April 24, RE: 2017 Transformation Ideas. Dear Administrator Verma:

Transcription

1 April 24, 2017 Seema Verma Administrator Centers for Medicare & Medicaid Services Department of Health & Human Services Hubert H. Humphrey Building 200 Independence Ave., S.W. Washington, D.C RE: 2017 Transformation Ideas Dear Administrator Verma: America s Health Insurance Plans (AHIP) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) Request for Information (RFI) from the Final Announcement of Calendar Year (CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. AHIP is the national association whose members provide coverage for health care and related services. Our members offer coverage across the entire spectrum of private-sector and public programs. We are committed to market-based solutions and believe that every American deserves affordable coverage that provides them with access to high quality care. We commend CMS for soliciting ideas for using transparency, flexibility, program simplification and innovation to transform the Medicare Advantage and Part D programs for Medicare enrollees to have options that fit their individual health needs. We firmly believe such an approach by CMS to transform Medicare has significant potential to improve outcomes and quality of life for beneficiaries and reduce costs by enhancing private sector innovation and empowering beneficiaries (and the Medicare program) to obtain higher-quality, more costeffective care. We strongly encourage efforts by CMS to create policies, set goals and priorities, and find innovative administrative and structural approaches to better manage and support the Medicare Advantage (MA) and Part D programs, which continue to grow both in number of enrollees and popularity. Value of MA and Part D Programs AHIP s members are strongly committed to serving Medicare beneficiaries under the MA and Part D programs and continuing to provide cost-effective, high quality, and accessible health care. Plans are implementing patient-centered innovations that include:

2 April 24, 2017 Page 2 integrating and coordinating care for beneficiaries; mitigating the harm of chronic diseases by focusing on prevention, early detection, and care management; reducing beneficiary costs; addressing the needs of vulnerable individuals, including low-income beneficiaries; and applying clinical best practices to increase patient safety and to limit unnecessary utilization of services. Today more than 18.5 million Americans about 32 percent of all Medicare beneficiaries have chosen to enroll in the MA program, and 16.6 million of them receive drug benefits through their plan. 1 An additional 25 million Americans receive drug coverage through a stand-alone Prescription Drug Plan (PDP). Since 2010, MA enrollment has increased by 60 percent, and Part D enrollment has increased from 24 million in 2007 to over 42 million today. While average payment to MA plans is equivalent to fee-for-service (FFS) costs, MA bids are 10 percent below FFS costs and MA plans often offer additional benefits to enrollees for no additional premium. Ninety percent of beneficiaries can choose from at least five MA plans. Moreover, MA plans have proven to be more efficient than FFS in delivering access to care in an impactful manner. For example, in one study, post-acute care utilization in MA after hospital discharge was lower than FFS. 2 Readmission rates were also found to be about 13 percent to 20 percent lower than FFS. 3 Another study found that MA plans had higher rates of annual preventive care visits (53 percent vs. 33 percent in FFS). 4 Part D coverage has also been shown to reduce spending: one study found that enrollees with Part D coverage had 8 percent fewer hospital admissions, incurred 7 percent lower Medicare expenditures, and used 12 percent fewer total resources than beneficiaries without Part D coverage. 5 The Need for a New Framework Even with the demonstrated success of the MA and Part D programs, we believe fundamental changes in CMS s approach to management and oversight would further improve the programs for beneficiaries. For example, CMS can adopt policies encouraging closer collaboration with 1 CMS monthly enrollment files, April 2017, available at: Systems/Statistics-Trends-and-Reports/MCRAdvPartDEnrolData/index.html?redirect=/mcradvpartdenroldata/. 2 Huckfeldt, Peter J., Escarce, Jose J., Rabideau, Brendan, Karaca-Mandic, Pinar, Sood, Neeraj. Less intense postacute care, better outcomes for enrollees in Medicare Advantage than those in fee-for-service. Health Affairs 36(1): January Lemieux, Jeff, Sennett, Cary, Wang, Ray, Mulligan, Teresa, Bumbaugh, Jon. Hospital readmission rates in Medicare Advantage plans. American Journal of Managed Care 18(2): February Sukyung, Chung, Lesser, Lenard I., Lauderdale, Diane S. et al. Medicare annual preventive care visits: Use increased among fee-for-service patients, but many do not participate. Health Affairs 34(1): January Kaestner, Robert et al. Effects of prescription drug insurance on hospitalization and mortality: Evidence from Medicare Part D. National Bureau of Economic Research Working Paper February Available at:

