Getting a Solid Grip on the 2014 CMS Application

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PROVIDING POWERFUL SOLUTIONS Getting a SOLID GRIP on the 2014 CMS APPLICATION

Welcome!

PRESENTERSWhats your Quest? Let us guide the way.Account ManagersDarren Huff, Eastern Region Darren.Huff@QuestAnalytics.com

Michelle LeCloux, Western Region Michelle.LeCloux@QuestAnalytics.com

Contact us at:920.739.4552

AGENDAReference File ChangesCounties Changing ClassificationsSpecialty Code ChangesBeneficiary ChangesMinimum Provider Count ChangesTime & Distance ChangesMedicare & Dual DemonstrationsNetwork Adequacy criteriaMA table uploads The Quest Analytics SuiteKey enhancements Answers to the testAutomate and simplify

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012Reference File CHANGESQuest Analytics

COUNTY CLASS ChangesTighter StandardsRelaxed StandardCounty SSACounty NameStateCounty Class for 2014County Class from 201303130YumaAZMetroMicro10380LibertyFLCEACRural11020BakerGACEACRural15580OrangeINMicroRural19390RapidesLAMetroMicro25120ClayMSRuralMicro33380MontgomeryNYMicroMetro44210DicksonTNMetroMicro45010AndrewsTXRuralCEAC45040ArcherTXCEACRural45880RunnelsTXRuralCEAC45980YoakumTXRuralCEAC49241Danville CityVAMicroMetro52400MonroeWIMicroRural

SPECIALTY CODE Changes

Modification of required specialty type Cardiac Surgery (009) and Thoracic Surgery (032) have been merged into a single Provider specialty, Cardiothoracic Surgery (035). Removal of required specialty type One Provider specialty has been removed from the HSD Provider Table: Oral Surgery (024). While applicants must ensure that beneficiaries have reasonable access to Medicare required oral surgery services, this specialty is no longer required to be reported to CMS on the MA Provider Table.6

BENEFICIARY ChangesWhy Do I NEED to Use the New Beneficiary FileNumber of Counties% ChangedBeneficiaries Changed in Counties303894.1%Beneficiaries Increased in Counties226470.1%Beneficiaries Decreased in Counties77323.9%Counties Remained the Same1905.9%Total Beneficiaries These values were updated to reflect the most recently published number of Medicare beneficiaries in each county. This affects the minimum number of providers and acute inpatient hospital beds criteria.7

MINIMUM PROVIDER Changes

82014 PROVIDER T/D Requirements

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012

NO CHANGESASIDE FROM THE SPECIALTY CHANGE SINCE CARDIAC SURGERY AND THORACIC SURGERY HAD THE SAME REQUIREMENTS, CARDIOTHORACIC SURGERY REMAINS THE SAME.92014 FACILITY T/D Requirements

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012

NO CHANGES10MEDICARE & DUAL DemonstrationsQuest AnalyticsNOIAs SubmittedOffering a new product type (such as a MA-PD, or Medicare-Medicaid Plan)Transitioning an existing non-or partial network PFFS to a full network PFFS Expanding the service area of an existing contract (SAE)Expanding only an employer-only service areaAdding prescription drug benefits to an existing contract for the first timeAdding Employer Group Waiver Plan (EGWP) market to an existing individualAdding individual market to an existing EGWP-only service area for the first timeAdding or expanding the service area of a Special Needs PlanPROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012The CY 2014 Medicare Advantage, Part D Prescription Drug Benefit, and Employer/Union-OnlyGroup Waiver Plan (Direct Contract or Employer Series) Initial and Service Area Expansion,Special Needs Plan Applications, and Medicare-Medicaid Plan applications will be posted on theCMS web pages and in CMS Health Plan Management System (HPMS) by January 10, 2013and will be due no later than 11:59 P.M. Eastern Time on February 21, 2013.12

Light Blue: Capitated Managed Care ModelDark Blue: Managed Fee-for-Service ModelGreen: Pursuing both modelsMaroon: Not seeking demonstrationDual Demonstration Stateshttp://dualsdemoadvocacy.org/

