In recent months we have received several memos and updates on changes to supplemental benefits communications, reporting, and now submissions via encounter data processing.
In a press release from Jan 25, 2024, CMS stated “For supplemental benefits, CMS has taken multiple actions that will ensure that, by 2025, CMS has data needed to answer key policy questions related to supplemental benefits, including what is being offered, what plans are spending, which enrollees use which services, the cost to enrollees, and plan-level utilization.”
New Guidance Released on Encounter Data Submission of Supplemental Benefits
The most recent Health Plan Management Systems (HPMS) memo from CMS titled, Submission of Supplemental Benefits Data on Medicare Advantage Encounter Data Records released on February 21, 2024, is a reminder to plans of their need to submit their supplemental benefits via the Encounter Data Submission Process. Many health plans are submitting their hearing and vision supplemental benefits, but services for providers that do not have an NPI or normal claims submission, called Atypical providers by CMS, has been a challenge for most health plans. CMS clarifies the expectations for submission of all supplemental benefits and provides some guidance and suggested action.
The highlights in this memo are:
CMS realizes plans may need time to implement the actions but should come into compliance as soon as possible for calendar year 2024 dates of service.
That MA health plans are required to submit all supplemental benefits through encounter data, but CMS acknowledges that a number of benefits could not be submitted because certain data elements required for EDS to accept the data did not exist or CMS had not provided specific instructions.
MA health plans currently successfully submitting the EDRs for any supplemental benefits should continue with those actions while they enhance current functionality to submit the additional supplemental benefits.
CMS will be monitoring submissions and reaching out to MA health plans that may not be submitting supplemental benefits based on their bid. They will use this process to provide technical assistance, gather feedback on challenges and provide additional guidance.
What Should Health Plans Do?
CMS expects plans to submit this data in the standard EDR format. Enhancements to Medicare covered services and supplemental vision and hearing benefits can be submitted without issue.
Supplemental Dental Benefits
Part A and Part B covered dental services are already submitted on the 837P and I file. For supplemental dental benefits CMS will be enhancing the X12 837D Version 5010 claim form. CMS will notify plans when this adjustment has been made and anticipates this will occur in June 2024. Plans will then need to go back to 1/1/2024 dates of service and submit to be caught up on those submissions by the end of the year.
Other Supplemental Benefits
A. Solution for Missing Data Elements Needed to Populate an EDR Record
In many instances with Atypical providers, data is not received from providers that allows the EDR fields to be populated because of a lack of specific information such as NPIs, procedure codes, diagnosis codes, and/or revenue codes.
The good news is that your Atypical providers who do not have and are not eligible for an NPI do not need to apply for one. CMS created defaults for use when the data does not exist. For all supplemental benefits for which there does not exist sufficient data to populate the EDR record, CMS has developed default codes. This was published on the CSSC Operations website in the guidance which include technical specifications on the Supplemental Benefits Service Submission Guidance page.
B. Guidance on Benefits Not Provided in a Reportable Manner
In other instances, benefit usage is not reported in a manner that can be submitted on an EDR record. The non-medical benefit may have different patterns of use or be paid on a capitated basis and not a per usage basis. This would include things like annual gym membership, pre-paid/flex cards, or use of an online app or monthly monitoring tool such as PERS.
This will be the more challenging process of the new guidance requirements. CMS provides guiding principles in the memo explaining what MA plans should consider and gives examples to help plans make determinations on how to report the benefit usage. Guiding principles include:
Per unit should be submitted whenever possible and practical.
When not practical, MA plans should consider submission options such as:
report when the enrollee first had access to and is able to use the benefit,
when benefits cannot be reported on a per usage basis, reporting at the end of the quarter the portion of the benefit used during that time period.
CMS provides several examples in the memo and in the Supplemental Benefits Service Submission Guide to assist MA plans.
Flex cards, a much-loved benefit by enrollees, may have some of the most challenging reporting. CMS indicated in the Supplemental Benefits Service Submission Guide that they expect pre-funded/flex cards that span multiple supplemental benefit categories such OTC and healthy groceries to report out each category uniquely.
Next Steps
What should health plans do? There are several steps that health plans should take in the next week.
Review your Encounter Data submission process to determine if you are submitting vision, hearing and Medicare enhanced supplemental benefits today. If your plan is not submitting these services, this should be a high priority as the Encounter Data submission process can accept these records with no need for default data.
Evaluate what your vendors are providing to you today to determine how it can be used, along with the default data to be submitted.
Identify what gaps exist with your current vendors. Do not conduct this analysis in isolation, as the CMS Part C reporting requirements contain new CMS Supplemental vendor reporting that may also require changes.
Review your vendor contracts to ensure they do not need updates or change requests to get the needed information.
Set up time with your vendors to discuss the gaps, these new requirements, and how your supplemental benefits vendors can provide the needed information.
Establish timelines that will allow for your MA plan to come into compliance with submitting 2024 data by the end of the year.
In our discussions with our health plan and vendor clients we have continued to state the scrutiny on supplemental benefits will only increase. Take some time to evaluate all the recent guidance to produce a consolidated plan to meet the new supplemental benefits requirements. If you do not get ahead of this, your organization should expect that CMS will outreach to discuss why.
If you have questions on supplemental benefits or any other Medicare Advantage topics you can contact us at contactus@rebellisgroup.com or fill out an information request here.