Key Takeaways From the Recent CMS Medicare Advantage & Prescription Drug Plan Fall Conference

4 Major Points From the 2017 CMS Fall Conference

The Centers for Medicare & Medicaid Services (CMS) recently held their fall conference and provided sponsors with many updates on current activities. There was a focus on the upcoming open enrollment period, past performance analysis, and encounter data.

Guidehouse provides four major highlights from the fall conference regarding changes and/or revisions affecting Medicare Advantage and Prescription Drug Plans.

1. Marketing Guidance Update
Demetrios Kouzoukas, Principal Deputy Administrator, Center of Medicare, provided an update to the changes that have been made. He shared the following for plans.

Plans are:

  • No longer required to upload all marketing materials and sales events into the Health Plan Management System (HPMS).
  • Able to send one document, such as the Annual Notice of Change/Evidence of Coverage, to multiple enrollees in the same household who are enrolled in the same plan. This will reduce the mailing costs to plans and the amount of paper.
  • May send marketing materials, such as formulary and provider/pharmacy directories, electronically.
  • Able to send marketing emails to beneficiaries.
    Only responsible for oversight of third-party website marketers if they are contracted.

2. Improved Communications With Members
CMS reviewed how they are improving communications with beneficiaries. They have revised the Medicare & You Handbook to further share the options beneficiaries have. Additionally, CMS will be enhancing the benefit package display on Plan Finder for the 2018 Open Enrollment Period. Enhancements include adding more benefit categories such as preventive care, in-network versus out-of-network costs, sharing of authorization and referral information, optional monthly supplemental benefits (premiums and deductibles), and an expanded display of drug cost and coverage. These modifications and enhancements are intended to assist beneficiaries with more information to ensure that they select the best plan based on their needs, ultimately resulting in better care.

3. Parts C & D Past Performance Analysis
Past performance analysis is an element of the application decision. CMS shared that if organizations have a recent history of performance problems they need to focus on their current books of business, not expanding until operations are compliant. CMS conducts past performance analysis twice a year — once in the spring to make contract determinations and once in the fall for informational purposes with an eye toward the spring. Analysis consists of 11 performance dimensions and identifies overall performance outliers, honing in on sponsors with problems in multiple categories and/or in one or more particularly high-risk areas.

Categories and point values have been updated since 2017, and will continue to be updated to reflect the most current and comprehensive available information. Point values may shift along with categories to reflect proportionate weights based on new information and analytic techniques. Scores will be posted in the HPMS prior to issuance of Notices of Intent to Deny to applicants. Applicants notified could either withdraw their applications or appeal the decision with the CMS Hearings Office.

Over the last several years, CMS’ application denials based on past performance have been consistently upheld in response to requests for an administrative hearing. 

4. Encounter Data
CMS presented a progress report on the current state of submissions. MA Encounter Data is Big Data. CMS forecasts that in 2017 there will be 775 million records submitted. Increased submissions are related to enrollment growth, but are also attributed to increased growth in the number of submissions per beneficiary. CMS developed a MA Encounter Data Integrity Plan (EDIP) and began implementation in 2015. The EDIP had two major goals: 1) validate completeness and accuracy of encounter data and 2) communicate with MA organizations (MAOs) on the best ways to improve encounter data submissions.

The following are core activities of the EDIP:

  • Analysis of encounter data is conducted in several areas to support the collection processing, completeness, and validity of data. Additionally, their analysis includes beneficiary-level utilization and diagnosis code maps.
  • Communication with MAOs enables effective collaboration in the submission and collection of complete and accurate encounter data. CMS gathers information about MAO encounter data processes; seeks stakeholder feedback; and provides guidance and technical assistance through a variety of communication activities such as site visits, one-on-one calls, and user group calls.
  • Monitoring ties together analysis and communication with MAOs. CMS views monitoring as an opportunity to improve the overall completeness and accuracy of encounter data. Monitoring outcomes are shared with MAOs.
  • Compliance activity is intended to follow up with MAOs whose performance in submitting complete and accurate data does not meet expectations.

CMS is committed to continued implementation and opportunities for enhancement of these integrity activities.


Contact us if you have any questions about the CMS updates. Guidehouse helps plan, create, and maintain sustainable business strategies and processes to meet the evolving Medicare Advantage and Prescription Drug requirements. We work collaboratively with our clients to consistently deliver high performance over time and across all key metrics.

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