Getting a Solid Grip on the 2014 CMS Application

P R O V I D I N G P O W E R F U L S O L U T I O N S

Getting a SOLID GRIP on the 2014 CMS APPLICATIONWelcome!

PRESENTERSWhat’s your Quest? Let us guide the way.

Account Managers

Darren Huff, Eastern Region [email protected]

Michelle LeCloux, Western Region

[email protected]

Contact us at:

920.739.4552

mailto:[email protected]


AGENDA

Reference File Changes Counties Changing Classifications Specialty Code Changes Beneficiary Changes Minimum Provider Count Changes Time & Distance Changes

Medicare & Dual Demonstrations Network Adequacy criteria MA table uploads

The Quest Analytics Suite™ Key enhancements Answers to the test Automate and simplify

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

http://www.QuestAnalytics.com/

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Reference File CHANGES

COUNTY CLASS Changes

Tighter Standards Relaxed StandardCounty SSA County Name State County Class for 2014 County Class from 201303130 Yuma AZ Metro Micro10380 Liberty FL CEAC Rural11020 Baker GA CEAC Rural15580 Orange IN Micro Rural19390 Rapides LA Metro Micro25120 Clay MS Rural Micro33380 Montgomery NY Micro Metro44210 Dickson TN Metro Micro45010 Andrews TX Rural CEAC45040 Archer TX CEAC Rural45880 Runnels TX Rural CEAC45980 Yoakum TX Rural CEAC49241 Danville City VA Micro Metro52400 Monroe WI Micro Rural

SPECIALTY CODE Changes

CMS Code Specialty CHANGE024 Oral & Maxillofacial Surgery ELIMINATED009 Cardiac Surgery COMBINED WITH 009032 Thoracic Surgery COMBINED WITH 032035 Cardiothoracic Surgery NEW-Combination of 009 & 032

BENEFICIARY Changes

Why Do I NEED to Use the New Beneficiary File

Number of Counties % Changed

Beneficiaries Changed in Counties 3038 94.1%

Beneficiaries Increased in Counties 2264 70.1%

Beneficiaries Decreased in Counties 773 23.9%

Counties Remained the Same 190 5.9%

MINIMUM PROVIDER Changes

Number of Counties % ChangedCounties That Changed Number of Required Beds 916 28.4%Counties That Changed Minimum Number of Providers 321 9.9%

Beneficiary Count Changes -> Minimum Provider Changes

2014 PROVIDER T/D Requirements


Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

001 General Practice002 Family Practice003 Internal Medicine004 Geriatrics005 Primary Care - Physician 006 Primary Care - Nurse S03 Primary Care 10 5 15 10 30 20 40 30 70 60007 Allergy and Immunology 30 15 45 30 80 60 90 75 125 110008 Cardiology 20 10 30 20 50 35 75 60 95 85010 Chiropractor 30 15 45 30 80 60 90 75 125 110011 Dermatology 20 10 45 30 60 45 75 60 110 100012 Endocrinology 30 15 60 40 100 75 110 90 145 130013 ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110014 Gastroenterology 20 10 45 30 60 45 75 60 110 100015 General Surgery 20 10 30 20 50 35 75 60 95 85016 Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110017 Infectious Diseases 30 15 60 40 100 75 110 90 145 130018 Nephrology 30 15 45 30 80 60 90 75 125 110019 Neurology 20 10 45 30 60 45 75 60 110 100020 Neurosurgery 30 15 60 40 100 75 110 90 145 130021 Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100022 Oncology - Radiation/Radiation Oncology30 15 60 40 100 75 110 90 145 130023 Ophthalmology 20 10 30 20 50 35 75 60 95 85025 Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85026 Physiatry, Rehabilitative Medicine30 15 45 30 80 60 90 75 125 110027 Plastic Surgery 30 15 60 40 100 75 110 90 145 130028 Podiatry 20 10 45 30 60 45 75 60 110 100029 Psychiatry 20 10 45 30 60 45 75 60 110 100030 Pulmonology 20 10 45 30 60 45 75 60 110 100031 Rheumatology 30 15 60 40 100 75 110 90 145 130033 Urology 20 10 45 30 60 45 75 60 110 100034 Vascular Surgery 30 15 60 40 100 75 110 90 145 130035 Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130

