Anthem Issues Comment on Agency Information Collection Activities

WASHINGTON, Dec. 27 -- Anthony Mader, vice president of public policy at Anthem Inc., Sacramento, California, has issued a public comment on the Centers for Medicare and Medicaid Services's notice entitled "Agency Information Collection Activities; Proposals, Submissions, and Approvals". The comment was written on Dec. 17, 2019, and posted on Dec. 18, 2019:

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Anthem, Inc. (Anthem) appreciates the opportunity to provide comments on the Centers for Medicare & Medicaid Services (CMS) Applicable Integrated Plan Coverage Decision Letter, as outlined by Federal Register notice dated October 18, 2019.

Through its affiliated companies, Anthem serves more than 77 million people, including more than 2 million Medicare and 7 million Medicaid beneficiaries, and is committed to providing access to high-quality, affordable healthcare services that help consumers improve their health and well-being. As one of the nation's leading health benefits companies, Anthem appreciates its partnership with CMS to serve dual eligible beneficiaries.

In CMS' proposal, the Agency outlines new requirements for Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) and Highly Integrated Dual Eligible Special Needs Plans (HIDE-SNPs) with exclusively aligned enrollment to unify and update appeals and grievance procedures. As part of these procedures, FIDE-SNPs and HIDE-SNPs will be required to issue an Applicable Integrated Plan Coverage Decision Letter (the letter) starting in Calendar Year 2021, in place of the Notice of Denial of Medical Coverage (or Payment) (NDMCP) form. We appreciate CMS' continuing efforts to integrate care for individuals who are dually eligible, while also aligning business practices. Anthem strongly supports the creation of a more simplified, streamlined appeals and grievance process. We provide the following recommendations to improve the proposed letter.

Implement Uniform Grievance and Appeals Templates across Dual Eligible Special Need Plans (DSNPs) We appreciate the statutory requirements CMS must abide by in creating this new letter, but we are concerned that the letter, as proposed, would add to the complexity of the appeals process, which could lead to increased confusion for beneficiaries. The different model coverage determination letters for integrated D-SNPs increase the opportunity for error when informing a beneficiary of a coverage decision and appeal rights. This is of particular concern in markets where multiple dual-eligible plans and D-SNP models exist. Therefore, we request that CMS implement uniform grievance and appeal letter templates for all integrated D-SNPs to increase consistency, avoid confusion, and accommodate varied state standards by combining the proposed letter with existing D-SNP coverage decision letters.

Promoting Uniformity and Standardization for All D-SNP Appeal Standards

The letter contains several additions allowing states to include state-specific updates. We are concerned that significant state-level changes to the letter will create operational challenges and increased opportunity for inaccurate information that may misinform beneficiaries. This comment is exclusive of Medicaid-specific appeals processes, particularly the Fair Hearing, where we know there is market variation existing today. We request that CMS limit the number of state-specific changes that may be made to the letter to content other than Medicaid appeals processes.

In sections of the letter, CMS provides an option for states to choose certain terminology, including "doctor or health care provider" and "service or item." We understand that in some instances a health plan may be required to fill in the name of a specific service or provider. However, in other instances where generic terms like "service" would be appropriate, we prefer that CMS hard code these portions of the letter so as to instruct all states to use the same term (i.e., "service" and "health care provider").

This would limit unnecessary variation across states with respect to terminology not materially unique to each state's program or population.

Similarly, in the letter section describing appeals options, the language currently reads "If you ask for a standard appeal, our plan will send you a written decision within <30 calendar days or for a Part B drug 7 calendar days>." We prefer that CMS instruct all states to use a more specific hard coded statement, such as "If you ask for a standard appeal, our plan will send you a written decision within 7 days for Part B drugs and 30 days for all other services or medications."

