If there’s one thing you can count on with Medicare Advantage Plans, it’s letters. Health Plans are mandated to send a variety of letters to their members. New to enroll? There’s a letter for that. Looking for a coverage decision or prior authorization? There are letters for that. Need to make an appeal? There’s a letter for that. I think you get the point.
Health Plans operating in the Medicare Advantage space have numerous reasons to communicate with their members and those communications often take the form of letters. These letters are crucial for maintaining compliance and ensuring effective communication with members. These letters are referred to differently across organizations but are most often referred to as member letters, required member letters or simply as member communications.
Member letters can be grouped into major categories.
Enrollment and Disenrollment, Grievances & Appeals, and Pharmacy are three prominent groupings of letters. The letters are generally event driven. Some examples are:
- Enrollment & Disenrollment: Letters are triggered when a member enrolls in the plan and as they re-enroll each year. Changes to a member’s status can also trigger a letter. As members there are several letters that will be sent around their membership, including Notice to Acknowledge Receipt of Completed Enrollment Request, Notice to Confirm Enrollment, Notice to Request Information, Notice of Rejection of Enrollment, and Notice on Failure to Pay Plan Premiums – Notice of Involuntary Disenrollment.
- Grievances & Appeals: Letters are often triggered when a member initiates the appeals or grievance process and continue throughout the process until it concludes.
- Pharmacy: Pharmacy letters are sent when there are formulary changes, as members make coverage checks and for things like a prior authorization request.
These letters are generally mandated, many having models supplied and updated by CMS (Centers for Medicare & Medicaid Services) and typically have tight SLAs (Service Level Agreements). A typical SLA is 48 hours, though some may have shorter or longer timeframes. Missing these SLAs can have severe consequences, including audits and potential fines.
Letters are often managed by different areas of a Medicare Advantage Plan, typically by the functional areas related to the type of letter.
Pros and cons of managing member communications across functional areas:
- Pros:
- Specialization: Each area can focus on its specific type of communication.
- Efficiency: Functional areas can develop expertise and streamline processes.
- Member focus: In some areas, having the appropriate functional area manage letter creation can result in the member consistently dealing with the same Plan Representative, or a smaller group of representatives.
- Cons:
- Scale: Managing communications across multiple areas can be challenging, especially as the membership grows.
- Inconsistency: Different areas may have varying standards and practices, which can result in delivering varying content to a member.
- Resources: It may require more resources to manage communications separately.
- Redundant Solutions: Different teams may find different solutions that accomplish the same goals. This has the potential to impact expenses.
Health Plans also need to consider member preferences when it comes to how they deliver member letters. While many letters are printed and dropped into the mail stream, any letter can be emailed to a member as long as the member initiates a request to receive communications electronically. Plans need to remember that this process is not as simple as just pushing send. It’s important to track receipt, handle bounce backs, and ensure SLA adherence.
Additionally, and more importantly, Medicare Advantage Plans are now required to continue to send member communications to members in an alternate format once a request has been made, which includes large print, audio, Braille, and translation to other languages in each format. This ensures members continue to receive communications in the format that benefits them, which has been a significant source of member frustration. It’s important to have tools in place to collect these preferences and make them available to the areas in the organization who are creating and distributing member communications.
The combined requirements can put pressure on the Health Plan, especially as membership grows.
Here are some things to consider:
- Is your process set up to create letters in all required formats and meet the required SLAs?
- Are there issues in particular functional areas that need to be addressed?
- Could centralizing letter programs bring greater efficiency or reduce expense in your organization?
- Do you have the reporting capabilities needed to confirm letters were created and distributed within the required timeframe?
- If you are managing your member letters in house, have you discussed thresholds that may indicate it is time to look for another solution?
How Toppan Merrill can help
At Toppan Merrill, we understand the complexities of member communications. We work with all types of data formats, we understand you’re working with tight SLAs and we are familiar with having to make a quick update because a model document changed. We would love to talk to you about our Letter Program. From document creation and management to sales enablement, omnichannel communications, printing services, and more, we deliver best-in-class solutions that help you respond quickly to changes in regulations, member needs, and markets.