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Technology Solutions to Simplify Healthcare

Automating Medicare Advantage

WebInsure Medicare

Published by: hCentive

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Industry

Technology Solutions to Simplify Healthcare

There is considerable confusion about the impact Affordable Care Act (ACA) had on Medicare Advantage. The ACA brought about many changes as part of an overall reform goal to control Medicare costs. One of the goals was to control Medicare costs and, therefore the act eliminated subsidies that were initially used to start the program. Many have questioned why the government made these cuts to the program. Some have pointed out that the government spent more on Medicare Advantage than it did for comparable care under traditional Medicare. So the ACA wanted to contain these costs and targeted to gradually reduce the subsidies until payments to Medicare Advantage plans align with the cost of traditional Medicare. The overriding theory has been that these cuts would result in a decrease in Medicare Advantage enrollments. However, reality has been the opposite. Enrollment in Medicare Advantage Plans has climbed from around 11 million in 2010 to a little over 14 million in 2013 , a 30 percent increase. Experts have revised their enrollment projections and predict continued growth in Medicare Advantage enrollment through 2014. The reasons for the enrollment growth are not entirely clear, but the bonus payments have certainly helped offset payment reductions and health plans are cutting costs as well. Over the next few years as additional payment reductions are made, the growth in enrollment may slow down or even decrease. If a decrease does occur, health plans may leave the market due to decreased profitably. If enrollment continues to increase, most plans will need to cut costs and keep premiums flat and will accomplish this by reducing benefits, increasing member cost sharing of various services or increasing prerequisite requirements. Either way, Medicare Advantage plans have been able to keep a fairly flat premium over time due to internal cuts as well as the influx of more beneficiaries in the market due to aging baby boomers. An additional benefit to the baby boomers is their experience and comfort with manage care plans compared to older beneficiaries. Across the country, there are approximately 28 percent of Medicare beneficiaries enrolled in Medicare Advantage plans. The majority of members are from a small number of large organizations and about half of the beneficiaries are enrolled in a zero-premium plan, which has grown in popularity over the last several years. HMO plans have the majority of enrollments followed by PPO plans.

This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosedin whole or in partfor any purpose other than to evaluate hCentive products or services. This document contains confidential and proprietary information specific to hCentive, Inc.

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Challenges

Technology Solutions to Simplify Healthcare

As the Medicare Advantage market grew, problems arose with marketing and enrollment in the Medicare Advantage (MA) and Prescription Drug Plan (PDP) market during the implementation of these programs so Congress held several hearings focused on the marketing and sales problems. Problems included: Complaints about the confusing practices that have led to beneficiaries enrolling in a plan he/she really doesnt understand. Cases of outright fraudulent actives where beneficiaries were enrolled without broker contact, or due to misrepresentation of the broker. Situations where the beneficiary thought they are signing an attestation but really were signing the enrollment form. Situations involving brokers telling the consumer that the application would be placed on hold but then submits the application. Improper activities with enrollment of individuals with Alzheimers disease or dementia, mentally incapacitated individuals, or beneficiaries with limited English proficiency who did not understand the products they were buying. Enrollment of dual-eligible beneficiaries into plans that are unnecessary or inappropriate. The Centers for Medicare & Medicaid Services (CMS) made several changes to address these challenges and worked on policy development around the marketing of MA and PDPs, including proposing major revisions to the regulatory framework. In addition, it expanded its monitoring of plan marketing through improved audits, secret shopper events, post-enrollment verification of calls and mandatory reporting of marketing and sales events. In addition, CMS provides information on its compliance monitoring and enforcement actions by making information about these activities publicly available on its web site so all plans can be aware of the requirements. Not only does Medicare Advantage have requirements around marketing and sales activities, but it also has an inherently complex enrollment process and regulations. This includes CMS requirements ranging from sending out required letters (i.e. Enrollment Acknowledgement Letter, Enrollment Confirmation Letter, Notice of Disenrollment, and several others) within certain time frames, processing various combinations of TRCs (transaction reply codes) that come in on the TRR (Transaction Reply Report). A health plan has various actions to perform depending on the codes. Interestingly, many plans handle these required processes manually and, therefore, create the potential for high error rates and tremendous inefficiencies.
This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosedin whole or in partfor any purpose other than to evaluate hCentive products or services. This document contains confidential and proprietary information specific to hCentive, Inc.

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Solution

Technology Solutions to Simplify Healthcare

With the large number of requirements and potential complications, many plans are realizing they need to automate the manual processes that they have used in the past. While human invention has worked, it has caused great organizational inefficiencies and become a drain on resources. hCentive has developed a solution that is tailored specifically for the Medicare Advantage market. This solution, WebInsure Medicare, is capable of handling Medicare interfaces and requirements most importantly automating previously manual processes, thus enabling resources to focus on marketing and enrollment activities. In addition, the solution automatically generates required CMS letters significantly increasing productivity and reducing administrative costs. Due to the requirements in place that brokers must be utilized in selling Medicare Advantage, WebInsure Medicare houses, in one centralized location, all of your broker data including license numbers, which can indicate if the broker has completed the mandated Medicare training. Since WebInsure Medicare manages the entire enrollment and post enrollment process it becomes your system of record, capturing all member data and storing it in one centralized location. In addition, the system manages the BEQ and MARx processing, and post enrollment activities as cancellations, disenrollments and reinstatements. WebInsure Medicare ensures adherence to CMS requirements by automating application validation, LEP and LIS calculation, OEV determination and enrollment period and effective date determination. Webinsure Medicare is compliant with CMS requirements and quickly adapts to changing guidelines. By utilizing several upfront validations, the system minimizes CMS rejections. In addition, we realize that organizations are looking for ways to automate CMS SLAs. WebInsure Medicare offers this ability. The system is designed to proactively monitor compliance of CMS SLAs. Multiple alerts can be configured to gauge against the most time sensitive SLAs activities within the system.

This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosedin whole or in partfor any purpose other than to evaluate hCentive products or services. This document contains confidential and proprietary information specific to hCentive, Inc.

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Technology Solutions to Simplify Healthcare

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This document is copyrighted property of hCentive, Inc. It should not be duplicated, used, or disclosedin whole or in partfor any purpose other than to evaluate hCentive products or services. This document contains confidential and proprietary information specific to hCentive, Inc.