In addition, CMS has allowed states the "discretion to implement standards different than those established in the final rule if the state standards are more protective for enrollees, such as shorter timelines for a plan to make a decision on an appeal." Anthem recommends markets with more accommodating appeals processes be considered for all integrated D-SNPs since we believe the current discretion presents challenges impacting operations and coordination in the ways listed below:

- Creates a distinction between a complaint and a grievance given variation in state definitions. Definitions should be consistent to mitigate challenges classifying and reporting grievances;

- Leads to variation in state grievance timeframes. Timeframe variation impacts when a grievance is identified and consistency with resolution timeliness; and,

- Leads to differences in state appeal timeframes and concurrent appeal process. For example, states Fair Hearing requests can be initiated by enrollees at different levels, or at the time the initial appeal is received.

The state appeal and grievance variations could lead to inconsistent Parts C and D reporting to CMS, and audit challenges. For D-SNP members, Medicare has a specific process that is followed for all members.

As CMS works to improve coordination between the D-SNPs and the state Medicaid program, the Agency's allowance of states' discretion to implement different standards may lead to false negatives as it relates to reporting of appeal and grievance responses and resolutions. We encourage CMS to leverage opportunities to improve enrollee protections while promoting uniformity and standardization for all D-SNPs.

Suggested Improvements to Clarify Coverage and Appeals Rights Opening Section Currently the letter reads as follows:

"<Health plan name> is called "our plan" or "we" in this letter. Our plan is your health insurance company. We combine: o your Medicare and Medicaid [Insert state-specific term for Medicaid, if applicable] services. o your doctors, hospitals, pharmacies, and other health care providers into one coordinated system."

We are concerned that the current language is more relevant to a FIDE-SNP, which operates a single network. Therefore, we ask CMS to improve the accuracy of the language to clarify expectations of each product for the beneficiary.

How to Keep Services or Items during Appeal

Currently the letter reads as follows:

"If you're already getting the <service or item> listed on the first page of this letter, you can ask to keep getting it during your appeal."

We recommend this section instead use the following wording:

"If we are stopping or reducing a previous approval of the service listed on the first page of this letter, you can ask to keep getting that service during your appeal."

Our suggested language would prevent beneficiary confusion around authorizations with a limited time period, versus authorizations that are terminated or reduced. This change is consistent with current New Jersey FIDE-SNP Integrated Delivery Network (IDN) language, which currently states "how to keep our services while we review your case: If we're stopping or reducing a service, you can keep getting the service while your case is being reviewed."

Medicaid State Fair Hearing (SFH) Language

We request the addition of Medicaid SFH language. Beneficiaries often ask for a SFH before a plan appeal, though the timing to request an SFH varies by state. We recommend CMS consider implementing a uniform timeframe for member to request a SFH.

Streamlining of Dates

Currently the letter reads as follows:

"You must appeal by [Insert specific appeal filing deadline date in month, date, year format - 60 calendar days from date of letter. Insert deadline date in bold text]. Our plan may give you more time if you have a good reason."

We suggest adding the language "you have 60 calendar days" due to the complexities of printing a date that may be inconsistent with when the beneficiary actually receives the letter. In addition, some markets with integrated D-SNPs have varying requirements for the date to be printed on the letter, which may not always correspond to a consistent date of receipt. Date of receipt can be either the date delivered or the date a member or authorized representative opened the mail.

Anthem appreciates CMS' recognition that a unified appeals and grievance process may not be appropriate or possible in all cases. Much of the operational and structural complexities come from misaligned program rules and incentives. While Anthem supports integration and aligns D-SNP entities where appropriate, this is not possible or an easy transaction in some states for a number of reasons, including the lack of a default enrollment process. Anthem strongly supports the creation of a more simplified, streamlined appeals and grievance process. Should you have any questions or wish to discuss our comments further, please contact Lisa Watkins at 202-508-7889 or [email protected].

Sincerely,

Anthony Mader

Vice President, Public Policy

About Anthem, Inc.

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The notice can be viewed at: https://beta.regulations.gov/document/CMS-2019-0149-0001

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