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Medicare Blog | Medicare News | Medicare Information

CMS - Flexibility vs Equality

Posted by www.psmbrokerage.com Admin on Wed, Feb 10, 2021 @ 08:55 AM

Tags: Medicare Advantage plans, Medicare News

Medicare Advantage enrollment in chronic illness benefits tripled in 2021

Posted by www.psmbrokerage.com Admin on Tue, Feb 09, 2021 @ 10:00 AM

Tags: Medicare Advantage plans, Medicare News, DSNP, Special Needs Plans, CSNP

Medicare Increases Access to Care, Affordability for Seniors

Posted by www.psmbrokerage.com Admin on Thu, Feb 04, 2021 @ 10:38 AM

Tags: Medicare News

As Use of Telemedicine Skyrockets, Need for Thoughtful Policy Grows

Posted by www.psmbrokerage.com Admin on Mon, Jul 20, 2020 @ 11:01 AM

Tags: Medicare News, Telehealth, Telemedicine

Medicare Marketing Guidelines

Posted by www.psmbrokerage.com Admin on Thu, Apr 11, 2019 @ 08:37 AM

Medicare Marketing Guidelines 

medicare guideline changes ahead

Rules Renamed to "Medicare Communications &
Marketing Guidelines"

The Medicare Marketing Guidelines (MMG) have seen some significant changes since 2019. The MMG, which governs Medicare Advantage Organizations (MAO) and Plan D sponsors, were also re-named to Medicare Communications and Marketing Guidelines (MCMG).

In this article, we’ll take a look at some important changes to the regulations that you should be aware of moving forward.

Below, I have highlighted some of what we consider the most relevant changes to the guidelines. It is not an exhaustive list, but I think it’s a good place to start.

The following sections have changed since 2019:

 

[ Note: Plans/Part D sponsors may impose additional restrictions on their subcontractors, downstream entities, and/or delegated entities, provided they do not conflict with the requirements outlined in the MCMG. ]

 

Let's look into some of the changes to the Medicare Communications and Marketing Guidelines:

20 – Communications and Marketing Definitions:

The most obvious change to this section is the distinction between Communications activities and Marketing activities. Communications activities do not need to be submitted for CMS review.

The MCMG defines Communications as:

Activities and use of materials to provide information to current and prospective enrollees. This is the more generic of the two categories and does not require CMS review. This can be seen as a loosening of the restrictions.

  • An example of Communications could be activities/materials that promote awareness of MA plans in general and the fact that you offer that type of plan.

The MCMG defines Marketing as:

Marketing can be considered a subset of Communications and provides more detailed information. Marketing materials are those that could include information on a plan’s benefit structure, cost sharing and measuring or ranking standards. These types of materials are subject to CMS review.

    • An example of marketing materials would be a flyer that provides specific details about a plan’s benefits, cost sharing or ranking standards.

Put another way, marketing materials are those with an intent to draw a beneficiary’s attention to a MA plan or plans to influence a beneficiary’s decision-making process when selecting and enrolling in a plan or deciding to stay in a plan and contain information about the plan’s benefit structure, cost sharing, and measuring or ranking standards.

 30.6 – Electronic communication Policy:

Section 30.6 explains that a sponsor may initiate contact via email to prospective enrollees and to retain enrollment for current enrollees.

It also notes that text messaging and other electronic messaging (social media) is considered unsolicited and is not permitted.

 40.2 – Marketing Through Unsolicited Contacts:

As in 30.6 above, Section 40.2 adds email to the list of allowable unsolicited contact methods, as long as there is an opt-out function in the email.

This section also clarifies that unsolicited text messages are not permitted.

50.3 – Personal/Individual Marketing Appointments:

There is no longer any language preventing an agent from asking for referrals during a one on one appointment. (No more excuses)

60.4 – Plan/Part D Sponsor Activities in the Healthcare Setting:

Section 60.4 clarifies that waiting rooms are considered part of the common areas and common areas are approved for sales activities.

It also states that Communication materials may be distributed and displayed in all areas of the healthcare setting.

90.1 – Material Identification:

Section 90.1 includes a new material identification process, as well as guidance on what types of materials will require submission to HPMS. 

Note:

The section relating to the rules that apply to referral programs (30.9)  has been removed. This will allow for some flexibility in gaining referrals.