3 April 24, 2017 Page 3 plans who are serving Medicare beneficiaries. As a purchaser of health care coverage for millions of individuals, CMS should be developing regulatory and sub-regulatory policies, operational elements, and implementation schedules based on meaningful dialogue that draws upon the experience and expertise of plans that interact daily with beneficiaries. CMS should also ensure that all guidance, including sub-regulatory guidance issued through Health Plan Management System (HPMS) memoranda, provides plans with sufficient lead time to provide meaningful feedback prior to implementation. Furthermore, CMS should modify policies, including meaningful difference and total beneficiary cost, that limit beneficiary choices. Whenever possible, the Agency s policies should encourage plan flexibility that allows beneficiaries to choose plans that are most responsive to their individual needs. CMS should also prioritize and align the Agency s and plans limited resources through more proactive guidance, assistance, and direct communication with CMS staff, rather than through retrospective activities like audits. AHIP s Proposed Framework Our ideas in response to the RFI are designed to promote stability, innovation, and high quality care for the beneficiaries served by the MA and Part D programs. Below we propose a new framework composed of three broad categories for CMS to approach transforming these programs: 1. Improved transparency and predictability. CMS and health plans share the same core objective: ensuring the best possible coverage for beneficiaries delivered in the most costeffective way possible. CMS should actively and meaningfully collaborate with plan policy and operational experts to achieve those goals, in the same way other purchasers (e.g., employers) partner with plans. These changes would include: using Agency resources to focus on proactively sharing information, soliciting input, and avoiding issues before they result in potential penalties and sanctions; improving the guidance process; and ensuring program changes are developed and implemented with aligned strategic priorities. See Attachment 1 for specific recommendations. 2. Enhanced beneficiary experience and choice through increased plan flexibility. Innovation is a key theme throughout our recommendations. Agency policies should support innovation over standardization where appropriate; enhance beneficiary choice and plan flexibility; promote the use of telehealth services; and ensure payment policies are aligned with broader health policy goals. In addition, CMS should consider a range of improvements for beneficiary communications and the enrollment process, including improvements to Medicare Plan Finder. See Attachment 2 for specific recommendations. 3. Reduced program complexity and regulatory burden. AHIP and the Administration agree that regulatory burdens need to be reduced. MA and Part D programs are already

4 April 24, 2017 Page 4 complex, with layers of sub-regulatory policy and operational guidance often provided on top of regulatory standards. The additional costs and complexities often do not have a clear benefit to the most important end user of the program: Medicare beneficiaries. We recommend a moratorium on new regulatory or sub-regulatory requirements that would introduce additional costs or complexities in the MA or Part D programs. Going forward, economic impact analyses should be rigorously applied to any new guidance to move toward a simpler, less costly program structure that encourages innovation and limits unnecessary burdens. Similarly, various CMS data collection and reporting requirements should be limited to those that provide clear program benefits that outweigh costs, and audit reviews should be coordinated and minimized so that they focus on essential oversight and minimize the risk of duplicative, overlapping, and unnecessarily burdensome program costs. See Attachment 3 for specific recommendations. Please note that our RFI response focuses on critical structural issues and certain key policies and administrative practices. Where appropriate, we identify legal bases supporting CMS authority to implement such changes. Our response is not intended to present the entire range of policy and technical improvements we believe are needed in the MA and Part D programs. We believe certain legislative and other changes would provide additional flexibility and ensure parity among the MA and FFS programs. For example, allowing MA plans to be designated as Advanced Alternative Payment Models under new rules pursuant to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules will allow network providers to be properly incentivized to continue focusing on the delivery of high value care. In addition, addressing the policy of capping county benchmark rates at the pre-affordable Care Act (ACA) levels would strengthen the fundamental goal of the Star Ratings program to encourage continued quality improvement. Accordingly, AHIP and our members appreciate the opportunity to continue our engagement with CMS on these issues, providing a comprehensive group of suggestions and supporting data, and supporting CMS with additional information as we work together to improve the health of the beneficiaries our members serve. Again, we commend CMS for soliciting ideas through the RFI to transform the MA and Part D programs. We strongly support the Agency s efforts to build upon the current success of MA and Part D and look forward to working with you to improve these important programs to provide better care, better outcomes, and lower costs for Medicare beneficiaries. Sincerely, Marilyn B. Tavenner President and CEO

