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Annual Enrollment Period (AEP) is Right Around the Corner-From Bid to Enrollment Processing

By June 13, 2020June 23rd, 2020AEP, Audits, Enrollment

8 Tips to Ensure Your Plan is Ready

After months of hard work and planning, everyone sighed with relief when bids and formularies were submitted earlier this month.  But, as with all things Medicare-there is still more work to be done. How can you ensure that all the planning that went into your go-to-market strategy delivers and results in a successful and compliant annual election period and 2021 plan year?

Annual Member Material Development and Review

It is no small task to ensure accurate and timely annual member material creation and delivery. A single point of contact who collects various inputs should invest the time to coordinate among the Plan’s departments to populate the required materials with information from the Plan Benefit Package (PBP) .   Various stakeholders involved in the development of the plan design and bid strategy will have important insights in how those nuances will be described.

When developing the Evidence of Coverage (EOC) and Annual Notice of Change (ANOC), all reviewers should use the PBP as source documentation.  Creating extracts or summaries can lead to errors.  Ensure that you are tracking HPMS updates to the model documents to include all required edits.

Final quality review of each member material should be conducted by at least two reviewers. Reviewers should print the document rather than review on-screen.  This allows the reviewer to see the document as a member would.  In addition, prior to beginning the review, you should create a checklist for reviewers of important items to be double-checked as part of their final review. Don’t forget areas commonly missed, such as validating the accuracy of phone numbers.  Dial the listed number and ensure it reaches the intended contact.  Test the table of contents and verify that page numbers match. Finally, if using an external vendor for printing, be sure to review the final print version to ensure changes to formatting are not introduced by the printing system.

Section 1557 Regulations Changes

In one of the more significant changes happening this year with all member materials, effective August 18, 2020, plans are no longer required to include the 1557 nondiscrimination statement or language taglines on member materials.  The final rule released in June 2020 implemented this change to eliminate the billions of dollars spent to comply with this regulation.

While plans will welcome this opportunity to save significant administrative dollars related to printing and mailing, it is important to remember that until the effective date, materials must continue to include the 1557 nondiscrimination statement and language taglines.  In addition, plans will need to coordinate internally and with any delegates and vendors to ensure they remove the 1557 nondiscrimination statement and language taglines from print coding effective August 18, 2020.

Training for Internal and External Sales Agents

Training is required for agents; however, training can also be an opportunity to highlight your brand and value proposition. Know your sales force and customize your training to your sales force preferences.  Use your training to highlight changes and if possible, explain the rationale or regulatory requirement driving the changes.  Encourage a feedback loop so that your sales team can provide feedback on market reaction to any changes.

Provide tools and collateral to support the sales process.  This may include a Sales presentation for use by agents and scripts for telephonic sales. Be clear on how your plan is accepting applications and if there are any changes to those methods. If you are accepting paper applications, ensure agents have access to current paper applications and know how to get more. Brokers and agents rely heavily on online information, so ensure online Plan information is accurate, easy to access and easy to understand. Also, consider how COVID-19 may impact in-person sales appointments and meetings and be ready to adjust.

Other Key Stakeholder Training

Make sure that key stakeholders within and outside your organization are aware of changes in the upcoming plan year.

Member Services

Keep in mind that your member services center is on the front lines with members and they can be your first line of defense to quickly detecting and correcting any issues that arise.  It is important that they understand what changes are occurring and know how to escalate complaints, concerns or trended questions that may indicate member confusion, problems with benefit administration, network adequacy issues, and/or marketing misconduct.

Network Providers

Network Providers must execute the changes in the field, so ensure they are also trained annually, particularly on changes. Target key high volume providers and/or providers with significant changes through in-person trainings (breakfasts or lunch and learns, if possible), webinars, email communications and flyers. Include provider front-line staff as well as medical providers.

Utilization Management Staff

Utilization Management (UM) and Care Management (CM) staff provide another direct line to your members and providers. Ensure they are well-educated on new and/or changing pre-certification benefit requirements or auto-approved services. If there are vendors or delegates supporting any or all aspects of UM and/or CM, all delegate staff will need to be aware of the changes and fully trained on any new processes and benefits.