If you offer a gift for referrals, just remember, you will still need to abide by the Nominal Gift standards (40.4).

 

Appendix 2, Disclaimers:

Disclaimers have been simplified and are now located in Appendix 2 of the MCMG. Some of the relevant proposed changes are listed below.

The following disclaimers may be removed from your materials:

  • “A sales person will be present with information and applications.”

The following disclaimer may be removed from your advertising materials:

  • “This is an advertisement”

The following disclaimer may be removed from your materials:

  • “Non- health or non-plan related information”

The following disclaimer may be removed from your materials:

  • “Medicare has neither reviewed nor endorsed this information.”

You no longer have to put the following text in email subject lines. As long as the material is not considered Marketing.

  • “Marketing”

 

Appendix 3, Pre-Enrollment Checklist:

The Pre-Enrollment Checklist was added to consolidate disclaimers on a given plan. The Checklist is designed to help enrollees understand important rules before making an enrollment decision.

 

Conclusion

This update marks a significant change to the MCMG. There are new additions, several sections have been moved around and others removed entirely.

We recommend reading through the entire guidelines to ensure you’re aware of any possible impact to your business.

We have pre-approved Medicare Marketing Materials as well as carrier approved marketing materials available for our agents.

As always, our experienced marketers are here to answer any questions you may have.

Additional Updates:

Tags: Medicare News, medicare marketing guidelines

Medicare's New "What's Covered" App for Smartphones

Posted by www.psmbrokerage.com Admin on Mon, Mar 11, 2019 @ 10:44 AM

Medicare's New "What's Covered" App for Smartphones

Are you or your client unsure if Medicare will cover a medical test or procedure? The Center for Medicare and Medicaid Services ("CMS") has a new app available to help answer those questions. 

The app is called "What's Covered" and is available for free on both the App Store and Google Play.

The app delivers accurate cost and coverage information right on your smartphone. Search for "What's Covered" or "Medicare" and download the app to your phone.

The app delivers general cost, coverage and eligibility details for items and services covered by Medicare Part A and Part B. Search or browse to learn what's covered and not covered, how and when to get covered benefits; and basic cost information. You can also get a list of covered preventative services.

Click on the link below to read more about the What's Covered app. 

https://www.medicare.gov/blog/whats-covered-mobile-app

Additional Updates:
 

Tags: Medicare, Medicare News

Medicare Advantage Insurer Anthem Wants to ‘Push Innovation Buttons’ with Senior Living

Posted by www.psmbrokerage.com Admin on Fri, Oct 26, 2018 @ 02:40 PM

Medicare Advantage Insurer Anthem Wants to ‘Push Innovation Buttons’ with Senior Living

As senior living providers assess how they can seize new opportunities in Medicare Advantage (MA), they should consider one of the nation’s largest insurance companies an interested potential partner.

Indianapolis-based Anthem Inc. is the largest for-profit managed health company under the Blue Cross and Blue Shield umbrella. It is also the most prominent insurer to announce benefits packages created under newly relaxed Medicare Advantage rules, which allow for coverage of non-skilled in-home care and other services.

The Centers for Medicare & Medicaid Services (CMS) first announced this MA policy change last April. In the months since, senior living operators have been contemplating what the change could mean for them, because the newly allowed benefits cover the sorts of services typically provided in settings like assisted living.

However, it’s been unclear how insurance companies that offer MA plans might structure these benefits and when — and if — these insurers will start to offer this type of coverage.

Anthem has been one of the first insurance companies out the gate, announcing its new benefits packages in early October. These benefits, which take effect in 2019, could be tapped by plan members residing in senior living communities. And Anthem’s speed in bringing these new offerings to market should be a signal to senior living providers that the insurance company wants to be on the leading edge of innovation. As part of that effort, Anthem is open to developing future benefits and business arrangements that are more tailored specifically to the senior housing sector.

“It’s an open question for me, how do we work with these facilities in the future?” Martin Esquivel, vice president of Medicare product management at Anthem, told Senior Housing News. “Going forward, we want to push the innovation buttons and see what we can do together.”

Anthem’s offering

The new benefits offered by Anthem-affiliated health plans are branded “Essential Extras” in Georgia, Indiana, Kentucky, Missouri, Ohio, Virginia and Wisconsin;

“Everyday Extras” in Tennessee, Texas, and New Jersey; and the new benefits are not branded in Anthem’s health plan affiliates in California or Arizona. They cover services such as food delivery, transportation, adult day center visits, installation of assistive devices in the home, and up to 124 hours of in-home non-skilled care. Individuals enrolled in plans with access to “Essential Extras” or “Everyday Extras” will need to choose one of the services offered in the package.

