LBodnarchuk, Author at ProspHire

HEDIS Opioid Measures and Strategies to Mitigate the Use of Opioids

Written by LBodnarchuk on January 12, 2023. Posted in Insights.

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As the COVID-19 pandemic wanes through the public health lens, attention is shifting towards America’s pre-pandemic epidemic: opioid misuse. In 2017, the US Department of Health and Human Services declared the opioid crisis a national emergency. The CDC has stated that the opioid crisis began in the late 1990s, but an increasing number of individuals affected by addiction and opioid use disorder deaths over the last decade has increased public awareness of the topic.

Opioid addiction often begins with a prescriber trying to help a patient manage pain. Patients can receive excessive amounts of opioid-containing pain medications, leading to addiction and unlawful obtainment and use of medications within this class. It is estimated that tens of thousands of Americans die every year due to opioid misuse. With this, HEDIS (Healthcare Effectiveness Data and Information Set), managed by the National Committee for Quality Assurance (NCQA), has set forth three measures specific to mitigating overprescribing, misuse, and overuse of opioids. Here, we will highlight the opioid specific HEDIS measures, along with strategies and best practices for plans to consider.

As defined by HEDIS, the opioid measures include:

Use of Opioids at High Dose (HDO) – Members 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.
Use of Opioids from Multiple Providers, Prescribers and Pharmacies (UOP) – Members 18 years of age and older receiving prescription opioids for ≥15 days during the measurement year from multiple providers. Three rates are reported:
- Multiple Prescribers: The proportion of members receiving prescriptions for opioids from 4 or more different prescribers during the measurement year.
- Multiple Pharmacies: The proportion of members receiving prescriptions for opioids from 4 or more different pharmacies during the measurement year.
- Multiple Prescribers and Multiple Pharmacies: The proportion of members receiving prescriptions for opioids from 4 or more different prescribers and 4 or more different pharmacies during the measurement year.
Risk of Continued Opioid Use (COU) – Members 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:
- The percentage of members with at least 15 days of prescription opioids in a 30-day period.
- The percentage of members with at least 31 days of prescription opioids in a 62-day period.

What Can Health Plans and Providers Do To Improve Opioid Overuse?

These three HEDIS measures create opportunities for providers and plans to control opioid utilization and identify members who are/or at risk of becoming opioid dependent. Without careful implementation and maintenance of these measures, members may face an unhindered path to becoming addicted, suffering opioid-related disorders and potential overdose deaths. Outlined below¹ is a list of best practices and strategies health plans and providers can take to mitigate the risks and negative consequences of uncontrolled opioid use.

best practices and strategies health plans and providers can take to mitigate the risks and negative consequences of uncontrolled opioid use

Supporting Sensible Prescribing Practices: Health plans can support the appropriate prescribing of opioids by aligning their formulary structure and opioid monitoring system. Members should be monitored when initiating opioid treatment or maintained on chronic therapy. Initial prescriptions for opioids exceeding 50 MME per day should automatically flag for health plan pharmacist review. Rationale for use should be provided by the prescriber and documented in the member’s medical record regarding duration of therapy and indication for use.

Focusing on Enhanced Member Results: Promoting enhanced member results should place an emphasis on the utilization of nonopioid pain treatment regimens. Simplistic changes can consist of monitoring patients on over-the-counter (OTC) pain medications, such as acetaminophen or ibuprofen, before beginning opioid therapy. Health plans should also consider triaging patients to appropriate alternative therapy, such as chiropractic care or physical therapy. Treating the source of the pain instead of promoting medication use may prove beneficial to some members.

Recognizing Overuse, Misuse and Fraud: To identify issues with opioid prescribing or member consumption, health plans can consider incorporating prescription drug monitoring programs into daily practice. Providers and pharmacists alike should review the local state prescription drug monitoring program prior to writing a prescription for opiate therapy or dispensing the medication to the patient. These programs have decreased the number of multiple providers writing opioid prescriptions for members and decreased substance abuse admissions. Dispensing profiles can help identify the validity of prescriptions for members or duplicative therapy that can impact the member’s overall health.

