The Bridge – Volume 10

We Wish You a Successful and Compliant AEP Season!

While we are all in the throes of Annual Enrollment Period (AEP), Madena is looking to support you by dedicating a newsletter to upcoming critical activities that can easily be overlooked during this busy time.

Jennifer Young
Jennifer Young, Executive Vice President

CMS Low Income Subsidy Processing

Have you reached out to your members potentially losing LIS based upon the October file from CMS? We recommend creating a checklist to make sure your organization covers all the necessary steps from now through year-end.

  • Provide notice to your Call Center about the LIS Loss and Reassignment process, expected dates, and copies of all communication (directly sent to your members) from CMS and your plan.
  • After processing your LIS Reassignment Special TRRs:
    • Identify members you are losing. Ensure your membership and PBM systems are updated, and there is a disenrollment notice with the ANOC. Prepare your Call Center to field calls for any members opting to stay in the plan.
  • Identify members you are gaining and take similar steps. INDUSTRY NOTE: the accompanying address file from CMS is in a different format and many health plans have had to manually manipulate the file to load and process it. Make sure your file is not sitting in an error report! Remember to send 4Rx data for CMS reassigned members (due within 72 hours of CMS notifying the health plan).
  • Perform 2021 premium billing validation testing to ensure that the LIS amounts have been updated and will be reflected on the invoices (generated in December) for the January premium month.
  • Perform 2021 validation testing with the PBM to ensure that the low-income cost sharing amounts and deductibles have been implemented and tested before going into effect.
  • Make sure job aids for your teams are updated with the new LIS subsidy and cost sharing amounts.

Sue Dahlkamp, Interim Compliance Officer & Senior Consultant

Timeliness Monitoring Project

In October, CMS issued a memo regarding the 2020 Timeliness Monitoring Project (TMP). As in previous years, CMS will once again be conducting an industry-wide monitoring project in 2021.

What’s changed?

Beginning with the 2021 TMP, CMS will no longer collect the Part D Coverage Determination Appeals and Grievances universes used to evaluate these measures. The review time period is starting one month sooner, in January.

Who’s going to be monitored?

Part C sponsors with active contracts in both CY2020 and CY2021. If you had a program audit in 2020, you are off the hook if you successfully submitted the ODAG universes without any Invalid Data Submission (IDS) conditions and had at least one month of 2020 data for each of the required universes. If you did have an IDS on any of the required universe(s), the good news is you only have to resubmit the affected universe(s). If you had just a validation audit in 2020, you are still on the hook.

CMS Readiness Review

CMS Readiness Review: How to Utilize the Results for CPE Risk Assessment and Internal Monitoring Activities

The CMS Annual Readiness checklist is published right when we are all eyeball deep in AEP readiness. The checklist is intended to be a reminder of common failures guidance that is expected to be implemented by 1/1/2021.

The following is Madena’s approach to using a readiness review to feed into a Compliance Program Effectiveness (CPE) risk assessment and internal monitoring activities.

In August, we recommend plans use the prior year’s CMS Annual Readiness checklist PLUS a readiness checklist that spans other important functions not included in the CMS checklist. Create a true measurement of readiness:

  1. Is there a system in place or is there a manual process?
  2. Is there documentation and training to support the process?
  3. Is there dedicated staff to perform the function?

Through this assessment, you may certify a process as “ready” but it may still have inherent risk (new staff, manual processes, lots of hand-offs).

Combining the readiness review with the risk assessment is a great way to feed two birds with one kernel of corn. You should be able to create your internal monitoring plan from your risk assessment.

When the Annual Readiness checklist comes out, be sure to look for changes from one year to the next. Those processes should be your area of focus and validation of readiness. Sound daunting? Not to worry, we’re here to help. Within our end-to-end Medicare Consulting Services we provide all the tools, templates, and expertise you need to help you navigate this process.

And if you were not able to plan ahead, don’t forget that your readiness review is a critical activity to avoid compliance gaps and a potential notice of non-compliance from CMS.


Remember to download the 2021 MARx Plan Monthly Calendar!


Dates & Deadlines

View/download a PDF version of the November newsletter.

Author: admind