2014 Provider Time and Distance Requirements

Metro Micro RuralSpecialty

Geographic TypeCEACLarge Metro

CMS Code


2014 FACILITY T/D Requirements


Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)040 Acute Inpatient Hospitals 12.2 20 10 12.2 45 30 12.2 80 60 12.2 75 60 12.2 110 100041 Cardiac Surgery Program NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140042 Cardiac Catheterization Services NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140043 Critical Care Services – Intensive Care Units (ICU) NA 20 10 NA 45 30 NA 160 120 NA 145 120 NA 155 140044 Outpatient Dialysis NA 20 10 NA 45 30 NA 65 50 NA 55 50 NA 100 90045 Surgical Services (Outpatient or ASC) NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100046 Skilled Nursing Facilities NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 95 85047 Diagnostic Radiology NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100048 Mammography NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100049 Physical Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100050 Occupational Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100051 Speech Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100052 Inpatient Psychiatric Facility Services NA 30 15 NA 70 45 NA 100 75 NA 90 75 NA 155 140054 Orthotics and Prosthetics NA 30 15 NA 45 30 NA 160 120 NA 145 120 NA 155 140055 Home Health NA NA NA NA NA056 Durable Medical Equipment NA NA NA NA NA057 Outpatient Infusion/Chemotherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100061 Heart Transplant Program NA NA NA NA NA062 Heart/Lung Transplant NA NA NA NA NA064 Kidney Transplant Program NA NA NA NA NA065 Liver Transplant Program NA NA NA NA NA066 Lung Transplant Program NA NA NA NA NA067 Pancreas Transplant Program NA NA NA NA NA


Specialty

Geographic TypeMicro Rural CEACLarge Metro Metro

CMS Code


Quest Analytics

MEDICARE & DUAL Demonstrations


NOIA’s Submitted

Offering 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 area Adding prescription drug benefits to an existing contract for the

first time Adding Employer Group Waiver Plan (EGWP) market to an existing

individual Adding individual market to an existing EGWP-only service area for

the first time Adding or expanding the service area of a Special Needs Plan


Light Blue: Capitated Managed Care Model

Dark Blue: Managed Fee-for-Service Model

Green: Pursuing both models

Maroon: Not seeking demonstration

Dual Demonstration States

http://dualsdemoadvocacy.org/





States 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.




Quest Analytics

CMS APPLICATION

A NEW MODEL EVOLVES

CMS Revamps the process to:

1. Address geographic disparities across any state

2. Prevent adverse selection

3. Provide transparency of requirements

4. Apply consistency across plans

5. Leverage across programs

CMS created 5 county types using population/density parameters defined on the right Large Metro Metro Micro Rural Counties with

Extreme Access Criteria (CEAC)

COUNTY CLASS Methodology

COUNTY TYPES

Two primary adequacy criteria:

Minimum number of providers Must contract with sufficient numbers of each provider specialty

type Must contract with sufficient number of each HSD facility type

Maximum Travel Time & Distance to Providers/Facilities 90% of beneficiaries have access to at least one provider/facility Contracted providers are not limited to the boundaries of the

county or counties as long as the provider is within the time & distance requirement

ADEQUACY Methodology


21


2014 PROVIDER T/D Requirements


Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

Time(minutes)

Distance(miles)

001 General Practice002 Family Practice003 Internal Medicine004 Geriatrics005 Primary Care - Physician 006 Primary Care - Nurse S03 Primary Care 10 5 15 10 30 20 40 30 70 60007 Allergy and Immunology 30 15 45 30 80 60 90 75 125 110008 Cardiology 20 10 30 20 50 35 75 60 95 85010 Chiropractor 30 15 45 30 80 60 90 75 125 110011 Dermatology 20 10 45 30 60 45 75 60 110 100012 Endocrinology 30 15 60 40 100 75 110 90 145 130013 ENT/Otolaryngology 30 15 45 30 80 60 90 75 125 110014 Gastroenterology 20 10 45 30 60 45 75 60 110 100015 General Surgery 20 10 30 20 50 35 75 60 95 85016 Gynecology, OB/GYN 30 15 45 30 80 60 90 75 125 110017 Infectious Diseases 30 15 60 40 100 75 110 90 145 130018 Nephrology 30 15 45 30 80 60 90 75 125 110019 Neurology 20 10 45 30 60 45 75 60 110 100020 Neurosurgery 30 15 60 40 100 75 110 90 145 130021 Oncology - Medical, Surgical 20 10 45 30 60 45 75 60 110 100022 Oncology - Radiation/Radiation Oncology30 15 60 40 100 75 110 90 145 130023 Ophthalmology 20 10 30 20 50 35 75 60 95 85025 Orthopedic Surgery 20 10 30 20 50 35 75 60 95 85026 Physiatry, Rehabilitative Medicine30 15 45 30 80 60 90 75 125 110027 Plastic Surgery 30 15 60 40 100 75 110 90 145 130028 Podiatry 20 10 45 30 60 45 75 60 110 100029 Psychiatry 20 10 45 30 60 45 75 60 110 100030 Pulmonology 20 10 45 30 60 45 75 60 110 100031 Rheumatology 30 15 60 40 100 75 110 90 145 130033 Urology 20 10 45 30 60 45 75 60 110 100034 Vascular Surgery 30 15 60 40 100 75 110 90 145 130035 Cardiothoracic Surgery 30 15 60 40 100 75 110 90 145 130


Metro Micro RuralSpecialty

Geographic TypeCEACLarge Metro

CMS Code


2014 FACILITY T/D Requirements


Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)Number/1,000

Maximum Time

(minutes)