Advocating for Safe Communities: Participating in activities, such as prescription drug takeback programs, can help to keep members of the community safe. Health plans should consider utilizing local agencies to sponsor these takeback programs. Unnecessary prescription drugs, including opioids, can be misused or abused by individuals prescribed the medications or unregulated members of the community. Increased prevalence of these programs in the community is the best way to dispose of used or expired medications.

Don’t Wait to Provide the Highest Quality Possible for your Members

At ProspHire, we want to help you provide the highest quality of care possible for your members. With our team’s extensive healthcare industry knowledge and commitment to delivering valuable results, we are here to help you optimize strategy and execution of care.

Aligning best practices with strategy can assist plans in reducing the inappropriate use of opioids. From providing current state assessments to implementation playbooks, our experienced staff can help health plans develop an improvement pathway that is tailored to meet the needs of your organization.

ProspHire’s team of clinical experts are ready to partner with your health plan and work shoulder to shoulder to improve member and community safety. Connect with us today.

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ProspHire Names First Chief Marketing & Communications Officer

Written by LBodnarchuk on December 25, 2022. Posted in News.

PITTSBURGH, PA – Founding Principals Lauren and Chris Miladinovich today announced that ProspHire has named Tricia Egry as its first Chief Marketing & Communications Officer. Tricia was previously Senior Director and remains a member of the Firm’s Executive Leadership Team. She is responsible for enhancing and amplifying the ProspHire brand and building and driving a marketing & communications strategy and digital-first programs that drive engagement and conversation, while inspiring a team of nearly 100 employees and consultants across the U.S. ProspHire is a woman-owned and rapidly expanding Pittsburgh-headquartered management consulting firm focused on healthcare advisory, project delivery and strategic resourcing.

“Since Tricia joined ProspHire in 2021 she has championed an aggressive multi-functional digital marketing strategy that focuses on creating a Best-in-Class client experience to drive lead generation, cross-selling and sales,” said Lauren Miladinovich, ProspHire’s Managing Principal and CEO. “Tricia’s dedication to ProspHire and its people is exceptional and we are thrilled to promote her to be our first Chief Marketing & Communications Officer.”

A proven marketing leader, Tricia brings considerable experience in delivering high-impact, integrated marketing, brand and communications strategies across diverse industries, locations and geographies. Prior to joining ProspHire, she served as National Marketing & Communications Leader of Field Teams at BDO, USA, where she led marketing & communications strategies for more than 60 U.S. offices by managing the development and execution of go-to-market plans that included digital and social media campaigns, public relations and advertising initiatives, sales enablement and bid management and event and sponsorship strategies. She came to BDO through the expansion of Alpern Rosenthal, where she led strategic marketing initiatives for numerous industries as Director of Marketing. Tricia’s career experience also includes being a journalist and news producer for NBC and a disc jockey at several radio stations in Western PA.

“The story of ProspHire is one that I can really relate to,” commented Egry. “It’s a brand that lives at the intersection of relationships and innovation and the leadership aims to help our people, our clients and our communities prosper. I look forward to continuing to evolve the Firm’s marketing and communications program and playing a critical role in our continued momentum and expansion.”

“This is a big moment for ProspHire,” said Christopher Miladinovich, ProspHire’s Principal and Chief Operating Officer. “Tricia’s extensive experience leading marketing organizations at various stages of growth will help our Firm drive revenue and accelerate as we embark on our next chapter.”

New CMS Proposed Rule

Written by LBodnarchuk on December 21, 2022. Posted in Insights.

The Centers for Medicare and Medicaid Services (CMS), the federal oversight body for all Medicare programs, released a proposed rule on December 14, 2022, addressing policy and technical changes to the Medicare Advantage programs including Medicare Stars. Proposed rules are not final law, but they do outline what changes CMS intends to make to existing laws impacting how Medicare programs operate.

Health plans and other affected groups can submit comments to CMS for consideration by February 13, 2023, as CMS develops the final rule, which becomes law at the time of release.

Here’s what you need to know about the latest proposed changes from CMS relevant to Medicare Stars.

