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Creating an Interoperability Strategy that Delivers Results: How to Prioritize Integrations within Care Management and Across the Healthcare Ecosystem

To achieve seamless care coordination, reduce costs, and increase efficiencies, care management platforms must integrate effectively within care management functions as well as across the entire healthcare ecosystem. However, identifying and prioritizing the right integrations can prove challenging for health plans. To get the most out of an interoperability strategy, health plans should understand market drivers and establish goals for what should be accomplished through enhanced integration.

After working with many health plans on developing and executing their interoperability strategies, we have a thorough understanding of how the most successful plans view interoperability.

With the right integrations in place, health plans can break down siloes, support new regulations and payment models, and improve the member experience.

The Race is On: Market Dynamics and Priorities Driving Urgency for Interoperable Care Management Systems

New regulations, evolving payment models, and shifting member expectations are driving urgency for health plans to advance interoperability across multiple systems. For example, the recently proposed CMS rule, “Advancing Interoperability and Improving Prior Authorization Processes,” will prompt health plans to address integration gaps in their prior authorization and utilization management processes. In addition, the transition to value-based care demands more advanced interoperability to allow for better collaboration and outcomes.

Meanwhile, payers are also investing in strategies that improve health outcomes and member experience to advance ratings in the CMS Star Ratings program. Star Ratings can have a significant financial impact for health plans, as moving up from a 3.5- to 4-star rating is worth an additional $400 per member per year on average for Medicare Advantage plans. With member satisfaction and care outcomes being key drivers of the health plan rating, many are finding interoperability to be a critical investment for advancement in these core areas.

Finally, innovation in digital experiences and rising consumerism in the industry continue to shift to member expectations of access to health data and information from across the broader healthcare ecosystem. Members are seeking ease of access to their health and claims data, making efficient exchange of information a top priority.

Integrating the Care Management Function

When building a successful integration strategy to address these needs, health plans should first consider several key integrations within the care management function. These integrations facilitate better care coordination, improve communication, and ultimately optimize health outcomes. To begin, payers should consider how their core care management platform will integrate with solutions housing these types of data:

Social Determinants of Health (SDOH): According to the National Academy of Medicine, new payment models are prompting health plans to prioritize strategies to improve the social wellbeing of their members. SDOH account for approximately 80-90% of a member’s overall health, with medical care accounting for only 10-20%. As a result, many health plans are elevating the importance of investing in ways to enable members to manage aspects of their environment that contribute to overall health.

By systematically integrating care management with SDOH data,  care coordinators can deliver more whole-person care and services by supporting social and economic needs that contribute to a member’s health status. By quickly and easily connecting members with social services, enabling seamless data exchange, and tracking and measuring progress, care coordinators can support overall health needs of their members.

Clinical Criteria: Integrating care management with clinical criteria platforms enables health plans to streamline utilization management (UM) workflows, while informing care strategies that improve outcomes for members and reduce costs for health plans. The integration has become more critical for health plans as costs continue to rise and health plans seek new strategies for improving efficiencies.

Lettering & Correspondence: Timely, clear, and effective communication can advance member engagement, a key factor when it comes to improving overall health outcomes. Integrating care management with lettering and correspondence solutions allows efficient creation of personalized member mailings. Streamlining the process of delivering real-time correspondence for denials, appeals and grievances, and other member communications strengthens member engagement and saves time for health plan administrators.

Business Rules: When business rules are seamlessly integrated with a care management platform, health plans can more effectively manage complex care, automate best practices, and streamline the prior authorization process. Improving efficiencies through this level of integration enables health plans to make strides in preparation for new CMS guidelines to improve processes and efficiencies related to prior authorizations.

Business Intelligence: Health plans are managing more data than ever before. To unlock insights and intelligence behind the data, health plans require use of advanced tools. Integrating reporting and business intelligence allows health plans and care managers to easily access and use the real-time data to improve care management strategy and workflows.

