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Medicare Compliance & Reimbursement

MEDICARE ADVANTAGE:

CMS Stresses Tight Timeline On MA Implementation

Published on Wed Oct 27, 2004

Health plans will need to act fast to take advantage of Medicare Advantage

Many questions surround the future of the revamped Medicare Advantage, but that hasn't dampened health plans' enthusiasm for the program.

America's Health Insurance Plans' annual Medicare conference last week attracted more than double the registration of 2003's record-high attendance, AHIP President Karen Ignagni said at the conference's Oct. 19 opening session.

In the keynote address, Centers for Medicare and Medicaid Services Administrator Mark McClellan laid out his broad vision of a future in which insurers and providers are rewarded for providing evidence-based, coordinated care that tailors treatments to individuals' health needs and manages chronic conditions before they become serious problems.

McClellan also suggested some specific directions in which he'll seek to move. Praising fledgling pay-for-performance programs in Medicare and elsewhere, he suggested that the agency hopes to pilot P4P reimbursement in several sectors, likely including health plans, for which he noted that consensus quality measures have existed for years.

Another priority: coordinating individual beneficiaries' care. Many health plans already coordinate care, and a large chronic-care improvement pilot is being launched for fee-for-service Medicare, said McClellan.
But care coordination can spread even farther, he vowed: Over time, "Medigap plans can also be a source of additional support for managing chronic diseases."

Current MA timelines are as follows:

  • Regions will be announced soon. The answer to one of the insurance industry's most burning questions - where and how big will be the areas to be served by new regional preferred provider organizations and prescription drug plans - will be revealed "well ahead of the end of this year," said McClellan.

    State-sized regions for larger states and multistate regions encompassing some smaller states appears a likely scenario, at least for the opening years of the program.

    It's important to allow established care-delivery networks to continue operating, said McClellan. Some such networks do cross state boundaries. CMS has "seen some considerable expression of interest in multistate regions," he said.

    At the same time, it's important that regions not be so large that plans have trouble scaling up to meet the quick deadlines, McClellan said.

  • E-prescribing standards are on track for earlier-than-required delivery. The MMA doesn't require implementation of electronic-prescribing standards until 2008, but federal agencies are working now on proposed standards and will announce them "soon," said McClellan, who added that he wants Medicare e-prescribing "in place by 2006."

    Linking all Medicare patients and their providers through electronic health records is a top priority for McClellan. To guide coverage decisions, the administrator wants to quickly develop evidence on the effectiveness of care regimens for various populations, and that depends on real-time production of clinical information on a broad scale.

    As for establishing registries to produce data on pharmaceutical treatments once Medicare's prescription benefit is up and running, "we're very interested in doing that for drugs," he tells MLR.

  • A "shell" Medicare Advantage application for 2006 will be on the Web before final rules are released. MA regulations won't yet be finalized, but to give insurers a head start on applying, a "shell" application for 2006 participation will be on the CMS Web site in late November, with details filled in as they become available, said Patricia Smith, head of the agency's Medicare Advantage group.

  • Memo to health plans: Be sure your application is clean. "Early January, I hope," will see the final MA and PDP rules, said Smith. By late January, final applications will be available.

    In late January or early February, health plans can come to Baltimore "for the better part of a week" for intensive training on filling out the application, Smith said.

    The training could be vital. Because of short statutory deadlines, CMS must streamline the application process - from initial submission to approval - from the previous 19-week time frame to eight weeks, said Smith. More automation within CMS will help some, but the key change will have to come from health plans and "will be a challenge" for the industry. The deadline for submitting applications - not bids - for 2006 participation will be 60 days after the final regs appear.

    In the past, 60 days was the average time span for CMS to notify plans that their applications were incomplete and receive revised and completed applications back again. But the MMA requirement that plans submit their monetary bids by June 6 "does not allow for that amount of time," Smith said. Therefore, CMS is urging plans to "do the spadework" up front and make their initial submission as clean as possible.

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