Summary of Proposed Changes | Stars Program

With the CY2024 Proposed Rule Changes, CMS is once again aiming to dynamically alter the Medicare Stars Quality program. The changes, only in the “proposed” stage, are subject to commentary and public review before the final rule is codified. One of the biggest changes in the proposed rules is the proposed shift of the Member Experience: Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Administrative Measures from a weight of 4x back to the previous 2x weight in measurement year 2024 (Star Year 2026). This shift would have significant impacts on the relative scoring weight of the measure domains.

CMS is also proposing the addition of five new HEDIS and Part D measures in measurement year 2024 (Star Year 2026). These measures, listed below, will require new member-level data analysis, internal process changes, and intervention development.

Kidney Health Evaluation for Patients with Diabetes (KED)
Care for Older Adults (COA) Functional Status Assessment
Concurrent use Opioids and Benzodiazepines (COB)
Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH)
Polypharmacy Use of Multiple Central Nervous System Active Medications in Older Adults (Poly-CNS)

In addition to new measures and changing weight, another major proposed change from CMS is the replacement of Reward Factor with a Health Equity Index (HEI) Factor in measurement year 2025 (Star Year 2027). This change, further discussed below, will have significant impacts on the overall scoring of the Stars Program. This change will likely have disproportionate impacts on the higher scoring health plans (>4.0 Stars) given the nature of the reward factor calculation. Although much is not yet known regarding the specifics of the HEI Factor calculation, this shouldn’t come as a major shock to health plans. CMS has been signaling for some time now a commitment to health equity initiatives through quality programs, and this is very much so in line with that thinking.

Lastly, CMS is proposing the risk-adjusting at the sociodemographic level of the 3x weighted Medication Adherence measures in measurement year 2026 (Star Year 2028). These potential adjustments could have tremendous impacts to plans, especially depending on the member mix (i.e. DSNP allocation, MAPD allocation, etc.).

Weighting Shift

In Star Year(SY) 2023, CMS shifted the weight of Administrative and CAHPS measures to refocus health plan’s initiatives on improving member experience. The new CMS proposed rule will reverse this change and reduce the weight of patient experience and access measures to even the weight across domains.

Weighting Shift Key Insights

Final Proposed Weighting: (MY2024/SY2026)

Patient Experience/Complaints and Access Measures – 2x
Process Measures – 1x
Intermediate Outcome Measures – 3x
Part C and D Improvement – 5x

The current 4x weighting likely caused a shift away from health-related measures and outcome driven measures given the relative weighting importance. Reducing the weighting will better align the patient experience/complaints and access measures more closely with other domains.

Plans should continue to focus interventions around listening to the voice of the member given the important link between patient experience, retention, medication adherence, and other health outcomes.

Measure Weighting Adjustment SY2024 vs. SY2026

New and Revised Measures

The period of effect is beginning on or after January 1, 2024.

Replace Reward Factor with HEI

CMS is proposing to replace the reward factor with a health equity index(HEI) reward for the 2027 Star Ratings to incentivize plans to focus on improving care for enrollees with social risk factors (SRF).

What is the Health Equity Index and Final CMS Stars Ratings for 2023

Timeline Impact

Proposed Stars changes will set in starting in MY2022 (SY2024), with tiered rollout continuing through MY2026 (SY2028).

Is your health plan’s Stars program ready to respond to these upcoming changes?

ProspHire’s team of Stars experts are ready to partner with your health plan to prepare and plan for these changes to the Medicare Stars program. We work shoulder to shoulder with clients to improve Star ratings and enable long-term sustainable program success.

What Is Value-Based Healthcare?

Written by LBodnarchuk on December 8, 2022. Posted in Blog, Clinical Services Optimization.

Jump to:

What Is Value-Based Care and How Does It Work?
Examples of Value-Based Healthcare
What Does Value-Based Care Mean for Payers and Providers?

Traditional fee-for-service healthcare does not always provide a desirable system for all patients. It can result in inadequate or overpriced services, making it a less attractive option for many individuals. 

Value-based care (VBC) is changing the landscape by lowering prices and boosting satisfaction for patients, payers and providers as well as aligning incentives and promoting quality care.