Prioritizing Integrations Across Healthcare Ecosystem

In addition to interoperability within the function, care management solutions should integrate with platforms across the healthcare ecosystem to improve efficiencies and reduce costs. As health plans build their interoperability strategies, health plans should prioritize integrations with other functional systems, including:

Core administrative processing system (CAPS): Integrating claims data into care management workflows allows care managers to incorporate indicators such as repeat provider visits, lack of medication adherence, and missed encounters to create the most effective care plans. With access to the complete view of member history and claims data, care managers can make more informed decisions. Efficient exchange of this type of information is integral to the success of value-based care.

Payment integrity platforms: Interoperability between care management and payment integrity platforms ensures payment teams can access real-time clinical data. As a result, they can improve the accuracy of the claim, configure more effective benefit packages, and reduce provider and member abrasion. The integration also improves efficiencies and reduces costs by eliminating manual data entry.

Digital health management tools: The availability of digital tools and remote monitoring devices for connectivity to patients continues to grow exponentially. With better access to patient data from multiple sources, care managers can more effectively care for members and improve outcomes. According to HIT Consultant, “Creating and utilizing clinical-grade digital health innovations increases adherence and provides members with more accessibility. By utilizing things consumers already have – such as smartphones and videoconferencing platforms – these innovations can create new pathways to care.” Integrating care management platforms with innovative digital health tools not only improves member satisfaction, but also promotes better health outcomes and care quality. By delivering results in these areas, health plans can support value-based care and boost Star Ratings.

Delivering Interoperability Strategy with GuidingCare®

GuidingCare takes a multi-faceted approach to interoperability that includes both integrations within the care management function, as well as those across the entire healthcare ecosystem. With more than 75 unique vendor integrations and 12 productized integrations, and 75 API endpoints to integrate content into native workflows, GuidingCare provides the tools and resources health plans need to successfully execute their care management interoperability strategies.

To learn more about how about how GuidingCare’s highly interoperable platform can accelerate your organization’s care management strategies, visit the GuidingCare page on the HealthEdge website.

Legal compliance refers to the adherence to laws, regulations, and standards that are applicable to a specific industry or organization. At HealthEdge, Compliance is an essential component of business operations, as it helps to mitigate legal and financial risks and ensures HealthEdge operates ethically and in the best interests of stakeholders.

What is Legal Compliance at HealthEdge?

Legal compliance is the ongoing process of ensuring that a company, business, or other organization is adhering to the applicable laws, regulations, and industry standards. This can include complying with financial reporting requirements, implementing privacy and security safeguards, training workforce members, and conducting operations in accordance with the numerous laws that govern businesses, such as employment, tax, and insurance laws.

The purpose of having a strong compliance program is to help organizations operate at a high level and to avoid the penalties, financial losses, and reputational damage that can result from violations caused by non-compliance. The financial penalties for violations can be significant and have the potential to cause additional harm that can be devastating to the success of a business.

A quality compliance program provides assurance to prospects and customers that a business is well-managed, trustworthy, and reputable. A compliance program can be tailored to support an organization maintain its ethical standards (like transparency, honesty, and respect) which also helps build trust with stakeholders, customers, workforce members, and shareholders.

HealthEdge prioritizes compliance throughout the company so that all workforce members are aware of and involved with its success. The compliance group takes a cross-functional approach to engage company-wide support and increase the efficiency of compliance efforts. By working with multiple departments, HealthEdge ensures that the compliance requirements are met, and regular work is unaffected so business can continue as usual.

HealthEdge is committed to working for the best interests of its customers, and the strength of its compliance program helps demonstrate that commitment.

How does HealthEdge achieve Compliance?

Implementing company-wide compliance is a complex process that requires knowledge and awareness of the many laws, regulations, rules, and standards that require strict adherence. HealthEdge takes a detailed approach to ensure the compliance program is performing at a high level, and that the compliance program is working as intended. The program is designed around the seven foundational elements of a compliance program outlined by the United States Sentencing Commission, incorporating an additional element from the Department of Health and Human Services (HHS) Officer of Inspector General (OIG) Compliance Guidelines:

1. Governing Authority: HealthEdge has a Compliance Officer (CO) and the Risk Compliance and Governance Committee, that is comprised of members of the executive leadership team is responsible for the execution, correction, and oversight of all aspects of the compliance program.
2. Policies and Procedures, and Code of Conduct: HealthEdge commits to complying with all applicable federal and state regulations and standards–this includes providing guidance to workforce members on compliance-related matters. HealthEdge also provides procedures that assist in the identification and correction of non-compliance. These policies and procedures are reviewed on a regular basis and updated as needed based on requirement changes or regulations.
3. Training and Education: HealthEdge provides various training to its workforce members, including new hire, annual refresher, and role or product-specific training.
4. Reporting: HealthEdge is committed to fostering a culture of compliance, good corporate governance, and ethical behavior and encourages the reporting of improper, unlawful, or unethical behavior. Workforce members are encouraged to discuss any suspected violations with appropriate individuals within HealthEdge. HealthEdge has a strict non-retaliation policy–there can be no retaliation, penalty, or retribution for good faith reporting of any suspected compliance issue.
5. Monitoring & Auditing: Proactive auditing and monitoring of routine business practices is vital for the identification of potential compliance issues. HealthEdge routinely conducts audits and monitors business processes to identify risks. These processes help:

• Ensure compliance with policies and procedures, laws, and regulations.
• Confirm that corrective actions have been implemented.
• Evaluate the overall effectiveness of the compliance program.

6. Enforcement & Discipline: HealthEdge does not tolerate non-compliance with company policies or applicable laws. Any non-compliance could compromise HealthEdge’s operations, the services provided to customers, or its Violations of the HealthEdge Code of Conduct and other policies and procedures require a corrective action and reporting to the appropriate regulatory or law enforcement agency when applicable. HealthEdge has well-publicized disciplinary standards that:

• Prohibit authorization or participation in activities that violate HealthEdge policy.
• Articulate expectations for reporting compliance issues and assists in their resolution of issues.
• Provide timely, consistent, and effective enforcement of the standards when non-compliance or unethical behavior is detected.
• Encourage good-faith participation in the compliance program.

7. Response & Prevention: HealthEdge has a well-developed compliance program, with established procedures, processes, and system implementation for promptly responding to compliance issues. The HealthEdge compliance program ensures that:

• Issues are acknowledged as they arise.
• Potential compliance problems are investigated.
• Concerns are proactively identified through rigorous auditing and monitoring.
• Problems are corrected promptly and thoroughly to reduce the potential for recurrences.

8. Background Checks: In addition to the seven foundational elements of a compliance program outlined above, HealthEdge also incorporates Background Checks that include an investigation of criminal history, exclusions, and reference checks. HealthEdge makes reasonable efforts to ensure personnel and business partners are not engaged in illegal activities or conduct that is inconsistent with an effective compliance program.

Conclusion

Achieving compliance requires a thorough understanding of all applicable laws and regulations, the development of policies and procedures to ensure compliance, the implementation of controls and monitoring systems, and ongoing maintenance and updates to ensure compliance with changing requirements. HealthEdge’s compliance program ensures the company meets established standards, upholds its commitments, protects its business reputation, and avoids financial penalties. By prioritizing compliance, HealthEdge mitigates legal and financial risks, operates ethically, and serves the best interest of its customers.

What Health Plans Should Know as Interoperability Continues to Change the Game for Healthcare

Interoperability has transformed every facet of the healthcare delivery system, creating new opportunities to improve outcomes, reduce costs, and improve efficiencies. It has also been the key to enabling healthcare technology solutions to achieve their full potential.

By gaining a deeper understanding of the origins, current status, and future potential of interoperability, health plans can seize the opportunity to implement modern and innovative care management integration capabilities that deliver results for digital payers.

Defining Interoperability

Interoperability in healthcare refers to the ability of various information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner, in order to provide timely and seamless portability of information and improve the health of people and populations around the world.

Interoperability is the basis on which healthcare providers are able to deliver coordinated and comprehensive care to patients by accessing and sharing critical patient data in real-time. It also enables health plans to streamline administrative processes and reduce costs. As the healthcare industry continues to evolve and adopt new technologies, interoperability will also become an increasingly vital aspect of healthcare delivery and management.

