Over the last decade, enrollment in Medicare Advantage has more than doubled. As a private plan alternative to Medicare, it accounted for 42 percent of the total Medicare population and $343 billion of total Medicare spending in 2021.

Kaiser Family Foundation doesn’t expect the trend to stop, projecting the program to again double over the next 10 years. For health plans and the healthcare BPOs that often support them, this represents tremendous opportunity—provided they can navigate the demanding regulations.

With the Annual Election Period (AEP) rapidly approaching (running October 15 to December 7th), here are six items Medicare Advantage Plans and BPOs must ensure are complete within the CMS regulatory timeframes.

1. CMS Readiness Checklist

Released annually, the readiness checklist reminds Medicare Advantage plans of critical part C&D readiness items prior to AEP and coverage beginning January 1. Plans need to review the checklist and take the necessary steps to fulfill requirements for the upcoming contract year.

2. Call Scripts

Annual plan benefit and regulatory changes may impact existing informational, enrollment, and telesales scripts. Plans should review all scripts, identify changes needed, and submit any scripts requiring change to CMS for review and approval.

3. Member and Provider Website and Material Updates

CMS has strict Medicare Advantage communication and marketing guidelines, including requirements surrounding:

  • ID Cards
  • Plan website
  • Posted Materials
  • Member and Provider communications
  • Many of these updates require CMS approval within a defined timeline.
4. System Updates

As annual benefits, premiums, and guidance change, plans need to verify internal and external systems are updated to align with the new calendar year rates and benefit offering including but not limited to:

  • Plan premiums
  • LIS premium and co-pay levels
  • Deductible
  • Maximum out of pocket, benefit maximums and limitations.
5. Vendors and Oversight

As a result of annual plan and regulatory changes, plans need to work with their vendors to ensure the following meet both CMS and Plan Requirements for the upcoming year:

  • Member material
  • Operating systems
  • Inbound and outbound file transfers
  • Policies and procedures
6. Annual Policy and Procedure Review

Plan operations and regulatory changes can and often due impact existing policies and procedures, plans should ensure the update, review, approval, and distribution process are completed by end of year.

There are many health plans offering Medicare Advantage. Competition is stiff. With the ever-changing regulations and heavy workloads within health plans, healthcare systems, and BPOs, successfully executing Medicare Advantage AEP is easier said than done. At GarnetCare our clients are often faced with these common challenges:

  • Missed deadlines
  • Employee burnout
  • Quality issues and Compliance failures
  • Rising Operational Costs

The GarnetCare team can guide you through AEP and help deliver where gaps exist. We have experience in all areas of healthcare business solutions, and we are a proven partner in helping our clients establish “best-in-class” regulatory industry standards with effective monitoring and oversight tools.

Photo of Nicolle Dugan, GarnetCare practice co-lead
Nicolle Dugan

Nicolle Dugan is co-practice lead for Garnet Care. She has more than 35 years of experience in health care, including Medicare Advantage and Medicaid operations, Third Party Administrator (TPA) and Business Process Outsourcing (BPO) operations, audit and business development. Her Medicare management experience spans a national Medicare BPO presence and Medicare Advantage and Medicaid Advantage Plus implementations and operations management in six states. She has led Medicare and Medicaid business implementations and quality control programs.

Photo of Courtney Seypura, GarnetCare practice co-lead
Courtney Seypura

Courtney Seypura is co-practice lead for Garnet Care. She has more than 20 years of experience in Medicare and Medicaid operations and project management. Her subject matter expertise is Medicare operations, including Medicare Advantage (MA), Medicare Advantage Prescription Drug (MAPD), Prescription Drug Programs (PDP), Special Needs Programs (SNPs) and the start-up and administration of Medicare-Medicaid plans. She is proficient in management and analytics specific to oversight and regulatory concepts, business requirements and functional specifications development.

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