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2018 is Around the Corner – Are You Ready?

By September 15, 2017September 25th, 2017ANOC/EOC, CMS, Compliance, CPE, CTM, HPMS, PBM, Uncategorized

Bid approved – check.
Member materials sent to printer – check.

What other items should be on your radar over the next few months?

The Centers for Medicare and Medicaid Services (CMS) will be releasing its annual readiness checklist in the next few weeks. The readiness checklist provides you with the most critical operational requirements spanning thirteen areas for consideration leading into the new year. Be sure to schedule time with your operational areas to review the memo and ensure that all staff are up to date on the contractual obligations. The Compliance Officer will meet with their CMS account manager to explain plan readiness, discuss any issues or concerns the plan has and/or take the opportunity to seek clarification on any of the CMS expectations.

Below we’ve highlighted a few areas to consider:

Administrative Changes

Do you have any delegated entity changes occurring with the new benefit year? Remember that you must notify CMS 60 days prior to the effective date of the contract. If you are changing your Pharmacy Benefit Manager (PBM) in 2018, all 4Rx data must be updated before the effective date of the PBM to reflect the new Beneficiary Identification Number (BIN) and Process Control Number (PCN).

Agents and Brokers

While the requirement to upload events into the Health Plan Management System (HPMS) was recently removed, CMS can still get a glimpse into a plan’s sales and marketing program through the Complaint Tracking Module (CTM) and Compliance Program Effectiveness (CPE) program audit tracers. Noncompliance in sales and marketing can negatively impact Star Ratings and program audit scores. It is important to ensure all systems are updated with the current compensation rates and any agent who is selling on your behalf has been trained, tested and appointed to represent your organization.

Annual Member Material Notification

Inaccurate or late member materials can lead to increased complaints, member disruptions and Civil Money Penalties (CMPs). Internal staff and vendors should work closely together to ensure that a plan can upload the required mailing data into the Health Plan Management System (HPMS) for all 2018 Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documentation. A plan has 15 days from when the date materials are mailed to input the actual mail date into HPMS, along with the number of members who received the documents. Materials are due to members no later than September 30.

It is critical to set aside time to review final production versions and double check all ANOC/EOC materials. In the event an error is found, you must develop errata sheet to be sent no later than October 31. The only exception to the October deadline for errata is for stand-alone Dual Special Needs Plans (DSNP) which must be sent by December 31.

Marketing and Website

2018 member materials must be posted on websites by September 30, 2017. Both the 2017 and 2018 materials must be available for review throughout the remainder of this year. It is also important to post your 2018 Star Ratings and the required monthly updates for provider and pharmacy directories.

Do you have all materials available in the required languages for your population and alternative mechanisms in place to accommodate your members? Website formulary accuracy should also be checked on a monthly basis, especially if changes are made, to assure compliance with the CMS submitted formulary.


Have you completed your annual risk assessment for 2018 and determined your audit plan? The annual risk assessment informs the monitoring and audit plans for the year. It is important to include first tier entities in your risk assessment since CMS expects plans to assure these entities are operating compliantly. A common finding in CMS audits is a failure to monitor and audit first-tier entities for full compliance.

Coverage Determinations

Misclassification of appeals and grievances continues to be the most common Immediate Corrective Action Required (ICAR) finding in CMS program audits. It is important to train customer service staff thoroughly and frequently to ensure areas that touch the member are identifying and routing coverage determination and grievance requests timely. Members need to be notified in the ANOC/EOC that they can make coverage determination requests before January 1st to provide for a smooth annual transition. A common staffing mistake is making multiple changes to the formulary and not staffing the call centers with enough folks and training to handle the calls. Reviewing these critical areas now can assure a smooth transition for the start of a new year.

Pharmacy Benefit Set-up

Have you begun testing your 2018 benefits in the claims adjudication system including assuring that the PBM has programmed your formulary correctly? This is especially critical if a plan has negative formulary changes for next year.  A plan must develop and test their processes to prospectively transition impacted members.  Make sure the tier exception processes fully comply with the guidance outlined in the 2018 Call Letter.

Customer Service

Not only is open enrollment and transition into the new year a busy time for plan call centers, but it is also when CMS conducts secret shopping of customer service call centers. Remember that your hours of operation from October 1 through February 14 must be seven days a week from 8 a.m. to 8 p.m. in each time zone that you operate. By now you should have completed the first round of training for all customer service representatives. Make sure that you are pulling your call logs and reviewing documentation to ensure that calls are correctly classified and handled.


Did you remember to coordinate with your vendor or mailroom to ensure that you are tracking any returned ANOC/EOC materials? It is important to take advantage of the opportunity to collect financial information during phone enrollments to supplement your database with the correct information. Make sure you have put in place solid processes and controls to mitigate risks of collecting and storing this information.

Have you hired or are you working with third party vendors who will collect enrollment applications? Here is another opportunity to ensure your oversight, monitoring and controls are in place to meet your regulatory timelines. It is important to double check your processes for downloading enrollments from the Online Enrollment Center.

Is your team actively working the September and December loss of subsidy data files? Have you updated all your systems to reflect the 2018 changes in low-income subsidy cost sharing? Although it doesn’t occur until April 2018, a plan should make sure they are prepared to handle the conversion from the health insurance claim number (HICN) to the Medicare Beneficiary Identifier (MBI) number.

Medical Benefit System

Have you loaded and tested the 2018 benefits, including accumulators and maximum out-of-pocket values? Incorrectly calculating enrollee cost sharing for claims in accordance with the plan benefit design is one of the one-third financial audit findings for which CMS may impose enforcement actions, such as CMPs.

There are many areas a plan must think about as they enter a new plan year. Of course not all of the items you need to think about are covered here, but we wanted to make sure we help plans focus on critical areas that are easy to miss. If you are struggling to prepare for 2018, contact someone who can help. BluePeak Advisors has expert resources who have plenty of experience with annual readiness preparation, across all plan types and sizes.

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