Why Interoperability Matters

Interoperability can have significant positive implications across the healthcare ecosystem. Key goals of seamless integration include:

1. Advancing care coordination: Interoperability facilitates the sharing of member health information between payers, providers and systems, enabling better coordination and collaboration among organizations and teams.
2. Improving outcomes: By providing care managers and healthcare providers with access to comprehensive and up-to-date patient information, interoperability can help care managers create effective care plans and improve patient outcomes.
3. Streamlining administrative processes: Interoperability can reduce administrative burden, support new payment models, and ease claims processing.
4. Reducing costs: Interoperability can help reduce errors, streamline processes, and save time, leading to overall cost savings for payers, healthcare organizations, and members.
5. Improve member satisfaction: By improving data exchange, members have greater access to health and claims information, improving satisfaction and engagement.

The Beginning: Unlock the Power of Health Data through Interoperability

The need for interoperability originated as healthcare providers embraced widespread adoption of electronic health records (EHRs). EHRs were intended to revolutionize the way healthcare was delivered, enabling better coordination of care, reducing medical errors, and improving patient outcomes. However, in practice, EHRs created silos of health data that were not easily shared between providers or patients. This lack of interoperability led to fragmentation of care, duplication of tests, and unnecessary healthcare costs.

Recognizing the need to address these issues, the 21st Century Cures Act mandated that healthcare providers make patient health information available to patients and other providers in a standardized format through open, secure, and standardized application programming interfaces (APIs). The Act also created new provisions for healthcare data privacy and security, ensuring that patient data is protected when it is shared between providers.

These interoperability standards were important for several reasons. First, they empowered patients to take control of their health information and share it with any provider they choose. This increases patient engagement and allows for more comprehensive and coordinated care. Second, the rules helped to break down the silos of health data that had developed, enabling providers to access complete patient records, reducing the risk of medical errors, and improving the quality of care.

Finally, the interoperability rules promoted innovation in healthcare by encouraging the development of new applications and tools that can use healthcare data to improve patient outcomes, reduce costs, and improve efficiencies. Interoperability continues to be a priority for health plans and organizations across the healthcare ecosystem.

New Regulation and Innovation: Key Drivers Influencing Interoperability Today

Today, new regulations and continued innovation are driving urgency for greater interoperability. For example, the CMS Proposed Rule: Advancing Interoperability and Improving Prior Authorization Processes will directly influence integration priorities for many health plans. The proposed rule updates some of the policies included in the Interoperability and Patient Access Final Rule of 2020 and officially withdraws the December 2020 CMS Interoperability proposed rule. The objectives of the policy are to reduce the burden on both payers and providers, improve efficiencies, and advance patient access to health information. Some of the conditions take effect immediately, while others require implementation by 2026. Given the scope, it is important health plans to take action now and prepare their infrastructures for full implementation.

The proposed rule includes multiple requirements for payers that will directly influence their interoperability strategies:

Patient Access API: The rule proposes to require regulated payers to include information about patients’ prior authorization decisions to help patients better understand the process and contribution to their care. The proposed provision would also require impacted payers to report annual metrics to CMS about patient use of the Patient Access API.

Provider Access API: The rule proposes impacted payers build and maintain an API to share patient data with in-network providers where a treatment relationships exists with the patient.

Payer-to-Payer Data Exchange on FHIR: The rule proposes to require payers to exchange member data when a member changes health plans, with the member’s permission. The data elements include claims and encounter data, those identified in the USCDI version 1, and prior authorization requests and decisions – only if the patient opts in to data sharing.

Improving Prior Authorization Processes: The rule proposes a series of policies in an effort to improve the prior authorization process through greater efficiency and transparency.

The rule also outlines CMS’s recommended use of certain implementation guides for the APIs listed in the rule, but does not propose requiring their use.

