A First Look At The New CMS Model

We took a first pass at the new CMS models. Did anyone else notice that there are a lot of variable areas in the PPO model that CMS did not turn blue? We can assume it was an inadvertent oversight, but seasoned EOC veterans who turn on their blue text radar can’t fly through the books this year. Pay special attention—you have been forewarned.

Besides the expected minor language changes and the aforementioned blue issue, the 2016 ANOC/EOC models should not be regarded as a major overhaul of last year’s models, but there are some differences. The addition of section breaks makes the final product a little user friendlier for the end user but no change in workload for us.

Flipping further, check out Chapter 4, section 3.1. The Benefits Not Covered chart is totally new. Adding the Covered Under Certain Conditions column helps clear up some member confusion we have heard in the past. When TRAFFIK Health was invited to comment on the models a few months ago, this was one of the flags we raised. We are pleased that CMS incorporated our feedback to make this chart applicable in all conditions and scenarios. We all know how literal CMS is, and our advice is not to overthink it.

See Chapter 5, section 2.3. The Refills section finally has more options making this portion much longer, yet simpler since the selections should fit more plans, and requires less free-form writing which leads to more industry consistency. Truthfully, this adjustment is better for the consumer, and has actually made work slightly easier for TRAFFIK compared to last year. Less time and effort are required during the approval routing process—debates over verbiage are virtually a thing of the past.

From our vantage point, there seem to be minor changes in the actual model language, but nothing earth-shattering. If it seems like we’re rather calm about ANOC season, perhaps it’s because we’ve been there and done this for over a decade. Time to roll up those sleeves, and dive in.

This is just a first pass and only on the PPO Model. Stay tuned for more updates as we get through the other model, chapter by chapter. Have you looked at Chapters 4 and 6 yet, or are you still in denial that ANOC season is here?