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The CMS Final Rule: Improving Member Experience

The CMS Final Rule: Improving Member Experience

Over the past few weeks, we’ve seen and discussed a few changes that CMS released for 2019. For starters, Medicare Advantage plans now have much-improved flexibility for adding benefits like transportation, telehealth, and groceries.

Additionally, you may have heard about the new OEP (Open Enrollment Period) that will run from January 1 through March 31 and will allow beneficiaries to change plans if what they selected during AEP really doesn’t work for them. All of these changes mean that members will now have access to nutrition and home health benefits that they didn’t have before and will be able to “try out” plans with the ability to change after just a few months if necessary.

Now, CMS has released the “Final Rule.” CMS is expecting the rule to lead to $295 million in savings for the Medicare program over the next five years. It comprises of both administrative and care-oriented changes.

Care Changes

  • Reduce opioid misuse by allowing Part D sponsors to prevent at-risk beneficiaries from receiving coverage for opioids.
  • Prevent those who are automatically enrolled from entering a plan with a star rating of less than 3 when a better option is available
  • Offer more choices to beneficiaries
  • States now have more flexibility in determining the required Essential Health Benefits
  • Those with an SEP as a result of LIS or dual eligibility can now only change once per quarter within the first nine months of the year to prevent constant plan changes and help prevent opioid abuse.

Administrative Changes

  • Allow innovative approaches to improving “program quality, accessibility, and affordability”
  • Clarify program requirements regarding appeal rights & premium adjustments
  • Streamline paperwork processes to improve efficiency
  • Evidence of Coverage and other beneficiary documents can now be submitted electronically
  • The definition of marketing materials has been changed to “only materials that are most likely to lead to a beneficiary to make an enrollment decision.”

You’ll notice that all together, these changes are designed to improve the overall member experience. The happier the members are, the more likely they are to keep turning to you as their agent, and the less likely they are to complain to CMS. Everybody wins!