Ongoing Checks and Balances

After benefits are mailed and training is complete, it is important to continue to monitor cross-functional activities through AEP. For example, if in-person sales meetings occur, assign someone to attend these meetings to hear the information that is being communicated and determine if individuals raise questions or seem confused about the materials provided.  In addition, plan to regularly review complaints and inquiries to determine if there are trended questions or issues related to the materials, benefits or sales process.  Once pharmacy benefits have been set up, conduct thorough testing to ensure claims will adjudicate as intended and in accordance with the benefits submitted to CMS and articulated in the member materials. Ensure all benefit accumulators are tested prior to implementation and that your claims area is aware of any new or removed authorization requirements.

Don’t forget About Enrollment!

6 Enrollment System Updates

If your organization has filed for any plan changes, such as plan consolidations, new plan benefit packages (PBPs), termination of PBPs or service area reductions or expansions, the enrollment module will need to be updated.  It is critical to the success of your operations that these changes are coded and tested appropriately prior to processing enrollments in order to be ready for the new contract year.

Plan testing should include a diverse sampling of transactions to validate that filed benefits changes are coded and processing as expected and in accordance with your bid.  If your enrollment system is producing electronic feeds to any FDRs, it is always a good idea to validate that data as well.  Plans should strive to complete testing prior to September 2020 to allow for time in case issues are identified in the testing environment, which must be corrected and re-tested.

Online enrollment mechanisms should have a robust testing procedure to validate plan information, pharmacy and drug set up, as well as that the low income subsidy (LIS) is processing correctly and feeding accurately into the enrollment system.

7  2021 Enrollment Requests

Marketing for the new contract year begins on October 1st, however plans may not process enrollments for 2021 enrollments until October 15th.  Unsolicited applications received prior to AEP for the new plan year must be held for processing until October 15th.  Beneficiaries or agents may submit applications through December 7th with the last application processed being the final plan selection for 2021.

Enrollment Quality Review

The Enrollment Team plays an important role with beneficiaries enrolling into your plan.  It is critical that you train the enrollment team annually on any new plans that will be offered as well as any updates in guidance or HPMS systems.

Quality Assurance (QA) is critical to the overall success of enrollment processing.  Staff conducting quality reviews must be trained on upcoming changes to determine if any QA activity needs to be expanded or adjusted for the coming year, including dashboard reporting.  Ensure your enrollment staff is trained and tested timely on all plans for the coming year.

BluePeak Can Help Ensure you are Ready for AEP

Member Material Quality Check

Who couldn’t use a second (or third!) set of eyes on those member materials? BluePeak’s consultants have experience reviewing member materials from their work at Plans and for CMS. We can help you populate and/or review the annual required materials, as well as other member communications, such as Explanations of Benefi ts (EOBs), transition letters, denial notices, etc., that, if in error or not easily understood, could potential result in program audit conditions. This could be a huge cost saver in time and money for your organization.

Enrollment audits

Mock audits have become instrumental for plans to identify areas of noncompliance.  While enrollment is no longer a standard area of review in a program audit, CMS has conducted ad-hoc enrollment audits when issues of non-compliance are identified in CTMs and Part D reporting.  Whether your plan is new or renewing, performing a mock enrollment audit is always advantageous to an organization to ensure you are processing in accordance with Chapter 2 of the Medicare Managed Care Manual (MMCM), Plan Communication User Guide (PCUG), as well as the Retro-Processing Center (RPC), and other related guidance.


Given the many stakeholders that need annual training and the ever-changing guidance, training can be a resource drain for plans. BluePeak is pleased to offer online and instructor-led training, anytime, anywhere. Our training covers a wide range of government health related topics and can be delivered online, in person or via webinar. Any of our training can be customized for your organization.  Our professional curriculum and knowledgeable instructors can help ensure you plan is ready for AEP and beyond.


BluePeak supports numerous plans each year to test the accuracy of the set up of their Part C and D Benefits.  Let BluePeak Advisors assist you with testing that all of your benefits have been set up correctly as outlined in the Evidence of Coverage (EOC) so that there are no surprises on 1/1. BluePeak tests for a variety of standard and customized scenarios and provides detailed reports and an executive summary that outlines any issues.

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