“The reason we could jump so quickly [and offer these benefits] is Anthem and its affiliated health plans are committed to offering plans that offer high-quality medical care and other social and support needs,” Esquivel said. “We had a list we were already contemplating, and when the language came through, we were able to add to that list, pressure-test it all, and identify the items we knew we could deliver. Culturally, we were already there.”

MA insurers have multiple incentives for offering these sorts of benefits. For one, they might build enrollment by differentiating themselves from competing plans, and give consumers access to services that they want. Insurers also could see bottom-line benefits through better cost control. For example, by covering transportation and in-home assistance with daily activities, Anthem might help prevent a beneficiary from missing doctors’ appointments or experiencing a fall - and this in turn should cut down on costly hospital stays.

While the new benefits are most obviously tailored to people who are not living in institutional settings, there are certainly some MA beneficiaries who reside in independent living and assisted living communities, Esquivel acknowledged. Anthem does not track the exact number of its beneficiaries in senior living.

There might need to be some discussion among senior living residents, Anthem representatives and leaders at the senior living community about how to coordinate these newly covered services. For example, an assisted living apartment probably already has grab-bars and similar features installed, but a resident might tap the new MA benefit to get a particular type of toilet seat, Esquivel said. Similarly, a senior living community probably already provides some form of transportation, but a resident might want to supplement that through the new MA coverage. And if there are discussions to be had about residents using MA to pay for some services already being offered in senior living settings, Anthem is also open to those conversations.

“How do we innovate and leverage what [senior living communities are] offering their consumers today?” Esquivel said. “It could be as simple as a contracting arrangement where they bill [the insurer], or something much more innovative that we haven’t thought of yet.”

Anthem may need to ‘get in line’

In light of expanding Medicare Advantage benefits, it’s plausible that residents will be approaching senior living providers and saying, “I’m getting this [service covered] through my MA plan, so I shouldn’t have to pay for it out of pocket,” according to Anne Tumlinson, founder and CEO of Washington, D.C.-based health care consultancy Anne Tumlinson Innovations.

However, assisted living companies do not have to quickly reassess their fee structures in response to this move by Anthem.

https://seniorhousingnews.com/2018/10/25/medicare-advantage-insurer-anthem-wants-push-innovation-buttons-senior-living/

Additional Updates:
 

Tags: Medicare Advantage, Medicare, Medicare News, Part D

Venture-Funded Medicare Advantage Plans Launch into 2019 Market

Posted by www.psmbrokerage.com Admin on Fri, Oct 26, 2018 @ 10:59 AM

Venture-Funded Medicare Advantage Plans Launch into 2019 Market

New Medicare Advantage plans backed by venture funding are positioning themselves as innovative alternatives to traditional health plans

Venture-Funded Medicare Advantage Plans Launch into 2019 Market

Several Medicare Advantage (MA) plans entering the market for the 2019 plan year are backed by millions in venture capital funding and are planning to compete with established payers by promoting new health plan solutions.

The recent uptick in Medicare Advantage competition is not surprising as many payers have experienced billion-dollar profits, high enrollment totals, and health plan expansion opportunities from a booming MA business. Increased participation in the MA market is likely to present competitive challenges between payers vying to attract new health plan enrollees.

Many new MA entrants have received significant funds from private investors and venture capital firms to launch innovative health plan offerings in the Medicare Advantage space. These new MA plans also promote tools such as data analytics, care coordination platforms, and technology suites to improve member experiences and set themselves apart from established MA participants.

DEVOTED HEALTH LAUNCHES FLORIDA-BASED MEDICARE ADVANTAGE PLAN BACKED BY $300 MILLION INVESTMENT

Devoted Health has launched new Medicare Advantage plans in Florida after raising $300 million in Series B funding to implement technologies that enhance operational efficiency and customer service.

Devoted Health raised $61.5 million in previous funding rounds to develop technologies that help members navigate healthcare services and receive care at home.

Leaders at Devoted Health explained that the organization operates as a combination of a payer and provider to deliver integrated healthcare services.