Maximum Distance

(miles)040 Acute Inpatient Hospitals 12.2 20 10 12.2 45 30 12.2 80 60 12.2 75 60 12.2 110 100041 Cardiac Surgery Program NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140042 Cardiac Catheterization Services NA 30 15 NA 60 40 NA 160 120 NA 145 120 NA 155 140043 Critical Care Services – Intensive Care Units (ICU) NA 20 10 NA 45 30 NA 160 120 NA 145 120 NA 155 140044 Outpatient Dialysis NA 20 10 NA 45 30 NA 65 50 NA 55 50 NA 100 90045 Surgical Services (Outpatient or ASC) NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100046 Skilled Nursing Facilities NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 95 85047 Diagnostic Radiology NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100048 Mammography NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100049 Physical Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100050 Occupational Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100051 Speech Therapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100052 Inpatient Psychiatric Facility Services NA 30 15 NA 70 45 NA 100 75 NA 90 75 NA 155 140054 Orthotics and Prosthetics NA 30 15 NA 45 30 NA 160 120 NA 145 120 NA 155 140055 Home Health NA NA NA NA NA056 Durable Medical Equipment NA NA NA NA NA057 Outpatient Infusion/Chemotherapy NA 20 10 NA 45 30 NA 80 60 NA 75 60 NA 110 100061 Heart Transplant Program NA NA NA NA NA062 Heart/Lung Transplant NA NA NA NA NA064 Kidney Transplant Program NA NA NA NA NA065 Liver Transplant Program NA NA NA NA NA066 Lung Transplant Program NA NA NA NA NA067 Pancreas Transplant Program NA NA NA NA NA


Specialty

Geographic TypeMicro Rural CEACLarge Metro Metro

CMS Code


Where can I find more DETAILS?



Quest Analytics

How are you going to do this?


Will you be spending a lot of time GOOGLE MAPPING?

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



Is your TIME & DISTANCE correct?

All of these requirements are embedded into the Quest Suite.

Will you end up with a MESS?



Will you be searching from the right BENEFICIARY POINTS?




One Doc … MULTIPLE COUNTIES



Milwaukee County

LM=15 M

GreenCounty

MI=75 MI

Richland County

RU=90 MI

Waukesha County

ME=40 MI


One Hospital … MULTIPLE SERVICES


043044

045

042

041 050

047

061

049040

051


Do you want to avoid CMS Errors?

Quest Analytic Suite

™

There’s abetter wayto powerYOURHSD TABLES

PROVEN Partnership


2007 CMS Partnership BEGINS with Part D 2009 CMS Partnership EXPANDS to Part C 2012 CMS REQUIRES Medicare Standards for Dual

Demonstration Projects 2013 Network Adequacy at the FOREFRONT of

Qualifying and Monitoring Plans for the Exchanges

+



ADVANTAGES with Quest Analytics

Begin testing TODAY (Released 12/12/12)

Network Adequacy 24/7/365

Beneficiary File EMBEDDED

T/D & Minimum Providers EMBEDDED

All Counties, SSAs, & Classes EMBEDDED

Gap Map ANALYSIS

NPI DATABASE

AUTOMATE MA Tables (HSDs)



Latest ENHANCEMENTS

SIMULTANEOUS time & distance reporting

Review only SELECTED specialties

MINIMIZE out-of-county providers

UPDATED geocoding

NPI DATABASE


MA Provider Table

This table captures information on the specific physicians/providers in the applicant’s 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 applicant’s contracted network or on this table.

MA Facility Table

If 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



Quest Analytics

MEDICARE ADVANTAGE MODULE

How can we help?

Quest Analytics

VALUE PROPOSITION

Providing Network Adequacy SOLUTIONS

Answers to the test Complete First Run of Network Adequacy Pass/Fail Results with MA Provider and Facility Tables Deliver Quest Analytics Software Suite, with completed project file, including one day onsite training

A long-term solution in place to review network changes and “what if” scenarios

Software updates including year-over-year criteria changes

(Optional)Narrow Network or Targeted Gap Consulting

Start analyzing your 2014 Application Goals, using the same solution as CMS!

QUEST ANALYTICS SUITE™

ACCESS ANALYSISAccess Analysis I Access Comparison

ADEQUACY ANALYSISMedicare Advantage I Medicaid I Dual Eligibles I Exchanges

DISRUPTION ANALYSISTransparency & Confidence I Provider Change Analysis

GEOCODER & DATA STANDARDIZATIONAddress-Level Accuracy I Data Standardization

NARROW NETWORK ANALYSISProvider Ranking I Tiered Networks



QUALITYUNDERSTANDINGEVOLVINGSUPPORT TEAM

Network Adequacy Experts Providing SIMPLE I CONSISTENT I PROVEN Solutions

Let’s Continue the CONVERSATION!

Account ManagersDarren Huff, Eastern Region [email protected]

Michelle LeCloux, Western Region [email protected]

920.739.4552Call for an Onsite Product Demonstrationand we’ll fly right over >>>



Career

Getting a Solid Grip on the 2014 CMS Application