BlueCross BlueShield Association Comments on Agency Information Collection Activities

WASHINGTON, Dec. 20 -- Jane Galvin, managing director for regulatory affairs at the BlueCross BlueShield Association, has issued a public comment on the Centers for Medicare and Medicaid Services' notice entitled "Agency Information Collection Activities; Proposals, Submissions, and Approvals". The comment was written and posted on Dec. 17, 2019:

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The BlueCross BlueShield Association (BCBSA) appreciates the opportunity to provide comments on the Centers for Medicare & Medicaid Services (CMS) Applicable Integrated Plan Coverage Decision Letter, as outlined in the agency's Federal Register notice on October 18, 2019.

BCBSA is the national federation of the 36 locally operated Plans that serve one in three persons in this nation today. Plans participate in Medicare Advantage and Part D and also many Plans are Medicaid managed care options in many states today. Some of our Plans offer Special Needs Plans in their service areas serving those with both Medicare and Medicaid.

In the CMS proposed letter, CMS outlines new requirements for Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs) and Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs) 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," starting in CY 2021, in place of the current Notice of Denial of Medical Coverage (or Payment) (NDMCP) form.

Implement Uniform Grievance and Appeals Templates across Dual Eligible Special Need Plans (D-SNPs)

BCBSA overall is concerned that the Applicable Integrated Plan Coverage Decision letter (the letter), as proposed, would add to the complexity of the appeals process, which might increase confusion for vulnerable beneficiaries. The different model coverage determination letters for DSNPs increase the opportunity for error when informing a beneficiary of a coverage decision and their appeal rights. Therefore, we request CMS implement uniform grievance and appeal letter templates across 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 draft letter contains several additions for state-specific information. 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. We request that CMS limit the number of state-specific changes that may be made to the letter.

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 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 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." BCBSA believes this discretion presents challenges impacting operations and coordination in the following ways:

* 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 beneficiaries at different levels, or at the time the initial appeal is received.

The state appeal and grievance variations could lead to inconsistent reports to CMS from Part C and D organizations and sponsors, and audit challenges. For example, for D-SNP members, Medicare has a specific process that is followed for all beneficiaries. As CMS works to improve coordination between the D-SNPs and the state Medicaid agency, the Agency's allowance of states' discretion to implement different standards may lead to operational challenges for health plans and ultimately complicate efforts to educate beneficiaries about their coverage decisions and appeals rights. We encourage CMS to leverage opportunities to improve beneficiary 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:

* your Medicare and Medicaid [Insert state-specific term for Medicaid, if applicable] services.

* your doctors, hospitals, pharmacies, and other health care providers into one coordinated system."

If an entity operates a HIDE-SNP, even if fully aligned, the plan may still retain two networks. 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 as to 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."

BCBSA's 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 because beneficiaries often ask for a State Fair Hearing before a plan appeal. The current FIDE IDN letter states "You must ask us for an appeal and get a decision on that appeal, before you can request a Medicaid State Fair Hearing." We recommend the addition of this same language to the letter.

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 inconsistent with when the beneficiary actually receives the letter.

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BCBSA 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 incentives and a general lack of insight between the Medicare and Medicaid plan sponsors into the policies and processes of the different programs or benefit plans. While Plans attempt, where appropriate, to create "aligned" D-SNP entities, this is not possible or an easy transaction in some states for a number of reasons, including the lack of a default enrollment process.

BCBSA 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 [email protected]

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