Ed Park, CEO and co-founder of Devoted Health, said partnering with the best possible providers and equipping consumers with user-friendly technology allow the health plan to improve beneficiary experiences.

“Having industry-leading technology is central to what we do. With our latest funding, we will continue to grow the world-class team building out our technology and operations and will expand Devoted into additional markets,” he said.

Devoted Health has employed advisors, secured investors, and hired executive personnel that have several decades of experience in the Medicare Advantage market.

“In various parts of the country, there are local examples of organizations dramatically improving healthcare outcomes and bringing down costs,” said former US Senator Bill Frist, MD, a member of the Devoted Health board and investor.

“What makes Devoted so exciting is that they have the team, operating model, technology, and capital to scale this kind of performance nationwide.”

BRIGHT HEALTH ENTERS INTO NEW MEDICARE ADVANTAGE MARKET FOR A SECOND CONSECUTIVE YEAR

Bright Health has expanded its Medicare Advantage prescription plan option (MA-PD) into Tennessee, making it the second consecutive year the payer has entered a new MA market.

The payer has partnered with large healthcare systems across Tennessee in order to provide high-quality health plan coverage. The health systems include Baptist Memorial Health Care, the University of Tennessee Medical Center, and TriStar Health.

According to Bright Health executives, the partnership with the three health systems will provide beneficiaries with extensive access to high-quality providers.

Collectively, the health systems include 10 hospitals, 13 urgent care centers, six centers of excellence, over 1,000 physicians, and multiple specialist organizations.  

“Bright Health is committed to expanding access to the growing number of people in need of individual health plans and quality healthcare – both in Tennessee and across the country,” said Bob Sheehy, Bright Health's co-founder and chief executive officer.

“Baptist Memorial, TriStar and The University of Tennessee Medical Center have each demonstrated a unique ability to provide superior, personalized care to millions of patients each year, and we are thrilled to partner with them to meet the healthcare needs of hardworking Tennesseans.”

Bright Health has continued to expand at an accelerated rate due to successful fundraising campaigns. In 2017, Bright Health raised $160 million from investors to scale its individual health plan and MA business operations.

CLOVER HEALTH ANNOUNCES SIGNIFICANT MEDICARE ADVANTAGE EXPANSION FOR 2019

Clover Health announced an expansion into six Medicare Advantage markets for plan year 2019.  

Clover Health uses AI-driven technology to help risk stratify its 30,000 beneficiaries and identify opportunities to improve outcomes. The payer estimates that its platform is accurate 85 percent of the time when identifying patients at risk for a hospital readmission within 28 days. Leaders at Clover Health believe that the company’s AI solutions allow the payer to create optimal beneficiary experiences at scale.

“Expanding into new cities and deploying our AI platform with international partners are both core to Clover's mission of improving the health of our customers by uniting cutting-edge technology with committed, personalized medical care,” said Vivek Garipalli, CEO of Clover Health.

“We are already seeing the extremely positive results that our technology is having on the lives of our members and are optimistic about how we can begin to impact health on a global scale.”

Clover Health has received $425 million in investor funding since 2015, the company said.

OSCAR HEALTH EYES BIG MEDICARE ADVANTAGE MARKET FOR 2020

Oscar Health expanded into several new individual health plan markets and has for an even larger Medicare Advantage expansion in 2020.

The payer offers personalized Medicare Advantage plans through which consumers can use mobile apps and web-based services to make health plan choices.

MA beneficiaries can also access telemedicine and concierge services that help members receive care as needed, according to a recent press release about Oscar’s MA benefits.

Oscar Health CEO Mario Schlosser explained that the company has developed claims administration technology, enrollment services, and communications services to streamline health plan operations.

“Each new member and interaction with the healthcare system offers Oscar an opportunity to refine our member apps and make better recommendations for care; to enable our population health leads and concierge teams to drive more personalized interventions; to empower providers with easier tools that let them focus on delivering care,” Schlosser said.

