Like clockwork, every year Payors spend 6 to 9 months pouring through regulatory changes from the Centers for Medicare and Medicaid Services (CMS), state and federal regulatory agencies to ferret out changes that impact current product designs and benefit packages to be offered to members anxiously awaiting yet another round of confusing and every changing options to health plans choices, selection of Primary Care Physicians (PCP) and left exasperated to discover that their Specialist is no longer in-network, moved to another hospital system or closed their practice and moved to that long awaited retirement haven.
Annual enrollment cycles are painful for health plans, providers, hospital systems, members and their caregivers. For health plans it is a painful, tedious but necessary process which requires heavy lifting by all divisions to deliver a package heavy enough to act as a door stopper which members receive by postal service or email or both in the form of glossy marketing materials which include the standardized Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) instructions, ANOC/EOC Errata, and Provider Directory. Now what?
Evidence of Coverage (EOC)
The EOC, along with the enrollment form, is the member's contract with the Health Plan Administrator. These EOC documents explains the rights, benefits, and responsibilities of the member (patient / subscriber) as required by regulatory entities governing each Health Plan. So what is the "ask" and do members understanding their responsibilities? Even more importantly, how many members or their caretakers even take the time or have the time to read through these documents much less understand its contents?
It requires the same tenacity and courage needed to prepare and file your taxes. A necessary duty with the added deadlines for enrollment. So each member will at least attempt to understand using the Summary Guideline:
- What is covered and what is not covered - co-pays, Rx restrictions and more.
- How to get the care the member needs, including rules they must follow. - pre-authorization and certifications, and referrals.
- What member pays for their health plan - deductibles, life-time maximum etc..
- Rights as a member of the health plan, including treatment decisions, and use of advance directives.
- What to do if the member is unhappy about something related to getting their covered services - appeals and denials.
- Health Plan's responsibility to treat patients with dignity, fairness and respect.
- How to disenroll (request for termination premium hospital and medical insurance) from Health Plan's product and other options that are available?
- Member rights and responsibilities upon disenrollment.
- For member residing in multiple states, a list of Out-of-Network Coverage Rules governing PCPs, specialists, and hospitals.
The bad news is that not even 90% of Medicare Advantage Organizations (MOAs) members ever read those packages which arrive like clockwork by mail and email every enrollment season between September and April. For innovators who are experts in this space like RR Donnelly and Messagepoint, they take the complexity out of managing member materials by helping MOAs streamline annual updates by giving non-technical users full control of content updates, workflows and approvals. By automating 70% of the MOAs processes, organizations like RR Donnelly and Messagepoint claim to improve efficiency and reduce costs by up to 40%.
So what are MOAs doing to improve member experience by providing clearer communication and taking the anxiety out of the enrollment process? AI-powered customer communications management (CCM) solutions which are purpose-built to handle the complexity of regulated, personalized omni-channel customer communications in ways that others can only dream of.
Like RR Donnelly and Messagepoint, other providers like Cierant Corporation help their customers innovate solutions that leverage data to increase marketing effectiveness, enhance operating efficiency, and drive increased customer loyalty.
Are MOAs passing on innovation to members?
Are MOAs offering members more in person support (retail stores), automation and/or easier access via mobile applications, SMS text notifications, Click-to-Chat and realtime TeleHealth services?
The answer is a resounding "YES", however there are still a sizable number of Americans struggling to read or understand their health care information. According to a study completed in 2003 by the National Assessment of Adult Literacy (NAAL) which reported in the National Assessment of Literacy Survey (NALS), nearly 93 million of U.S. adults are functioning at basic and below basic literacy levels or they could master basic reading tasks needed to function in society. This information was confirmed by a 2004 Institute of Medicine (IOM) report, “Health Literacy: A Prescription to end Confusion” which states that of these, more than 90 million people, about 40 million read below the 5th grade.
- So what does this mean to members' need and want?
- Are health plans doing enough to reach their constituents?
- How will digital transformation and Telehealth bridge those gaps?
In 2021 as in 2019, packages will arrive like clockwork to members' mailboxes, and health plans can continue to tweak information to make it easier for members to understand by shading important elements and eliminating jargon wherever possible.
According to Anthem, plans like them may also make the ANOC-EOC available online. Nice, but are they keeping pace with member needs? Who has time to comb through all that paper even for critical information like monthly premium, changes in cost sharing or medical benefits, prescription drug costs and benefits and formularies for the upcoming year?
- SIMPLE to understand with skillful use of graphics
- EASIER TO UNDERSTAND guides highlight key instructions using larger fonts and simplified messaging
- PORTABLE for access via traditional websites, smartphone and mobile devices
Are health plans restricted by CMS marketing material guidelines or are they just leaning on those guidelines instead of innovating and leveraging technology instead of relying heavily on members' service providers (internal and external) and limiting transformation to innovations like intelligent desk top capabilities to improve member experience and reduce costs?
Payors should "run not walk" to partner with companies like RR Donnelly and Messagepoint focused on supporting Payors with platforms that provides efficient and effective member engagement which is key to maintaining existing and expanded into new markets to:
Frankly, most plans are just focusing on internal automation and transformation to improve delivery of mobile, channel and Telehealth experience for members. This will be a place to watch in the next 12-18 months.
- Ensure plan materials match annual bid submission
- Automate changes across plan versions
- Leverage CMS approved Models already built into the platform
- Manage collaboration and change control with an integrated platform
- Focus on member experience and simplifying communication
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