The provisions outlined in the CMS proposed rule facilitate moving the industry toward more streamlined communication and better information exchange that can benefit members, payers, and providers. As organizations await the final ruling, there are steps that can be taken now to prepare:

1. Understand how the ruling will impact your health plan. Assess guidelines and determine which provisions will apply to your organization.
2. Evaluate your current data management processes. Is all member information available in a single source in order to create the full record required? If not, what changes need to be made to maintain a record for each member?
3. Evaluate your current interoperability strategy. How is member information exchanged between payers, providers, and patients today? How is prior authorization information managed and exchanged today? In what format are the data points being requested and can they easily be delivered via a Patient API or Provider API?
4. Assess resource availability. Who will be responsible for implementing the new standards? Who will be responsible for ensuring data is available to patients and providers within defined timeframes? What processes will need to change in order to accommodate the new standards?

Future State: Interoperability Considerations for Digital Payers

The proposed rule could be considered just the beginning for innovation in interoperability that will impact health plans moving forward. Rapidly evolving regulatory requirements, new payment models, rising consumer expectations, and new market opportunities will continue to drive payers to advance interoperability. The results promised by continual digital advancements across the healthcare ecosystem rely on seamless data exchange. In fact, interoperability can be considered a prerequisite for many health innovations.

Digital payers should consider their care management system’s ability to meet key requirements for modern and evolving integration criteria:

1. Exchange a variety of data types: Health plans should ensure their care management system can access, ingest, and exchange various data types across other systems with industry interoperability standards.
2. Support real-time data exchange: Informing decisions in a timely manner is critical when it comes to effective care management. Health plans should ensure care managers have real-time access to member information.
3. Work seamlessly with other systems and data sources: Care management systems function as the core orchestrator of member care. But the most effective care plans rely heavily on data from multiple sources to inform optimal care plans. In addition, care management systems must work in tandem with claims, payment integrity, and other administrative systems to streamline processes and reduce costs.

GuidingCare® enables digital payers to meet these modern interoperability needs, plan for future requirements, and support continued innovation. To learn more about how about creating a successful interoperability strategy with GuidingCare, visit the GuidingCare page on the HealthEdge website.

In recent years, Medica, a Minnesota-based non-profit health insurance provider, has experienced explosive growth. To keep up with its growth, Medica’s was using HealthEdge’s core administrative processing system (CAPS), HealthRules^® Payer, which had resulted in multiple instances of the system.

However, the growing complexity of the multiple configurations led to the need for a more efficient way to manage the HealthRules Payer infrastructure, and Medica turned to the experts within the HealthEdge team for guidance.

Medica faced two main challenges: Firstly, the company needed to create new efficiencies to help reduce complexities and administrative burdens associated with maintaining multiple HealthRules Payer environments, reducing the time spent on issue research and resolution, enabling faster system audits, and improving tracking of configuration changes to support more seamless configuration changes. Secondly, the company needed to maintain quality, reducing occurrences of early promotion of another user’s work related to multi-user risks of promoting someone else’s work and eliminating the risk of wiping out another user’s changes.

The outcome of this collaboration was the creation of HealthRules Promote, a web-based application that all HealthRules Payer customers can now use to manage complex configurations and multiple instances of the solution. Medica noted that the collaborative effort between the two teams resulted in a powerful solution that helped the company support more than 400 configuration projects in the past year.

HealthRules Promote provides insight into the complexities of HealthRules Payer configuration and ensures that all unique dependencies are considered prior to promoting the configuration to production. It also allows multiple users across multiple lines of business to control and understand which users’ configurations are ready for promotion and which ones have conflicting dependencies.

For Medica, HealthRules Promote provides delivers several meaningful benefits:

1. The solution saves time through configuration artifacts by removing the need to create and maintain exports, eliminating separate spreadsheets for tracking, and easily importing configuration sets to new environments in just a few clicks.
2. The solution allows the company to confidently migrate configurations without errors that ultimately cause problems in production.
3. The dependency-and-compare features of HealthRules Promote allow Medica to easily audit builds across environments and identify development changes over time that may be causing product issues.

To explore how HealthRules Promote can empower your organization with actionable insights into the complexities of your multiple HealthRules Payer configurations, visit the HealthRules Promote page on the HealthEdge website or email [email protected].

 

What is the Transparency in Coverage Rule?