5 Attachment 1 Improving Transparency and Predictability Adopt a collaborative development process for critical payment issues Risk Adjustment Model CMS uses a closed process for developing and updating the risk adjustment model, with a limited comment opportunity that often occurs after substantial resources have been devoted toward changes in the model. Organize a task force with plans that has regular discussions (e.g., on a monthly or quarterly basis) on critical payment issues such as the risk adjustment model to enable meaningful dialogue, which may include: Approach and methods for making clinical updates and potential improvements to the existing model, Potential methodology for calibrating the risk adjustment model using encounter data, and Implementation of the risk adjustment provisions in the 21 st Century Cures Act. Implement full transparency around payment methodologies Explanation of Payment Methodology While the advance and final rate notices provides certain information about the rate development process, key details about the methodology including the growth rate, repricing, and various other adjustments are missing from the notices, which limits the ability of plans to assess the methodology. Additionally, the rate notices include reference to written guidance that is often difficult to interpret. As another example, CMS developed a new payment methodology for employer group plans without working with plans to identify alternative approaches that would minimize the potential impact on retirees. Include numerical examples and detailed methodologies, illustrated using step-bystep calculations, in explanations in the advance and final rate notices and CMS responses to plan questions on the methodology used to develop rates. Establish an ongoing dialogue with plans on methods to improve the clarity of CMS distributed materials, guidance and regulations. Notice of Payment Changes Changes in payment methodologies described in the advance rate notice do not include an estimate of the impact on county benchmark rates. Similarly, plans have not regularly been provided with impact analyses of risk adjustment model changes as part of comment opportunities. This limits the ability of plans to provide constructive comments and can create uncertainty during the annual bidding process, potentially leading to higher bids. Provide information on the potential impact of policy changes at the county level, such as the Average Geographic Adjustment Factor, with the advance rate notice. Provide each plan with data on the potential impact of other significant payment methodology changes, such as changes to the risk adjustment model, with the advance rate notice. Release proposed changes before the advance rate notice so that plans have adequate time to analyze the impacts (e.g., fall of 2017 for 2019 rates). 5

6 Attachment 1 Improving Transparency and Predictability Implement full transparency around payment methodologies (cont.) RADV Coding Guidelines CMS has developed detailed coding guidelines for the Risk Adjustment Data Validation (RADV) audit process. Though we understand that these guidelines are used by CMS staff and contractors to evaluate whether beneficiary medical records support diagnoses submitted for risk adjustment, CMS has not provided the guidelines to plans. This limits the ability of plans to determine whether coding practices used by their contracted network physicians comply with CMS standards. Publicly release the coding guidelines used in RADV audits to evaluate enrollee medical records for risk adjustment purposes. Enhance CMS process for significant and persistent data issues Encounter Data Process & Substance There are documented operational and systems issues affecting the acceptance and processing of encounter data for risk adjustment purposes. However, no intensive work group or other process to collaborate on encounter data system problems has been implemented at this time. This prevents plans from having clarity on the potential negative impacts of using encounter data to determine risk scores and causes a high degree of uncertainty in the bid development process as well as regular business and financial operations. Further, CMS has implemented monthly user group calls on encounter data, but information about system problems and fixes is not broadly shared through those calls or via other means, and our understanding is the calls do not solicit feedback or dialogue from plans. This prevents sponsors from learning about errors that may affect their companies and/or leading to duplicative remediation activities. CMS should work with plans to determine adjustments needed due to unresolved operational issues. CMS should not impose new requirements affecting payment until CMS can certify that critical operational issues have been fully resolved, consistent with Government Accountability Office (GAO) recommendations on encounter data. During the implementation of significant new payment initiatives with operational components, such as encounter data, CMS should work with plans to: Create a CMS/plan SWAT team in response to reports of widespread problems to prioritize issues and develop solutions, including creation of a list of solution milestones that must be met before CMS proceeds. Provide regular and accurate updates (e.g., on encounter data claim submissions and analyses) to plans that are both timely and accurate with respect to key data (e.g., risk scores under the encounter data program). Disseminate broadly to plans all identified problems and appropriate fixes. Modify the user group process so that it includes plan feedback on agenda items, and provide timely responses during or after calls to plans on questions and action items. 6