Oscar recently made national headlines after Alphabet, Google’s parent company, invested $374 million to help the payer expand MA operations for 2020. The investment is expected to help Oscar Health hire more engineers to build out concierge services and member engagement technologies.

https://healthpayerintelligence.com/news/venture-funded-medicare-advantage-plans-launch-into-2019-market

Additional Updates:
 

Tags: Medicare Advantage, Medicare, Medicare News, Part D

How Prior Authorization Can Impede Access to Care in Medicare Advantage

Posted by www.psmbrokerage.com Admin on Thu, Oct 25, 2018 @ 04:53 PM

How Prior Authorization Can Impede Access to Care in Medicare Advantage

While Medicare Advantage (MA) plans are required to cover the same health services as Original Medicare, they are not required to offer the same level of provider access and can impose coverage restrictions—like prior authorization—that require enrollees to take additional steps before accessing prescribed care. If a service is covered “with prior authorization,” enrollees must get approval from the plan prior to receiving the service. If approval is not granted or sought, the plan generally will not cover it.

A new analysis from the Kaiser Family Foundation looks at the prevalence of prior authorization in MA and found that many plans utilize this flexibility: 80% of MA enrollees are in plans that require prior authorization for at least one Medicare-covered service. Original Medicare, in contrast, does not require prior authorization for the vast majority of services, making this an important distinction between the two coverage options.

In some instances, prior authorization may be an appropriate utilization management tool. In particular this is true when both beneficiaries and providers are likely to benefit from advance knowledge of Medicare coverage. However, MA’s broad application of prior authorization can impede access to care.

On our National Helpline, we frequently hear from MA enrollees who are experiencing a range of denials for health-related services, and who are concerned and confused about their plan’s service denials and coverage requirements. While each MA plan has different rules, as the KFF report indicates, many require enrollees to obtain approval before receiving an array of critical services:

  • At least 70% of enrollees are in plans that require prior authorization for Part B drugs and inpatient hospital stays.
  • 60% of enrollees are in plans that require prior authorization for ambulance, home health, procedures, and laboratory tests.
  • More than half of enrollees are in plans that require prior authorization for mental health services.

In such situations, there is minimal value to beneficiaries or providers in procuring pre-service determinations. Instead, these requirements can often create barriers that may delay or prevent timely access to needed, affordable care.

Additionally, coverage denials can have significant financial implications for the enrollee. Many face high out-of-pocket costs as a result, in particular those who miss the short 60-day window of time to appeal. Unlike Original Medicare, MA enrollees must appeal within 60 days of the date of service. If they miss this deadline, they are held responsible for the charges.

While we support efforts to lower Medicare program costs and increase certainty about the scope of coverage, the potential consequences of such policies must be carefully considered, and any harms to to people with Medicare must be thoughtfully and thoroughly mitigated.

We are pleased to see that many in Congress recognize the severity of these adverse impacts. Earlier this month, more than 100 lawmakers sent a letter to the Centers for Medicare & Medicaid Services (CMS) expressing concern about the use of prior authorization in MA, and asking for agency guidance to ensure that these requirements do not create inappropriate barriers to care for people with Medicare. The effort was led by Rep. David P. Roe (R-TN-1) and Rep. Ami Bera (D-CA-7), and the Medicare Rights Center recently thanked them for their leadership.

We look forward to working with Congress, the Administration, and our organizational partners to strengthen these and other beneficiary protections within Original Medicare and MA, with the goal of improving the health and economic security of people with Medicare.

Read the KFF report.

Read our letter to Reps. Roe and Bera.

Read the Congressional Letter to CMS.

Read more about the differences between MA and Original Medicare.

Source

Additional Updates:
 

Tags: Medicare Advantage, Medicare, Medicare News, Part D

New CMS Pay Model Targets Soaring Drug Prices

Posted by www.psmbrokerage.com Admin on Thu, Oct 25, 2018 @ 04:24 PM

New CMS pay model targets
soaring drug prices


The Trump administration on Thursday accelerated its efforts to bring prescription drug prices under control.

Speaking at the Hubert Humphrey building, President Donald Trump announced a proposal that would shift Medicare Part B drugs to a level more closely aligned with prices in other countries. The CMS calls the program the International Pricing Index model. 

American taxpayers and patients are projected to save more than $17.2 billion over five years.

"In an era where the pharmaceutical industry is pricing drugs at levels approaching a million dollars—and jeopardizing the future of our safety-net programs—the time has come to fix the perverse incentives in the Medicare program that are fueling price increases," CMS Administrator Seema Verma said in a statement. 

The move from current payment levels to ones based on international prices would be phased in over a five-year period, would apply to 50% of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines such as infusions.

Read the full article here

Additional Updates:
 

Tags: Medicare Advantage, Medicare, Medicare News, Part D

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