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012Light Blue: Capitated Managed Care Model: These states have proposed using a capitated managed care model to better align the financing of Medicare and Medicaid programs and integrate primary, acute, behavioral health and long term services and supports. This model involves a three-way contract between CMS, the state and participating health plans, in which plans would receive a prospective blended rate from Medicare and Medicaid for primary, acute, behavioral health and long-term services and supports for dual eligible beneficiaries.Dark Blue: Managed Fee-for-Service ModelThese states have proposed using a managed fee-for-service model which involves an agreement between CMS and the state in which the state would be responsible for duals care coordination to ensure integration and access to all needed Medicare and Medicaid services. The state would receive retrospective performance payments based on savings to Medicare for duals served by the state program.Green: Pursuing both modelsThese states have proposed using both the capitated managed care and managed fee-for-service models.Maroon: Not seeking demonstrationThese states are not seeking to do demonstration projects.

13States on the HOT SEAT

2014 Notice of Intent to Apply as a Medicare-Medicaid Plan through the Financial Alignment Demonstration were due on November 14th for the highlighted states on right.

CY 2014 applications will be posted on CMS website by January 10, 2013.

Applications will be due on February 21, 3013, to include a network compliant with CMS Medicare standards.

http://dualsdemoadvocacy.org/

CMS APPLICATIONQuest AnalyticsA NEW MODEL EVOLVESCMS Revamps the process to:Address geographic disparities across any statePrevent adverse selectionProvide transparency of requirementsApply consistency across plansLeverage across programs

CMS created 5 county types using population/density parameters defined on the rightLarge MetroMetroMicroRuralCounties with Extreme Access Criteria (CEAC)

COUNTY CLASS Methodology

COUNTY TYPESTwo primary adequacy criteria:Minimum number of providersMust contract with sufficient numbers of each provider specialty typeMust contract with sufficient number of each HSD facility typeMaximum Travel Time & Distance to Providers/Facilities90% of beneficiaries have access to at least one provider/facilityContracted providers are not limited to the boundaries of the county or counties as long as the provider is within the time & distance requirementADEQUACY Methodology

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 201221182014 PROVIDER T/D Requirements

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012

NO CHANGESASIDE FROM THE SPECIALTY CHANGE SINCE CARDIAC SURGERY AND THORACIC SURGERY HAD THE SAME REQUIREMENTS, CARDIOTHORACIC SURGERY REMAINS THE SAME.192014 FACILITY T/D Requirements

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012

NO CHANGES20Where can I find more DETAILS?

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012

How are you going to do this?Quest AnalyticsWill you be spending a lot of time GOOGLE MAPPING?

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012Countless hours using mapping like Google trying to determine which providers fall within the different T & D criteria.

Key TakeawaysTime savings = money (saved and revenue opportunities missed). Case study of mentioning a client that had intentions on SAE in 5 counties, but by the time they found out, in the end could only file for 1, what is the costs of lost revenue. Human error=TD; crow fly vs. driving distance/timeAccuracy=measuring stick vs. CMS, apples/apples

23Is your TIME & DISTANCE correct?All of these requirements are embedded into the Quest Suite.

24Will you end up with a MESS? All of these requirements are embedded into the Quest Suite.

25Will you be searching from the right BENEFICIARY POINTS?

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012If you are not searching from all the right beneficiary points, are you missing providers that can impact your success.26One Doc MULTIPLE COUNTIESAll of these requirements are embedded into the Quest Suite.

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012

Milwaukee CountyLM=15 MGreenCountyMI=75 MIRichland CountyRU=90 MIWaukesha CountyME=40 MI

LM=15 RedM=40, Green Micro=75, BlueRural=90,. Yellow

If you were going to expand into these 11 counties this one Dr. meets the TD requirements for all 11 counties, therefore needs to be listed on your HSD table 11 different times.

