Using prescription drug data for identifying missing diagnoses and for medical management in the Medicare Advantage market

Even though the Centers for Medicare and Medicaid Services does not use prescription data in assigning risk scores, Rx data can still be a valuable resource for Medicare Advantage (MA) plans. Because the revenue for an MA plan each year is based on member diagnoses incurred in the prior year and submitted within 13 months of the end of that period, MA plans have a meaningful period of time to ensure complete and accurate coding as well as to identify members for disease management and potential drug adherence outliers. Milliman consultants Corey Berger and Brooks Conway provide perspective in this paper.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

CMS announces special enrollment periods for Americans impacted by recent hurricanes
As a result of Hurricanes Harvey, Irma, and Maria, the Centers for Medicare and Medicaid Services (CMS) will make available special enrollment periods for all Medicare beneficiaries and certain individuals seeking health plans offered through the Federal Health Insurance Exchange. This important step gives these individuals and families who have been impacted by the hurricanes the opportunity to change their Medicare health and prescription drug plans and gain access to health coverage on the exchange immediately if eligible for a special enrollment period.

To learn more, click here.

Population health and value-based care collaboration: Primary care case study

Many health systems around the world are introducing new care models which claim to replace expensive acute inpatient care with more primary and community-based services. This paper by Milliman consultants examines the primary care redesign of seven US practices over the course of three years, including their reported utilisation and savings achievements.

Midyear 2017 financial results for medical professional liability specialty writers

This article by Milliman consultants Eric Wunder and Brad Parker summarizes some key financial results for a composite of medical professional liability specialty writers through the second quarter of 2017. The decline in premium isn’t slowing down, and favorable reserve runoff from prior years is providing less financial relief. Future investment results look promising.

This article was originally published in the September 2017 issue of the Medical Liability Monitor.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

IRS issues guide on ACA information returns
The Internal Revenue Service (IRS) released Publication 5258, “Affordable Care Act (ACA) Information Returns (AIR) Submission Composition and Reference Guide.” The purpose of this document is to provide guidance to all types of external transmitters about composing and successfully transmitting compliant submissions to the IRS.

To download the guide, click here.

IRS issues guide on electronic filing of ACA information returns
The IRS released Publication 5165, “Guide for Electronically Filing Affordable Care Act (ACA) Information Returns for Software Developers and Transmitters.” The guide outlines the communication procedures, transmission formats, business rules, and validation procedures for information returns transmitted electronically through the AIR system.

To download the guide, click here.

Risk adjustment modifications in view of potential CSR subsidy termination

If the cost-sharing reduction (CSR) subsidies of the Patient Protection and Affordable Care Act (ACA) were eliminated, it could expose insurance carriers to a substantial increase in selection risk related to their particular mixes of business. In August, the Centers for Medicare and Medicaid Services (CMS) announced its intention to propose a set of risk adjustment modifications for states in which insurance carriers raise silver premiums in response to potential CSR subsidy termination.

In this paper, Milliman’s Jeffrey Milton-Hall, Doug Norris, and Jason Karcher explore the CMS proposal along with the current ACA risk adjustment program and three other potential alternative modifications to risk adjustment in response to the possible elimination of CSR funding.