7 Attachment 1 Improving Transparency and Predictability Develop with plans a long term strategic plan for adoption and retirement of Star Ratings program measures Strategic Plan On an annual basis, CMS proposes changes to Star Ratings measures and other components of the program. In recent years, these proposals have often been published with a short comment period in the Fall and are re-published in the draft Call Letter. Such proposals are otherwise not published outside of the Call Letter process. While CMS announces the adoption and retirement of particular measures in the Call Letter, these changes are not reflected within a CMS strategic plan. Lack of clarity around the criteria used to adopt and retire Star Rating measures leads to uncertainty around programmatic goals; long-term strategy for adoption, removal, and maintenance of measures; alignment of internal quality improvement efforts with those of CMS; and assessments of programmatic needs and impacts. Hold meetings with plans and other relevant stakeholders to discuss issues and solutions around the Star Ratings program. Work alongside plans and other relevant stakeholders to develop a multiyear strategic plan and framework for the Star Ratings program that provides a longterm guide for: Articulating the goals in a clear and concise statement; Adopting, maintaining, and retiring measures in the Star Ratings program; Determining which measures are most appropriate for quality; Assessing the reporting and other burdens of individual and collective measures on providers, plans and other stakeholders; and Assessing the impact of frequent changes of measure composition, specification, and thresholds on the ability of plans to design quality improvement programs. Retrospective Changes to Star Measures Changes to Star Ratings measures are sometimes implemented retroactively. In other words, the initial measurement period for collecting data pre-dates the change, preventing plans from working with providers in a predictable and meaningful way. Only make prospective changes to the Star Ratings program well in advance of the measurement period, and only after holding meaningful and timely discussions with plans. Adjusting for SES CMS has implemented the Categorical Adjustment Index (CAI), but a long-term solution has yet to be created to address deficiencies of the Star Ratings program for plans serving a high proportion of low-income or disabled beneficiaries. Create a task force to determine the approach and methods for permanently adjusting Star Ratings measures for socioeconomic status. Alignment of Star Ratings with Overall HHS Efforts Star Ratings program measures appear to be developed solely within the context of the MA and Part D programs without clear alignment with other CMS and Department of Health and Human Services (HHS) efforts to develop core quality measures and to harmonize these measures across programs. Develop an intra-agency process to ensure the strategic plan for the Star Ratings Program, including its goals and framework, align with other CMS and HHS activities on quality measurement and performance improvement. 7

8 Attachment 1 Improving Transparency and Predictability Adopt a more timely, consistent, and transparent guidance process Timing of Requirements & Guidance CMS has imposed effective dates for new requirements that require system development or other operational changes before providing sponsors with the detailed information necessary to accurately estimate implementation costs and timelines. This can have adverse impacts, including: preventing plans from determining appropriate costs to include in annual bids; requiring plans to delay critical IT upgrades and other changes for existing compliance requirements; and creating pressure for implementation delays, which results in inefficiencies. A recent example is the attempted implementation of prescriber enrollment requirements in Part D, the deadline for which has had to be delayed multiple times due to the absence of comprehensive policy and operational guidance from CMS that would enable systems development and other changes to take place. Another example is the Social Security Number Removal Initiative (SSNRI), which has an approaching effective date and plans are in need of guidance. Adopt policy such that the effective date for any new requirement with significant operational components would be no less than 12 to 18 months after all forms, documents, templates, and other information is provided to plans. This would allow plans to accurately estimate the costs and establish systems requirements and process changes without potential adverse impacts on other aspects of the program. Updates of CMS Manual Chapters In certain instances, CMS has released updated manual chapters without highlighting changes, making it difficult for plans to ensure they have identified all new requirements and creating the risk of inadvertent compliance violations. Update manual chapters on the same cycle, clearly identify any changes, and provide an opportunity for plans to comment. Release of Guidance CMS guidance is not released in a uniform manner. In certain instances, CMS and its contractors provide guidance on various topics, such as submitting and processing encounter data, in multiple locations. Because there is not one central document or resource, it can be difficult to find and track guidance, and this causes confusion on a wide range of policy and operational issues. There are also instances when new policies and requirements are released via HPMS memos and slide decks. In some instances, it appears CMS s contractors have released policy guidance to plans and it is treated as official guidance. Clearly indicate which documents of record contain guidance and supersede prior guidance found in other documents. Consolidate guidance, particularly on major initiatives with substantial operational components like the encounter data system, in one, easily accessible, online location to prevent duplication and confusion. Establish clear and limited sources of new policy and operational requirements. Ensure that all policy guidance is released by CMS and not its contractors. 8