We are exploring the different facets of VBC to help you better understand this care model. Learn what value-based healthcare really means, how it works, and its many benefits. 

What Is Value-Based Care and How Does It Work?

Value-based healthcare programs are designed to reward providers for delivering the highest quality of care. They involve incentive payments for the efficiency and ultimate effectiveness of the services delivered. These systems work as a form of reimbursement and rival traditional healthcare programs that operate with retrospective payments based on bill charges. 

The U.S. federal government first introduced VBC programs in 2008 to improve healthcare services provided to people with Medicare as part of the Medicare Improvements for Patients and Providers Act (MIPPA). In 2010, the Affordable Care Act (ACA) also further advanced the development of value-based healthcare. 

Today, both federal and commercial payers are leading the way in value-based care initiatives by focusing on common areas of duplication, supporting care pathways and evidence-based medicine goals. Removing unnecessary variation in care delivery means better outcomes and lower costs.

Examples of Value-Based Healthcare

Value-based healthcare is available in a variety of options. The following are some of the most popular programs you can choose from:

Accountable Care Organizations

Originally intended for Medicare patients, accountable care organizations (ACOs) coordinate various healthcare providers to offer coordinated care for a defined population of patients. Providers in the organization share not only the responsibility for improving care, but also the associated risks and incentives in quality performance metrics and lowering costs. While ACOs must invest in technology, people and processes to improve care, the risk arrangements often allow for returns on the investment.

Bundled Payment

A bundled payment, also called an episode-based payment, encompasses a program that allows patients to pay for an entire episode of treatment for medical and surgical care. The bundled payment methodology usually begins during hospitalization or surgical procedures and ends ninety days after the initiation of the bundle. This allows providers to emphasize not only the treatment provided within the hospital but the post-acute services, such as rehabilitation or nursing care afterward. It helps incentivize better care transitions and utilization of high-quality post-acute providers that keep the patient safe and avoid unnecessary readmissions.

Patient-Centered Medical Homes

A patient-centered medical home (PCMH) is another value-based healthcare model that is centered on a team-based approach to care, anchored in the primary care setting. Providers are typically reimbursed with additional payments to support a more patient-centric and care management delivery model often including services for physical health, mental health, wellness and around-the-clock availability to meet patient and caregiver needs.

Hospital Value-Based Purchasing

CMS has also established metrics for most US hospitals related to penalties and risks for quality and cost of care. The programs require hospitals to improve performance on hospital-acquired conditions, value-based purchasing and readmission reduction. These programs place a significant portion of Medicare revenue at risk for hospitals and allow hospitals to grow and support other providers in value-based arrangements.

What Does Value-Based Care Mean for Payers and Providers?

Now is the time to consider examining or re-examining these programs and the impact on quality care and lowering costs. Are the current programs effective? Are patient outcomes improving and is the expense of operating in these models truly impacting cost? While research is mixed, there is no question that rethinking healthcare reimbursement is here to stay. The most successful organizations are finding the right combinations of care management, pathways, reimbursement and patient engagement that is pushing healthcare delivery in the right direction.

There are several challenges to success in value-based care. One challenge is access and analysis of timely data that provides the necessary feedback on what is working and what may not be working in care delivery. Often data that providers see is outdated and not well presented to allow real-time interventions or change.

Another challenge is the lack of coordination between payers and providers and coordinated use of resources for patient/member care management. Care management services may be offered by physician practices, hospitals and payers without a patient-centric approach which can be duplicative and sometimes conflicting. In an ideal system, these important care management and care transition services should be coordinated and focusing on ensuring patients are guided through chronic and acute illnesses and services without overlap or complications.

Working together, payers, providers and patients can optimize value-based care models by learning from past experiences and continually finding new and innovative ways to align incentives, improve engagement and concentrate on quality outcomes and appropriate costs.

ProspHire wants to help you provide the highest quality of care.

Turn to ProspHire to Learn More

Value-based healthcare can assist in advancing the Quadruple Aim. From providing better care at lower costs to improving health management strategies, this type of care offers many benefits.

At ProspHire, we want to help you provide the highest quality of care possible for your patients. With our team’s extensive healthcare industry knowledge and commitment to delivering valuable results, we are here to optimize your project resource management.

