related activities don’t require a clinical visit, such as CO4 and CO5 (members’ impressions of their physical and mental health). Consider addressing those activities for members through other avenues, such as IVR messages or annual wellness visits conducted via telehealth. 

CMS change: 2021 Stars ratings for HEDIS and CAHPS will be carried over from 2020 

Our perspective

You may feel that all the work you did last year to drive HEDIS and CAHPS results was wasted, since it won’t count toward your next Star rating. But that’s not at all the case.

Member engagement is a marathon, not a sprint. So any and all investments you make in keeping members healthy and connected—both last year and this year—will pay dividends in the long run. When we all emerge from this pandemic, your members will remember that you kept them connected to the information and services they needed during this critical time. 

CMS change: CMS expanded coverage for telehealth services, including allowing phone care for some preventive and chronic conditions

Our perspective

CMS expanded access to telehealth services—and relaxed the technology requirements— to ensure that in-person resources are reserved for the most critical care, including COVID-19 cases, and to reduce patients’ exposure to potential infection.

CMS is now allowing telehealth for preventative visits and screenings, remote management of chronic conditions, some behavioral health care, and much more. This expansion not only allows important care delivery to continue during this pandemic, but may also have a long-term impact as well. With the increased interest we’ve seen in telehealth in recent years, it’s easy to envision that it will become an ongoing and acceptable avenue of care for many services, even after the pandemic has ended.

CMS change: 2022 Stars ratings will be calculated based on 2020 performance, as expected

Our perspective

While CMS has instituted some guardrails for plans this year, knowing their performance may be impacted by the pandemic, it is NOT giving plans a pass on 2020 HEDIS and CAHPS data. That means what you do to engage and support your members this year is critically important.

At NovuHealth, we’re working with many plans to develop a 2-pronged strategy. In the near-term, while many services are deferred during shelter-at-home periods, we’re helping plans:

  • Promote high-value activities that don’t require an in-person visit
  • Transition select activities to telehealth, such annual wellness visits and mental health visits
  • Identify vulnerable populations and those with chronic conditions who need ongoing care during this time.

We’re also helping plans prepare now for the dramatic increase in demand that will no doubt flood the system when shelter-at-home orders are rescinded. For example, we’re helping clients:

  • Prioritize the measures that matter most, such as key HEDIS and CAHPS activities that may have been paused
  • Target high-priority and at-risk populations to ensure they receive the in-person visits they need
  • Optimize member engagement within a condensed time period. Even if shelter-at-home orders last into the summer, it’s not too late to drive meaningful member engagement and gap closure.

To learn more about these changes and the implications for your plan, check out our on-demand Medicare and Medicaid webinars below!

CMS’s Latest Guidelines and the Implications for Medicare Plans

CMS’s Latest Guidelines and the Implications for Medicare Plans

Ever-evolving Policy Changes and Implications for Medicaid Plans

Ever-evolving Policy Changes and Implications for Medicaid Plans

About NovuHealth

NovuHealth is the leading healthcare consumer engagement company, driven to improve consumer health and health plan performance. NovuHealth motivates consumers to complete high-value healthcare activities by leveraging its sophisticated engagement platform, proven loyalty and behavioral science strategies, and deep industry and regulatory expertise. Headquartered in Minneapolis, NovuHealth has worked with nearly 40 health plans and served nearly 15 million consumers across all 50 states. Learn more at novu.com.

Read more