9 Attachment 1 Improving Transparency and Predictability Adopt a more timely, consistent, and transparent guidance process (cont.) Appeals and Grievances Guidance and Process CMS has comprehensive manual chapters that establish rules relating to organization determinations, grievances, and appeals. However, the application of these rules is not always clear. For example, plans must determine whether an enrollee complaint triggers appeals procedures, grievance procedures, or both. Deciding how to categorize a particular complaint can often be unclear based on the facts. This can lead to disputes (e.g., in subsequent audits) about whether a plan resolved a complaint or dispute through the appropriate procedure. Separate state and CMS reporting and process requirements continue to exist for appeals and grievances within otherwise integrated programs. These redundancies create confusion for beneficiaries and caregivers, and result in decreased efficiency and increased administrative burden for plans such as dual eligible Special Needs Plans (D- SNPs). Create a collaborative process for CMS to receive input from plans and address guidance requirements that are overly complex and/or unclear. We recommend that CMS begin with appeals and grievance requirements. Continue and expand CMS efforts to align Medicare and Medicaid processes and timeframes for appeals and grievances across the two programs. Mailboxes & Staff Contact CMS requires responses to questions for a number of matters, including those relating to the risk adjustment model and encounter data systems, be submitted by to a general mailbox. Questions are not always answered in a timely fashion which can discourage use of the mailbox and lead to considerable uncertainty about policy and operational issues. Replace the current system of using a mailbox to address technical questions on important issues like the risk adjustment model with CMS staff names and contact information of who would be responsible for these inquiries. Implement a tracking and monitoring system to ensure timely and complete responses to questions. 9

10 Attachment 2 Enhancing Beneficiary Choices and Experience Significantly improve the process for beneficiaries to choose program options Medicare Enrollment When first enrolling in Medicare, individuals are not required to make an active choice between FFS Medicare and MA. Beneficiaries who do not make an active choice are auto-enrolled in FFS Medicare. Require individuals to make an active selection into MA or FFS when first enrolling in Medicare. Medicare Plan Finder The Medicare Plan Finder (MPF) allows Medicare beneficiaries to compare MA and Part D options where they reside, but the site still remains difficult for beneficiaries and family members to navigate. Create a task force comprised of CMS staff, plans, beneficiary advocates, providers, and other stakeholders to consider ways to improve the MPF or develop alternatives. Welcome to Medicare Materials The package of information CMS sends to individuals at the beginning of their initial enrollment period, including a Welcome to Medicare letter and booklet, may not be easily understandable or provide clear information about the program and beneficiary choices. Convene a task force to review and implement changes to these materials to make it easier for enrollees to understand their options. FFS Quality The Star Ratings program only applies to MA plans which makes it difficult for beneficiaries to compare MA plans with FFS. Develop a comparable quality metrics system for Medicare FFS that will enable beneficiaries to compare MA plans with the FFS option. 10

11 Attachment 2 Enhancing Beneficiary Choices and Experience Expand plan benefit flexibility Definition of Supplemental Benefits Current definition limits supplemental benefits coverage to items or services that CMS considers to be health related. Expand the scope of health related services to include a range of assistive devices, items and services that can help beneficiaries compensate for physical impairments, diminish the impacts of an illness or injury, and enhance quality of life and/or reduce other costs. Uniform Benefit Structure CMS has interpreted Section 1852(d)(1)(A) and Section 1860D 2(a) (and applicable regulations) to require plans to offer benefits uniformly to all enrollees residing in the service area of the plan. This interpretation is restrictive and prevents plans from offering additional benefits tailored to meet the care and needs of enrollees based on health status or other enrollee characteristics. Adopt an interpretation that is more expansive and allow plans to structure enrollee cost-sharing and other services to encourage enrollees with particular clinical conditions to consume high-value clinical services, as long as each person who meets the criteria has access to the same benefit. We believe this is a reasonable and appropriate application of the uniformity requirement. Telehealth In general, MA plans include the costs of providing basic Medicare benefits in their bids. Costs for supplemental benefits are separately identified and are financed through rebates and/or beneficiary premiums. CMS has interpreted the provisions of Section 1852(a)(1) to include in the basic benefit costs associated with telehealth services only to the extent they would be covered under the FFS program. Because coverage of telehealth services is extremely limited in FFS, this interpretation has limited the ability of many plans to adopt innovative telehealth services. Adopt an interpretation of basic benefits that is more expansive in the case of telehealth services. The statutory scope of Part B benefits under Section 1832 and the statutory definitions of covered services under Section 1861 do not specify limits on the use of telehealth for MA. Also, existing regulations at 42 C.F.R (b) give CMS specific authority to issue regulations or instructions for MA that supersede general coverage guidelines for FFS. Accordingly, CMS should permit the use of telehealth as a mode of delivering basic health care benefits. Allow diagnoses from telehealth encounters to be counted for risk adjustment purposes, which would further reflect the evolution in delivery of health care. Meaningful Difference CMS applies a meaningful difference test for determining whether a sponsor can offer an additional option in a given service area. The test is exclusively a CMS requirement; it is not mandated by statute. It limits the number of plan offerings and beneficiary choices. It also does not recognize provider networks and premiums as elements constituting meaningful differences, yet these are extremely important factors for beneficiaries in making enrollment decisions. Eliminate the meaningful difference requirement to allow market competition to determine the appropriate number and types of plan options. Alternatively, if the meaningful difference standard is retained, revise it to allow plans to be treated as meaningfully different based on provider network and/or premiums differences. 11