Are you interested in learning more about how ProspHire can enhance your organization’s processes and improve your performance with integrated clinical care solutions? Contact us below to get started today!

ProspHire Honors the Memory of Managing Director Hannah Hass

Written by LBodnarchuk on December 1, 2022. Posted in News.

One year after ProspHire Managing Director Hannah Hass passed away, the Firm unveils ‘In Her Shoes’, a Women in Leadership Training Program, in her honor. This program is focused on inspiring and empowering the women of the Firm through professional development.

‘In Her Shoes’ is a 6-week program that aims to develop future female leaders within ProspHire, focusing on driving innovation, creating high-performing teams, managing difficult situations and developing within your leadership style. “In memory of our colleague and dear friend, Hannah Hass, the ‘In Her Shoes’ program is dedicated to making a positive impact on ProspHire’s Women in Leadership by women empowering women,” says Lauren Miladinovich, Co-founder, Managing Partner and CEO of ProspHire.

The oldest of three sisters, Hannah spent her early life exploring the hills and mountain rivers near Elkins, West Virginia. She loved being on the river and you could often find her sharing a kayak with her German Pinscher, Franz. She had a successful career as a consultant at Deloitte and moved on to build a loving work family at ProspHire, where she was admired by her colleagues for her independence, intelligence and humor. Hannah loved bringing people together.

Donations may be made in Hannah’s name to Project HEAL.

Remembering ProspHire Senior Principal Advisor Rick Dorman

Written by LBodnarchuk on December 1, 2022. Posted in News.

It is with great sadness that we inform of the passing of our friend and colleague Rick Dorman. After facing a battle with cancer, he died on November 12, 2022, with his family by his side. Our sincere condolences go out to Rick’s family during this difficult time.

“Rick represented the best qualities of an advisor, partner, mentor and teammate,” said Lauren Miladinovich, Co-founder, Managing Principal and CEO of ProspHire. “He will be greatly missed by his colleagues across the Firm.”

Rick spent 27 years at Deloitte Consulting, becoming Principal in 1999. Upon retiring, he became an advisor at ProspHire. He was passionate about project management and business development. He was candid, but kind – he never held back. He was a man of sarcasm with much love behind it.

He was an active force on the ProspHire board of advisors and coached new and aspiring partners. Those who worked closely with Rick know how much pride he took in his profession and how he enjoyed life enthusiastically. His knowledge of wine often led to him being designated to select the wine for leadership team dinners.

“More than anyone I know, Rick loved life, he loved the profession and he loved ProspHire. He was the consummate teammate and friend and cared deeply for every staff member,” shared Chris Miladinovich, Co-founder, Principal and Chief Operating Officer of ProspHire. “Together, we remember Rick and the indelible legacy he left at the Firm.”

Rick was a mentor to many, including ProspHire’s Dan Crogan, Principal and SVP of Consulting, when he entered the Firm’s partnership. “Rick brought a wealth of business knowledge to the executive leadership team, but more importantly he was a great man and dear friend,” said Dan. “His patience and mentorship behind the scenes will be truly missed.”

Donations may be made in Rick’s memory to the Target Cancer Foundation (www.targetcancerfoundation.org) or the Woodlands (www.mywoodlands.org).

Star Year 2023 Data Insights

Written by LBodnarchuk on October 10, 2022. Posted in Insights.

On October 6^th, 2022, the Centers for Medicare and Medicaid (CMS) released the official Star Year 2023 Data – including contract and measure level detail to the public. As we’ve talked about for some time now, the industry did observe a great Stars recession with average ratings plummeting year over year and returning to pre-pandemic levels (SY2020). With many important regulatory changes already in place and several on the way (Tukey Outlier Deletion), Health Plans can anticipate more disruption in the marketplace.

Distribution of Star Rating Change from Prior Year

Nearly 20% of Health Plans experienced a drop out of the Quality Bonus Payment (QBP) range in SY2023. Last year, about 70% of contracts achieved the QBP whereas in 2023 only about half of contracts got the QBP. This drop will put added financial pressure on health plans to achieve cost savings either through improved medical management or enhanced revenue capture. More importantly, this negative shift represents the new Stars reality, where CAHPS and Member Experience performance will drive the bulk of the marketplace and will force plans to invest more time and effort into benefits, personalized member experiences, and improved operational excellence.