Key TakewayManual processTime spentHuman error27One Hospital MULTIPLE SERVICES

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012043044045042041050047061049040051

28Do you want to avoid CMS Errors?

29Quest Analytic SuiteTheres abetter wayto powerYOURHSD TABLES

CMS is now using the QAS to measure adequacy of MA plans and Part D plans.

CMS completely redefined the county classification standards from Urban, Suburban, Rural

To

Large metroMetroMicroRural

CMS defined time and distance standards based on those county classifications. Then they asked QA to provide them with reporting and measurement capabilities.

30PROVEN Partnership

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 20122007 CMS Partnership BEGINS with Part D2009 CMS Partnership EXPANDS to Part C2012 CMS REQUIRES Medicare Standards for Dual Demonstration Projects2013 Network Adequacy at the FOREFRONT of Qualifying and Monitoring Plans for the Exchanges

+

ADVANTAGES with Quest AnalyticsBegin testing TODAY (Released 12/12/12)Network Adequacy 24/7/365Beneficiary File EMBEDDEDT/D & Minimum Providers EMBEDDED All Counties, SSAs, & Classes EMBEDDEDGap Map ANALYSISNPI DATABASEAUTOMATE MA Tables (HSDs)PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012Latest ENHANCEMENTSSIMULTANEOUS time & distance reportingReview only SELECTED specialtiesMINIMIZE out-of-county providersUPDATED geocodingNPI DATABASEPROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012MA Provider TableThis table captures information on the specific physicians/providers in the applicants contracted network. If a provider serves beneficiaries residing in multiple counties in the service area, list the provider multiple times with the appropriate state/county code to account for each county served. Providers that have opted out of Medicare cannot be included in the applicants contracted network or on this table. MA Facility TableIf a facility offers more than one of the defined services and/or provides services in multiple counties, the facility should be listed multiple times with the appropriate SSA State/County Code and Specialty Code for each service.

CHALLENGES with the MA Tables

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012SIMPLE Solution

All you need is:ONE Record/Provider Location/Specialty

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012NO need for County or SSA Code in dataNO push pins and radius ringsNO Google/MapQuest searches

Alternate Gravity Well 35

MEDICARE ADVANTAGE MODULE

How can we help?Quest Analytics36Network Adequacy OUTPUT

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 201237GAP Analysis & Mapping

38Available PROVIDERS? Overlay NPI Providers/Targeted Recruitment

39

MA Facility/MA Provider OUTPUT

The Quest Suite will COMPLETE your MA Provider & Facility tables with all the providers in your data that fall under the criteria for the reporting county (whether they are in the county or not). The Quest Suite will POPULATEthe county codes, servicing providers, specialty crosswalk and previously listed.In addition you can export directly to TXT format and we will include the proper header row for upload to HPMS.The Quest Suite will save you a lot of time auto populating these for you.40Auto populate the data required for the MA Provider/MA Facilitator tables to be exported and sent to CMS.

GEOCODER

Quest Analytics41Geocoding & Database MANAGEMENTSame GeocodingIdentify invalid addressesStandardize addressesGeocoding OptionsPre-geocodeOn-the-flyCommand lineCity/Zip/Address Lookup

Using the Same Tools as CMS

STANDARDIZE Your DataIt all begins with data!

fix the errors before submission.

Standardizing and understanding how CMS is reading your data allows you to

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 2012ADDITIONAL RESOURCES PROVIDEDQuest Analytics44

Hospital Service Lines CHALLENGESMost Health Plans maintain a single record for each hospitalDont track services Hospitals performCreates database architecture challengesCMS requires Adequacy Standards on over 20+ servicesMost of these are performed at a Hospital

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 201245

ENHANCED Hospital TableServices providedBased on claims dataFrom claims submitted by Hospitals to CMSCross-walked & ready to leverageIncludes:NPIMCNNumber of Beds

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 201246POPULATE your data

PROVIDING POWERFUL SOLUTIONS I Since 2003 I www.QuestAnalytics.com I 920.739.4552 I 201247

Additional RES...