12 Attachment 2 Enhancing Beneficiary Choices and Experience Increased beneficiary choices Total Beneficiary Cost (TBC) Section 1854(a)(5)(C)(ii) allows, but does not require, CMS to deny a bid based on the increase in cost-sharing or decrease in benefits from one plan year to the next. CMS has developed the Total Beneficiary Cost (TBC) metric as a means of determining whether to deny a bid based on a change in costsharing or benefits. The TBC restricts innovation and does not allow for needed flexibility on plan offerings, which would increase choice for consumers. Eliminate the TBC requirement to allow market competition to determine the number and types of plan options. Margin Requirement CMS has developed a bid requirement that the margin for a plan be within 1.5 percentage points of margins from other lines of business (e.g., commercial). This requirement, which is not imposed by statute, inhibits plans ability to innovate and interferes with allowing market competition to determine bids. In addition, the Medical Loss Ratio requirement ensures that margin requirements will not be unnecessarily large. Eliminate the margin requirement or provide more flexibility to promote choice. Benchmark Cap There is broad agreement that the pre-aca benchmark cap prevents high performing plans from receiving incentives to enhance benefits for enrollees. However, CMS indicated in the final rate notice that it has not identified any authority under which it can exclude quality bonus payments from the application of the benchmark cap. Borrow from practices used by innovative private sector companies by actively soliciting proposals for legal analyses of the statute that will permit such interpretation. Network Adequacy CMS requires that each plan meet network adequacy requirements based on time and distance standards. While CMS permits certain exceptions, the Agency does not allow plans to demonstrate an exception that will encourage the use of higher value providers and CMS relies upon provider data that may not be current. Plans are also not permitted to comply with network adequacy standards using telehealth services even if such services are commonly used or present a significant innovation that can improve beneficiary access or health and/or reduce premium costs. This approach is limiting the ability of beneficiaries to have choices of finding plans that fit their individual needs. Update network adequacy exception criteria to include considerations around the use of high-value networks and telehealth, so that market competition can allow innovation and expanded options for beneficiaries. Allow D-SNPs to meet network adequacy requirements with respect to the numbers and residence locations of dual eligible beneficiaries in the proposed service area. 12

13 Attachment 2 Enhancing Beneficiary Choices and Experience Improve beneficiary communications ANOC and EOC Plan experience and feedback from members indicate that the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) model documents are too long (over 200 pages), difficult to understand, and not easily searchable. Create a task force comprised of CMS staff, representatives from the plans, and beneficiary and provider advocacy groups to develop ideas to improve the document readability and length and to create electronic versions that are easily searchable and prioritize the information that beneficiaries desire. Provide plans with flexibility in how they make the ANOC/EOC available to enrollees. For example, allow plans to ask members via a separate notice if they would like to receive their ANOC/EOC via mail or electronically only (similar to the process for disseminating provider directories). Encourage continuity of care Duals Special Enrollment Provision CMS rules under 42 CFR provide that dual eligible enrollees are exempt from the Medicare annual election period and have an ongoing special election period, enabling them to change Medicare plans or move between MA and FFS programs at the beginning of each month. This prevents plans, especially integrated plans, from engaging with new dual eligible enrollees to develop positive relationships with their assigned care manager, conduct enrollee needs assessments, implement plans of care and services covered by Medicare and Medicaid, and address immediate health and service needs. Modify the monthly special enrollment provision for dual eligible beneficiaries to require at least a three-month enrollment period. 13