Average Star Rating Year Over

Since the programs’ inception, Star Ratings have steadily increased year over year. Due to COVID guardrails and other “better of” protections, SY2022 was the highest on record and for many, was quite anomalistic. The SY2023 drop off was quite precipitous, with average ratings falling to near pre-pandemic levels. What does this all mean? It’s hard to say in the long run, but we cannot discount the impact that Member Experience and CAHPS will have on the programs overall average rating for the foreseeable future. Perhaps with these weighting changes, the program will see a ‘leveling off’ for the next few years as average scores remain neutral. In any case, those Health Plans that saw massive drop offs in scoring will have plenty of opportunity to rescue their scores in SY2024 and beyond.

Distribution of Star Rating SY2023

When analyzing the distribution of Star Ratings for SY2023, the biggest takeaway are the tail ends of the distribution. We saw a big drop off in 5-Star plans (year over year) and a massive increase in 2- and 2.5-Star plans (year over year). With almost 50% of plans facing a drop in Star Rating year over year, the distribution of ratings returned to a somewhat more normal distribution.

Plan Count by Overall Rating & Average Member Experience Rating

In SY2023, CMS adjusted the weighting of CAHPS and Member Experience measures to account for ~60% of the Overall Star Rating, shifting Health Plan’s focus away from majority gap closure efforts to putting member experience at the forefront of strategies. 254 contracts were able to achieve a 4.0 Star Rating with this adjustment in the Star rating landscape. Approximately 60% of contracts with 4.0 Stars or greater, scored >=4.0 Stars in the CAHPS Domains. This further emphasizes that CAHPS/Member Experience are major drivers in overall contract rating performance and failing to succeed in those areas will hurt your plan performance. Bottom line, 70% of plans with <4.0 Stars in CAHPS were not able to achieve the QBP and did not receive 4.0+ Stars at the contract level.

ProspHire Makes Modern Healthcare’s Best Places to Work for a 3rd Year

Written by LBodnarchuk on October 4, 2022. Posted in News.

PITTSBURGH, PA – ProspHire, a national management consulting firm focused on healthcare advisory, project delivery and strategic resourcing, announced today that for the 3rd year in a row, the Firm has ranked in the top ten on the Modern Healthcare Best Places to Work List under the category of healthcare supplier – ranking 6^th in 2022, 8^th in 2021 and 5^th in 2020.

Health, community, advancement and flexibility are the keys to attracting and engaging employees at the top organizations, according to the List. Each year this program singles out and recognizes outstanding employers in the healthcare industry on a national level.

“The last few years have been incredibly challenging for the healthcare industry, so it’s more important than ever to create an environment where our employees feel valued and fulfilled in their work,” said Lauren Miladinovich, ProspHire’s Co-Founder, Managing Principal and CEO. “ProspHire has such a strong and dedicated team and they are genuinely passionate about the Firm, our clients and our purpose to help people thrive every day.”

Christopher Miladinovich, ProspHire’s Co-Founder, Principal and COO, said, “This award is an absolute honor and represents the strong culture that our entire team has built. We are very proud that our culture is committee led and championed by everyone at the Firm.”

ProspHire leaders believe you must start internally with employees who then lead you to great clients. “It’s exciting to be named to Modern Healthcare’s List of Best Places to Work in Healthcare because this accolade is based on the views of our team members,” said Dan Crogan, Principal and SVP of Consulting. “Placing in the top-10 three years in a row while going through such steep growth is a true testament to our incredible people.”

2022 has been another award-winning year for ProspHire. In addition to being named to Modern Healthcare Best Places to Work List three years in a row (2020-2022), ProspHire has been named to Inc. Magazine’s annual list of America’s Fastest Growing Private Companies for three years in a row – the Inc 5000 (2020-2022). The Firm also made the list for the Pittsburgh Business Times Fastest Growing Companies in the Pittsburgh region for four years in a row (2019 – 2022). That means we have built the trust of our clients through consistent and reliable results over time and have made significant investments in experienced resources to continue to provide high quality, healthcare specific professional services.

