The Centers for Medicare and Medicaid Services' Final Rule for Medicare Contract Year 2019 is now in effect as of June 15, 2018. The ruling makes annual program refinements to Medicare Advantage and Part D benefit programs and incorporates specific requirements from the Comprehensive Addiction and Recovery Act of 2016.
This year's changes, announced in April, put a significant emphasis on customer experience and reflect some attention-grabbing updates to the stop-loss requirements initially specified in the Provider Incentive Plan (PIP) Regulations and discussed in our first paper for the Research and Insights section of our website.
Patient experience rules are changing to allow beneficiaries additional plan-switching periods if the plan they chose in the Fall doesn’t meet their expectations in the Spring. In addition, Access and Experience ratings will see a boost in their importance to Star ratings. Clearly, value means getting what you signed up for! Read more in the Gorman Health Group article.
The stop-loss tables, which are integrated into the PIP regulations, specify the attachment points and deductible structure available to provider groups participating in reinsurance programs based on aggregate panel size. The Final Rule updates to these requirements are based on the assertion by
CMS that medical cost increases and changes in utilization since adoption of the current rule raised concerns that "the current regulation is more conservative and more expensive than is necessary” (p. 16,679). CMS further states its interest to provide more flexibility in the stop-loss regulations, taking into account smaller panel sizes and offering simpler combined or split category reinsurance product choices.
In addition to adding this flexibility for PIP contract compliance with stop-loss requirements, the regulators have moved the tabular presentation out of the regulation itself and left only the approved methodology for updating the requirements calculation. This separation will simplify future changes by making the maintenance of the actuarial calculations the responsibility of the Call Letter development process and not require modification of the Federal Register at each technical update.
More exciting is the discussion of the eligibility of including non-risk populations in the pooling requirements for stop loss. “We are finalizing amendments to § 422.208 to permit use of the non-risk patient panel size in identifying the required stop-loss protection in paragraph (f)(2)(iii)” they write on page 16,685. This section (see below) is worth reviewing with your counselors as you design procedures to administer 2019 PIP programs and review your current arrangements.
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Overall Member
What is an Active Member?
An active member in AccuReports® is any member who is present in the most recent month of a plan data set. All plan data sets reflect a paid-through date. Active members will be those individuals eligible on the first of the month of the paid-through date. For example, data issued in July with a paid through date of June 30th will show all members who were eligible as of June 1 marked as active.A member who is present in a plan data set but is not eligible in the most recent month is considered an inactive member.
The purpose of the distinction is simple: active members are the most likely to respond to an appointment invitation.Users can filter all dashboards by active members by clicking on the "Show Active Members" button in the Dashboard Filters area.
Users can also isolate active members using the Active field's filter box.
A member who is present in a plan data set but is not eligible in the most recent month is considered an inactive member.