14 Attachment 3 Reducing Regulatory Burden Rigorously apply cost/benefit analyses to simplify the programs and reduce unnecessary costs Burden Estimates CMS develops economic impact analyses for regulatory changes and burden estimates for new or revised sub-regulatory data collection requirements pursuant to the Paperwork Reduction Act (PRA). However, the plan experience is that actual costs are typically much higher than estimated. This prevents decision makers from assessing the full impact of policy changes and may impose significant new complexities and costs that ultimately would affect beneficiaries through premiums and benefits. CMS should also ensure that sensitive competitive information is not publicly released. In addition, CMS has released a significant number of new requirements through subregulatory guidance that do not have economic impact analyses or burden estimates. Impose a moratorium on any new regulatory or sub-regulatory requirements that would impose additional burdens or complexities on the MA or Part D programs. Create a task force with CMS and plan stakeholders to improve economic impact analyses and other burden estimates. Develop and provide an opportunity for notice and comment on economic impact analyses for guidance, particularly when the economic impacts may be substantial. Guidance with substantial economic impacts must be approved in advance by the Office of Management and Budget (OMB). Reconsider publicly releasing data that is competitive and limits plans negotiation abilities (e.g., bid data). Prescriber & Provider Enrollment CMS has issued regulations that require prescriber enrollment in Medicare for Part D and provider enrollment requirements for Part C, to be effective January 1, However, an analysis of the benefit of such requirements compared to their costs, including implementing edits at point of sale in Part D, or the potential impacts on network adequacy in Part C, has not been provided. Eliminate the prescriber enrollment requirement for Part D and the provider enrollment requirement for Part C, including CMS efforts to implement a phased-in plan as part of the provider enrollment delay. Reporting Requirements In some instances, CMS has imposed Part C and D reporting requirements without a clear explanation of how and why the data are needed, and whether the benefits of such collection outweigh additional costs which can result in increased bids, reduced benefits, and higher premiums for enrollees. Eliminate reporting requirements (and do not add any additional reporting requirements) except to the extent: CMS explains the intended uses and benefits of such data collection for the MA or Part D programs; For existing requirements, CMS annually publishes information on how the data collection is being used; CMS certifies the benefits outweigh program costs for the data collection, including plan costs in compiling and submitting the data; and CMS further certifies it has no other source for the requested data (such as encounter data reports or prescription drug event reports). 14

15 Attachment 3 Reducing Regulatory Burden Implement a more coordinated and cost effective monitoring process Volume of Audits Plans report that the volume and types of audits have increased significantly in recent years. For example, last year CMS announced the creation of new targeted audits relating to provider directories and appeals timeliness audits. These audits will be conducted in addition to existing audits covering a range of compliance topics, as well as audits relating to bidding, risk adjustment validation, etc. Moreover, plans have already experienced multiple audits taking place simultaneously, resulting in a significant drain on plan personnel and added costs that can adversely affect plan operations. Do not subject an MA or PDP contract to more than one compliance audit within a reasonable time period of a prior compliance audit. Do not add any additional audits outside this timeline except for a targeted audit that is based on credible evidence of the potential substantial beneficiary harm. Coordinate all audits of plans across CMS divisions to ensure that contracts are not undergoing simultaneous or back-to-back audits, and that the same information is not collected multiple times. Work collaboratively with plans and providers to better educate and incentivize providers to update provider directory data on a timely basis. Impact Analyses of Audits CMS has developed new audit/monitoring initiatives without publishing economic impact analyses comparing the potential costs and benefits of the initiatives and alternative monitoring approaches. Develop, and provide an opportunity for notice and comment on, economic impact analyses for audit initiatives. Such analyses should include clear explanations of the purposes for each audit, along with the costs, benefits and rationale for each audit and alternative approaches. Lead time of Oversight In some instances, CMS announces new routine audits without sufficient lead time, causing potentially significant resource and cost impacts on plan sponsors. Also, audit protocols are not finalized with sufficient lead time to allow plans to implement any changes to their systems and programming. CMS may ask for information outside the audit process and provide short response times. Proactively inform plans what audits it intends to conduct well in advance, e.g., at the beginning of the year. Provide any changes to audit protocols for public comment and finalize well in advance of the audit year. Make other information requests within reasonable timelines. 15