About ProspHire

ProspHire is a national management consulting firm focused on healthcare advisory, project delivery and strategic sourcing. Founded on the core value of relationships, with the goal to “prosper together”, ProspHire partners with clients to identify and solve their most significant people, process and technology challenges. The women-owned and rapidly growing Pittsburgh-based firm has nearly a 100 dedicated practitioners and consultants who deliver on projects and services across the U.S.

ACA Compliance Requirements

Written by LBodnarchuk on September 20, 2022. Posted in Blog, Business Growth and Expansion.

Jump to:

What Is ACA Compliance?
What Companies Should Be ACA Compliant?
What Is Required in ACA Compliance?

Healthcare and insurance are essential for Americans, allowing them to receive necessary treatments and prescriptions. The passage of the Affordable Care Act (ACA) transformed many healthcare requirements, from more accessibility to lower premium costs.

However, the ACA also brought in new compliance regulations. Understanding the new compliance standards and how they affect insurance plans is critical, but ACA compliance requirements can vary by insurance type, making it a challenge to keep up with every regulation.

Learn more about ACA compliance requirements and how you can stay compliant.

What Is ACA Compliance?

ACA compliance refers to healthcare plans that comply with the Affordable Care Act (ACA). Also known as Obamacare, the ACA was passed in 2010 to increase healthcare coverage. The law had these three goals:

Increase access to affordable health insurance.
Expand the Medicaid program.
Implement medical care delivery methods.

Overall, the ACA was a massive reform for health insurance plans in America. The act aimed to improve access, coverage and affordability of most health insurance types across the country. These are examples of some of its updates:

Health insurance exchanges: The ACA created health insurance exchanges. In these marketplaces, individuals and families can buy guaranteed issue qualified health insurance plans. A guaranteed issue plan means that issuers must offer products to all eligible individuals in the state. If an individual applies and meets all the eligibility requirements, the issuer must provide them with insurance.
Updated issue coverage: The law also updated guaranteed issue requirements. It prevents issuers from refusing coverage or charging higher premiums due to pre-existing conditions.
Premium subsidies: The ACA also offers subsidies for low- and middle-income purchasers. These subsidies can lower overall costs and make it easier for enrollees to afford coverage.
Coverage for essential health benefits: ACA-compliant plans must cover 10 essential health benefits. To comply with the ACA, health insurance plans must provide coverage for each element, from ambulance services to pregnancy care.

An ACA-compliant health insurance plan abides by all the new changes set in the ACA. All new insurance plans purchased after January 1, 2014, must be ACA-compliant. This law applies to both individual and group insurance plans. In other words, all plans after this date must reflect the changes passed by the Affordable Care Act.

All companies offernig insurance plans after January 1, 2014 must be ACA complaint.

What Companies Should Be ACA Compliant?

All companies offering insurance plans after January 1, 2014, must be ACA compliant. The coverage specifics depend on the type of insurance and health plan enrollees’ purchase. For instance, all companies with 50 or more employees must offer health insurance for their workers, but those with fewer than 50 aren’t required to.

Another differentiation with ACA compliance is with grandmothered or grandfathered plans. These healthcare plans took effect before 2014 and are subject to different compliance requirements.

Here is a closer look at these types of plans and their ACA requirements:

Grandmothered plans: These plans are also called transitional plans. They were created in the transitional period between 2010 and 2014, after the ACA had been signed into law but before it was in effect. Grandmothered plans must abide by some aspects of the ACA, such as the ban on lifetime maximums and coverage of essential health benefits. However, the rest of their coverage policies can stay the same as before 2014.
Grandfathered plans: Grandfathered plans were active before March 23, 2010. Similar to grandmothered plans, they can use their previous structures as long as they abide by some crucial ACA updates. They can remain in place indefinitely as long as providers don’t make significant changes.

What Is Required in ACA Compliance?

