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CMS Will Look Closely at Member Materials

The past several years, the Centers for Medicare and Medicaid Services (CMS) has levied substantial findings and penalties related to Medicare Advantage and Part D health plans’ handling of Annual Notice of Changes (ANOC), Evidence of Coverage (EOC) and provider directories.

Penalties have been levied based on CMS’ standard that there should be “no beneficiary harm” in provision of services. Dangers potentially come to the fore in member materials: inaccurate benefit and network information can mislead members and impact care decisions and health. CMS’ regulatory standard goes beyond member materials to include activities throughout member touchpoints, including timeliness of authorizations, appeals and grievances, accuracy of correspondence, and proper effectuation of authorizations, appeals, and external review decisions.

CMS will look closely at ANOCs, EOCs, and provider directories as the open enrollment season approaches this fall. Scrutiny must not be on printed materials alone, but also on the accuracy and constant updating of plan websites.

In an August 17, 2017 Health Plan Management System (HPMS) memo, CMS notes that it will look closely at ANOC and EOC timeliness and accuracy. CMS may take compliance or enforcement actions on late and inaccurate ANOCs/EOCs, failure to properly submit documents, and failure to correctly enter actual mail dates.

While self-disclosures provide some protections against CMS sanctions, errata sheets are not considered self-disclosures and CMS could levy penalties for major mistakes. In addtion, disclosure of ANOC/EOC errors is important and mandatory because CMS will conduct retrospective reviews of ANOCs/EOCs and take compliance actions for unreported errors, These would likely be harsh.

CMS outlines the ongoing requirement to:

  • Submit materials with the correct material type/code.
  • Enter actual mail dates and number of existing individuals receiving the documents in HPMS so that CMS can confirm that plans meet the regulatory guideline. This needs to be done within 15 days of the mail date.
  • Plans must review their ANOCs/EOCs and use the standardized ANOC/EOC errata model to identify and address inaccuracies that are found. Errata sheets must be submitted for review, along with the corrected ANOCs/EOCs to HPMS based on the prescribed regulatory dates (10/31/2017 or 1/15/2018, depending on the type of ANOC.EOC). As with the ANOC/EOC mailings, plans must enter the actual mail date and the number of members impacted within 15 days of the mail date.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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