Prior to July 1,2022, most consumers of health care services were unaware of how much they cost, including myself.  My primary concern was whether it was a covered service and how much the copay or coinsurance was going to be after the insurance company processed the claim.  It never occurred to me that some providers may be charging vastly different prices for the same services.  The reality is that providers do have different rates for the same services.  The Transparency in Coverage (sometimes referred to as TiC) rule allows consumers to know the cost of a covered item or service before receiving them.

Beginning 1/1/2023, the Transparency in Coverage rule required that health insurance companies provide their members with an online tool that allows them to compare pricing data between different providers for several hundred covered services.  According to the rule, consumers should have the ability to access all their covered services using this same tool to make price comparisons no later than 1/1/2024.

How has this rule impacted the way consumers access healthcare services?

For me, the availability of price comparison data for my healthcare services is used to help me understand my potential out-of-pocket costs before I schedule services.  Even more importantly, this new ruling enables me to know how much of the cost is my responsibility before receiving the Explanation of Benefits (EOB) from the health plan.  Gone are the days when I would receive a bill from a provider indicating that I was responsible for tens of thousands of dollars for services rendered.  And yes, this did happen to me several years ago.

Providing consumers with this level of detail about their healthcare costs allows us all to engage in a more consumer-driven experience.  We now have tools to help us decide which providers we want to use, and this empowers each of us to play an important role in controlling the cost of our healthcare services.  As the saying goes ‘Knowledge is Power’ and it most certainly applies in this case.

Compliance with the Transparency in Coverage Rule

The good news is that health plans are complying with the Transparency in Coverage (TiC) rule and successfully implementing data processes and software applications to support this rule. Of course, this rule will continue to be refined and the processes in the background within health plans will continue to improve and evolve.  In the end, we will all benefit from the Transparency in Coverage (TiC) ruling by better understanding what is covered by our health insurance as well as managing the expected financial responsibility of our health care services.

Operationalizing Transparency in Coverage (TiC)

Making provider price comparison data available for use in an online tool for consumers is a massive undertaking for any health plan.  The data needs to include rates used for all covered items and services by in-network providers.  In addition, the allowed amounts, and billed charges from their out of-of-network providers are required.  Typically, this data is spread over multiple systems within a health plan, and consolidating the data is no easy task.

HealthEdge offers a suite of products to enable health plans to consume and transform the data needed to comply with this regulation.  Specifically, we can support health plans in the following ways:

• Adhere to the CMS mandate by understanding the health plans needs and system customizations
• Provide data in the required format that includes data dictionary updates
• Allows on-demand and monthly rate updates per contract configurations
• Enables data files access via SFTP line so they can be used to generate comprehensive rate lists

Learn more about HealthEdge’s suite of products here.

In the CY 2023 Final Rule, CMS made several changes that directly impact plans offering Dual Eligible Special Needs Plan (D-SNP) programs, which are a type of Medicare Advantage (MA) plan that are designed specifically for individuals who are eligible for both Medicare and Medicaid.

In general, the 2023 changes are intended to make the D-SNP population more attractive for providers, and therefore increase access to care for these beneficiaries. For payers, these changes are intended to increase clarification regarding different D-SNP programs and reduce the administrative burden of offering separate MA and D-SNP programs. However, many payers are concerned about the impact these changes will have on their bottom lines.

Here are four changes from the 2023 Final Rule that we believe deserve additional consideration.

1. Capturing Social Determinants of Health (SDOH) Data

The Final Rule requires D-SNPs to incorporate one or more questions in their standard health risk assessments (HRA) addressing beneficiary housing, food insecurities, and transportation. Acknowledging that many factors other than physical health go into a person’s ability to maintain their health, many physicians have already started collecting this type of information, which is commonly referred to as social determinants of health (SDoH). The goal of taking a more holistic view of a patient’s life, including psychological, functional, and environmental factors, is to increase the likelihood of better health outcomes and lower the total cost of care. Care management teams within many health plans are also on board with collecting SDoH data and are already using this data to tailor services beyond medical benefits to achieve optimal health outcomes. Some care management platforms, like GuidingCare^®, have already released capabilities within their platform that help health plans more systematically integrate SDOH into their care management programs.