While most health insurance plans must be ACA-compliant, the specifics of compliance vary. Here is an overview of the different types of health insurance types and ACA compliance requirements:

Individual and Family Coverage

Individual or family coverage plans are policies people purchase independently and not through their employer. For instance, an enrollee might buy a health insurance plan directly from a health insurance company rather than enroll through their worksite.

To comply with the ACA, individual plans must follow the outlined changes in the law. For example, all plans must feature:

Guaranteed issue to eligible applicants.
Coverage for pre-existing conditions.
Coverage for all essential health benefits.
No lifetime coverage maximum.

Small Group Coverage

The term “small group” refers to an employer or company that purchases health insurance for their employees. Businesses with 50 or fewer full-time employees are considered small groups. They are also required to comply with ACA requirements.

Small group requirements are very similar to the regulations for individual and family plans, including:

Guaranteed issue to eligible businesses.
Pre-existing conditions coverage.
No annual or lifetime limits.
All 10 essential health benefits covered.

Large Group Coverage

Employers with 51 or more full-time employees are considered large groups. The requirements for ACA compliance differ slightly for large group coverage. Many large group companies also choose self-insured plans, which can also follow large group rules.

ACA requirements for large groups include:

Mandated employee coverage: All employers with 50 or more full-time employees must offer health insurance to each employee. According to the Internal Revenue Service (IRS), a full-time employee is any worker who averages 30 hours or more of work each week.
Year-round guaranteed issue: Businesses can purchase plans year-round, allowing employees to enroll whenever necessary.
Coverage for minimum value: Large group insurance plans must cover a minimum value of at least 60% of average healthcare costs for each enrollee.
Coverage for preventative care costs: Unlike small group and individual plans, large group plans don’t need to cover all essential health benefits. However, large group plans must cover certain preventative care costs, such as cancer prevention or infectious disease prevention measures.

PropsHire works hard to ensure government compliance.

Contact ProspHire Today

Healthcare companies must stay compliant with ACA regulations. If you have questions and concerns, use the form below to connect with one of our healthcare leaders today.

Medicare Stars Plan Preview #2 Data Release

Written by LBodnarchuk on September 8, 2022. Posted in Insights.

In the waning hours of September 7^th, 2022, Health Plans received an HPMS memo indicating Plan Preview #2 availability for the Medicare Stars Program. Our team of Stars experts at ProspHire quickly put together a comprehensive data analysis of all cut points across each domain. Although we are still patiently waiting to understand the broader impacts to all health plans, we have some early indications of general performance – with CAHPS and other x4 weighted measures showing decreases in cut points.

HEDIS Performance – Cut Point Analysis

The HEDIS domain displayed inconsistent performance in cut points across most measures. With the lingering impacts of COVID and members forgoing preventative care, we may have anticipated more cut point decreases across the board. In terms of weighting, the x3 weighted Diabetes Blood Sugar measure showed improved performance at the 3-, 4- and 5- Star Level.

HOS Performance – Cut Point Analysis

The HOS domain remains challenging for health plans, with Reducing the Risk of Falling and Improving Bladder Control all showing a decrease in performance across nearly all cut points.

Operations Performance – Cut Point Analysis

The Operations domain (sometimes referred to as Admin domain) showed variable performance across the board. The 4x weighted measures (Call Center, Complaints, Members Leaving Plan) had non-consistent results. Cut point results indicate that there were more complaints in SY23. Additionally, the cut point analysis shows us that less members left their plan in SY23.

Pharmacy Performance – Cut Point Analysis

Following the historical trend, the Pharmacy domain continues to improve year over year. The 3x weighted Medication Adherence measures nearly showed 100% improvement across all cut points. Plans continue to do well in this category, and high-performing Stars Programs will continue to invest time and effort into this domain.

CAHPS Performance – Cut Point Analysis

As shown on the right-hand side, most measures across all star rating cut points had a drop in the cut point range, indicating that the distribution of CAHPS performance across plans saw a drop in scores from prior year. Despite much investment from Health Plans in member experience, there were no increases in any cut points across all measures.

Are you happy with your Plan Preview #2 data release? At ProspHire, we’ve been supporting Health Plans with their Stars Programs since our inception.

Author: LBodnarchuk