TOP IMPLEMENTATION ISSUES: WHERE WE ARE NOW AND SOLUTIONS FOR THE FUTURE

1. TOP IMPLEMENTATION ISSUES: WHERE WE ARE NOW AND SOLUTIONS FOR THE FUTURE John T. Tighe, III, CEO www.tmghealth.com

2. Current Conditions • Over 27 Million Medicare Beneficiaries are enrolled in Prescription Coverage • Approximately 380,000 new recipients sign up each week • About 7 million are enrolled in Medicare Advantage Plans, an increase of 2 million from last year • Approximately 5.8 million dual eligibles were auto-enrolled into PDP plans and an additional 600,000 were enrolled in Medicare Advantage Plans • The number is approximately 7.2 million duals if you include those enrolled in Medicare for 12 months and those in for part of the year due to new enrollment or death

3. Dual Eligible Members • Only group of Medicare recipients “loosing” a benefit • Have significantly more health care problems than other Medicare recipients • Almost 20% are in a nursing facility • Almost 40% have mental and cognitive issues • Significantly poorer, with 70% having incomes below $10,000 • 44% live alone without spouses, compared to 29% of other Medicare beneficiaries

4. Beneficiary Education • Multiple avenues to enroll causing duplicate enrollments and confusion among seniors • CMS Communications and Enrollment is adding a level of complexity for the beneficiaries that was unintended • Customer service issues affected most plans and CMS • Duals are more likely to have mental and cognitive disabilities • Duals are more likely to have reading comprehension and language issues • Duals are less likely to have family or social structure to guide them through confusing changes

5. CMS Systems and Testing • CMS Rollout of new MARX system created system issues • Testing time with plans was compressed • Batch summaries process was incomplete • TRR’s from CMS initially not released in timely manner causing plans to have a backlog • CMS to MA to MAPD migration issues • PDM and 4RX data incomplete • Earlier and more rapid timeline for Duals augmented issues • Transfer of State to CMS data compounded issues

6. Accuracy of Eligibility Data for Duals • Difficulty getting complete information to enroll and properly service dual eligible beneficiaries • Results in customer services and claims payment issues • Significant Reports from States about members being turned away at pharmacies • Confusion regarding new changes in formularies • Confusion regarding co-pay issues • Auto enrollment adds to the complexity issues and to member confusion

7. Member Materials Delayed • Plans had difficulty getting ID cards and welcome packets out to members and had to rely on the Acknowledgement letter process to convey eligibility information to beneficiaries • Duals are traditionally more difficult to reach due to changing addresses and incorrect mailing address data • Language, reading and comprehension issues often plague dual eligibles

8. Lock-In • General population doesn’t understand lock-in process • Through 2005 members could enroll or disenroll in MA plans on monthly basis • Beginning May 15, 2006 CMS has established lock-in • Members ability to enroll or disenroll depends on their election period • Member is ineligible to enroll because they used all their elections or they aren’t eligible for Special Election • Duals are not locked-in, but can change monthly

9. Requirements of Creditable Coverage • Will be changes in programs, files and testing once CMS releases new enrollment form and creditable coverage rules for the application • Internal system changes and file layouts will need to be programmed and tested • Fields on TRR address creditable coverage and late penalty, but not being used

10. COB Information • Model COB survey is not user friendly and is confusing to seniors • Many members don’t know what COB is • Need to continuously survey members until they respond • Plans need to update ECRS each time there are changes to a member’s COB • COB data for dual eligibles is often difficult to gather and will need to be gathered from state systems

11. Financial Reconciliation • Financial reconciliation is the current plan focus • Reimbursement issues are complex • Determine what amount of money government owes and track it • States picking up drug costs for duals • Determine which entity is financially responsible, the plan the state, the Feds, or another plan • Complexity of Premium billing for post MA is much greater • Receipt of subsidy information from CMS affects premiums

12. Formulary Changes • Formularies could change as often as once a month • Will it create the impetus for dual eligibles to change plans? • Duals can switch on a monthly basis and this could create constant swings and changes • Will need to be monitored for appeal process

13. Emerging Issues • Attrition of PDP and Medicare Advantage Plans is likely • What happens to Duals in 2007 with regard to policy, rules and low bidders? • Have accurate exchange of eligibility data between plans, states and CMS • Clinical or cost impact of changes not known • Managing the Grievance and Appeals Process

14. Emerging Issues • Dual members switching plans will increase complexity of reimbursement • Another 11.4 million beneficiaries will need to sign up to meet the CMS targets of 29.3 million • Will these issues create another period of massive change?

15. Solutions for the Future • Have more realistic timelines in the future • Institute better file submission between plans and CMS • Maintain current quality of communications between CMS, PDP’s and plans • Revisit lock-in policy • Monitor formulary issues and changes • Educate Duals on navigating through the system • Encourage active plan selection by Duals, reduce the number of auto enrollments

16. TheLeaderin Business Process Outsourcing for Medicare & Medicaid Health Plans www.tmghealth.com