2. Recalculation of the Maximum Out of Pocket (MOOP)

CMS also finalized changes to the way Medicare Advantage plans calculate MOOP, requiring plans to include all cost-sharing, including those paid by secondary payers, in the calculation of the beneficiary’s MOOP. Previously, MOOP was calculated only by the amount the enrollee had to contribute. The result? Beneficiaries are likely to reach MOOP faster, and health plans will have to pay 100% of the service costs sooner. Some industry experts believe this change will result in an additional $4B in costs to health plans, but the improvement in health outcomes and improved access to medical and non-medical care is projected to save $3B. Despite the pushback from health plans on this change, CMS proceeded with the implementation of this and made it effective June 1, 2023. The complexities and urgency of the implementation of this change is a perfect example of why health plans need a modern, highly flexible core administrative processing system (CAPS) like HealthRules^® Payer.

3. Enrollee Participation in Plan Governance

Medicare Advantage organizations offering a D-SNP must establish one or more enrollee advisory committees in each state to solicit direct input from beneficiaries on their experiences with the plan. Plans that operate D-SNPs in multiple states had to establish multiple committees, one for each state. Although these committees must have a representative sample of the population enrolled in this plan, very little direction was given about the committee meeting frequency, location, format and training.

4. Bringing Greater Definition to multiple Types of D-SNPs

Historically, the fully integrated dual eligible (FIDE) and highly integrated dual eligible (HIDE) SNP definitions have been confusing and inconsistent. Through this final rule, CMS is making changes to the definitions, which will support a greater understanding of the different types of D-SNPs, clarify beneficiary options, and improve integration. According to a National Law Review article, this means all FIDE SNPs, with the same legal entity holding the MA and Medicaid contract: 1) be capitated (with certain exceptions) for all Medicaid services, and 2) operate unified grievance and appeal processes. CMS also clarified the definition of HIDE SNPs requiring the plan to cover long-term services and supports, including i) community-based long-term services and supports and some days of coverage of nursing facility services during the plan year; or (ii) behavioral health services. For plan year 2025 and subsequent years, the FIDE and HIDE SNP must cover the entire service area for the dual eligible special needs plan. By helping health plans enroll the appropriate beneficiaries into the right categories and having the ability to create tiered or dual networks, HealthRules Payer enables health plans to quickly spin up whichever type of D-SNP program they believe would be most valuable for the communities they serve.

Turning Mandates into Advantages

While the only constant in government health plans, including D-SNP programs, is change, health plans with a highly configurable CAPS can turn mandates into competitive advantages. For example, health plans using HealthRules Payer now have the opportunity to pursue D-SNP populations with less IT and administrative burdens because the system can be configured to address the unique D-SNP requirements. Health plans don’t have to implement an entirely new system. Things like dual networks and tiered networks are completely configurable in HealthRules Payer. The business flexibility HealthRules Payer gives health plans is unmatched and dramatically lowers the cost of entry into new lines of business.

In addition, the requirement to capture additional data, such as SDoH, is another opportunity for health plans to convert mandates into competitive advantages. With modern data analytics and reporting solutions from HealthEdge, plans can easily turn data into actionable insights that can help drive improved member outcomes, higher HEDIS scores, and better Star ratings. For example, SDoH insights can help care management teams configure new non-medical services, like transportation or meal support, for certain populations. Utilization management data collected can be folded into benefit plan development, and even fed into payment integrity initiatives to minimize provider and member abrasion with more accurate payments.

Looking at the Whole Picture

When regulatory changes such as those mentioned above are put in place, health plans often make the mistake of just looking at the one part of their business that is directly impacted instead of taking an end-to-end approach to implementing the changes across their enterprise. That’s where the professional services team at HealthEdge can be a health plan’s biggest asset. With years of experience in helping government-related health plans properly configure their systems to support regulatory changes, the team knows how to guide health plans through all aspects of the business that may be impacted so that everything from enrollment to claims coming in and payment going out are aligned.

To learn more about how HealthEdge solutions help health plans turn mandates into advantages, visit www.healthedge.com or email [email protected].