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BluePeak’s Definitive Guide to Preparing for 2020

By June 11, 2019June 21st, 2019CMS, Marketing, MCMG, PDE, Training

Bids were turned in the first Monday in June and now it is time to implement those benefits, plan designs and formularies that your organization has been hard at work developing. Open enrollment is only 4 months away and the new plan year begins in 6 short months.  There is still a lot of work to be done in a short time. BluePeak has your definitive guide on how to be ready for 1/1.

PDE closeout

After June 28th, 2019, CMS will no longer accept 2018 PDE records for consideration for PDE Financial Reconciliation.  Although time is limited, plans can make final corrections to ensure relevant PDE records are accepted for financial consideration and they don’t leave potential revenue on the table.  Plans are also required to attest to the accuracy of the PDE record data prior to CMS performing financial reconciliation.  Plans should look to perform a PDE accuracy audit on 2018 and 2019 PDE records to ensure the data is accurate and consistent with CMS rules and regulations.  Just because a PDE is accepted doesn’t mean it is accurate.  Inaccurate PDE records will likely impact plan financials as well as increase the compliance risk of a finding during a financial audit.

Member Material Review

Model member materials have been released and it’s time to develop member communications. In order to ensure accuracy of member materials, Plans should use source documentation as their single source of truth.  Quality checks are critical, and it is a best practice to have a two-person review process.  Plans should use a cross functional team, including marketing, communication, product development, enrollment, servicing, appeals and grievances, and compliance, to ensure accurate and clear messaging and avoid misleading marketing complaints.

Avoid common errors by creating a checklist of common mistakes to guide your reviewers, such as validating accuracy of phone numbers, page numbers, page number references, and required disclaimers.  While reviewing documents on screen saves printing expenses and allows for easy access and revisions, it is a long-time best practice to print documents for review.  This allows the reviewer to experience the document as the member or prospect will.

When an external vendor is used for printing, the full document should be thoroughly reviewed when the final print version is provided to the plan.  Frequently, when the document is configured by the external print vendor’s system, unintended changes in margins, page numbers, and tables can result.

If your plan is dramatically changing its benefits or plan design, consider custom communications.  Even positive changes can lead to member confusion. Therefore, all changes, whether positive or negative, should be communicated and developed in accordance with the requirements in the CMS Medicare Communications and Marketing Guidelines (MCMG).

Using the model enrollment application can be beneficial to approval and printing timelines.  If a non-model enrollment application is developed, be sure to leave a buffer of time to accommodate the material review approval, print lead time, and packaging with sales kits.


Conduct refresher training with your Enrollment team by reviewing key turnaround timeframes for processing applications, disenrollment requests, and Transaction Reply Reports (TRR).  Ensure your team is made aware early on of any plans that are being added, consolidated, or terminated so they can familiarize themselves with the contract and PBP changes.   You should also communicate any changes to service areas to your Enrollment team.  Review the new contract year model and non-model enrollment communications as a team to avoid mailing incorrect letters.

Training Brokers and Agents

In advance of open enrollment, you will need to make sure your Sales team understands and can explain year-over-year benefit changes and their impact.  Develop sales presentations and scripts to use to assist you with training your Sales team.  Highlight the changes, whether positive or negative.  Agents have reported that side-by-side charts comparing benefits are most impactful.

Brokers and agents heavily rely on information from the internet, so ensure Plan information on your website is accurate, easy to access, and easy to understand.

Training Other Stakeholders

Train early — train often! Once is not enough.

Leverage scripts when possible to help ensure benefits and benefit changes are accurately explained. Provide examples and scripting on how to answer member questions on new and existing plan benefit changes.

Prepare Customer Service for changes that are likely to create member concern and, when appropriate, share the rationale that led to the change (i.e. why did premium increase, what is a preferred provider network, how do I utilize my vision benefit?)

Customer Service should also be made aware of regulatory changes.  For example, with the significant increase in the Part D cost-sharing threshold, members’ out-of-pocket costs will increase from $5,100 in 2019 to $6,350 in 2020.  Customer Service Agents should be prepared to answer questions and potentially document grievances around this.

Develop early warning escalation processes within the organization to identify trending complaints, concerns or questions that may indicate member confusion, problems with benefit administration, network adequacy issues or marketing misconduct.

Final formulary updates

Formularies were submitted June 3rd, but Plans can also update their formulary in the summer during a limited update window as well as during the final September formulary submission.  During this time, plans should be developing how they will validate the accuracy of the formulary, ensure prior authorizations are not more restrictive than the CMS formulary, and perform outreach to mitigate member impact because of formulary updates.  Plans should also proactively review any expiring prior authorizations and determine if any existing authorizations should be extended to avoid potential beneficiary impact.  Finally, Plans should also perform a review of how to manage any 2020 requests submitted by or on behalf of new and continuing beneficiaries prior to the start of 2020, to ensure beneficiaries do not experience an inappropriate delay or denial of their medication.

Readiness checklist

In October, CMS will release the 2020 Readiness Checklist.  This gives Plans insight into what CMS thinks is important and a preview of which it will focus in the coming year.  Don’t just “check the box” in completing the Readiness Checklist.  Rather, use it as a tool to test for readiness.  While the Compliance Officer is responsible for communicating readiness with CMS, the Readiness Checklist is not just a Compliance activity.  Each operational unit should be familiar with the checklist and actively assess their readiness.

Year-end testing for 2020

Plans should be strategizing ways to validate that the changes outlined within the call letter and new final rules are set up correctly for plan year 2020.  Plans should also be setting up test conditions to demonstrate under what conditions claims should be allowed to pay and rejected based on updated rules and regulations.  Additionally, Plans should undertake a comprehensive review to ensure the formulary and benefits are coded appropriately and claim processing is consistent with the its bid and/or set up documents.  Plans should also set up a clear work plan, outline who is responsible for each task, and track all progress until testing has been completed.  Plans should strive to have all or most of their testing completed prior to December 2019 to allow for sufficient time to do additional testing that is needed or to manage any issues identified within the test environment.

Plan now to make 2020 your best implementation year yet!

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