Opportunity is knocking.
What happens when you open the door?
Are you prepared for what’s on the other side?
Despite a strong economy, health systems and commercial health plans are facing new and increasing challenges.
Growing cost pressures and decreasing revenue due to shifts from inpatient to lower cost outpatient services and changing reimbursement models with a focus on value-based care
Financial pressures driving increased competition and consolidation
Rapidly shifting regulatory environment
New market entrants looking to challenge incumbents and the status quo
Evolving technology; there’s an app for that!
Changing consumer demographics, not just millennials, but today’s “new” seniors
Naya Advisory’s Healthcare professionals can help prepare you for what’s on the other side. No need to bar the door, we’ll prepare you for the exciting world outside.
Naya Advisors will help you develop a deep market understanding, including understanding the capabilities required to win, and an honest assessment of your capabilities— several of our leaders wear glasses, but not rose-colored glasses. We see clearly and speak honestly.
We’ll use market and internal data, advanced analytics, and deep market insight to conduct a strategic assessment of your business, your opportunities, and what it will take to win!
What are the emerging trends and key opportunities?
Strategic Opportunity Assessment
Feasibility study, including pro formas
What will it take to win?
Can we win?
From care delivery to care effectiveness to the patient / member experience; from integration and new product lines to workflow optimization to emerging technologies and markets, Naya Advisory will help you develop and execute a strategic roadmap for the world waiting outside your door!
There are those that say, "there's no better time than the present."
Medicare Advantage has certainly come into vogue in healthcare. Once a third rail for politicians and an afterthought for seniors, Medicare Advantage is now the darling of politicians and consumers alike.
Medicare Growth Forecast 1999-2024
Since 2015, there have been 27 new Medicare Advantage market entrants and that trend will continue as health systems and commercial health plans see a growing market and favorable political winds. Not only is the senior population growing, but today’s 65-year-old isn’t the 65-year-old of a decade ago. Today’s senior has grown up in a managed-care world and is two times more likely to choose a Medicare Advantage plan than seniors in 2009.
And that change is reflected in the Medicare Advantage growth forecast that is turning heads at Health Systems and Health Plans as they look for ways to diversify revenue and address challenges that are compressing margins and threatening to disintermediate them from their markets.
With the senior population growing rapidly over the next decade as baby boomers continue to march into retirement, many health plans and health systems see Medicare Advantage as the next great opportunity. And, it can be. But as more and more plans jump into the pool, is it right for you? A growing market doesn’t always signal success. Understanding the market, the capabilities required for success, and your ability to harness or develop those capabilities is critical.
As a result, approximately 5 million seniors are expected to enter the Medicare Advantage market in the next 5 years, increasing the number of Medicare Advantage beneficiaries to more than 25 million. And with total bonuses paid by CMS to Medicare Advantage plans more than doubling in the last 4 years, there is tremendous opportunity for high-performing plans.
This forecast membership and revenue growth, a favorable regulatory climate, and compressed margins on traditional, core businesses are driving more health systems and commercial health plans to explore expansion into Medicare Advantage.
Is Medicare Advantageright for ACOs?
Accountable Care Organizations (ACOs) formed to provide coordinated, high-quality care to the Medicare patients they serve, and with the move to value-based care, the coordinated care provided by ACOs helps ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and ensuring high quality. But while many ACOs have been successful at improving quality and reducing costs, often the value they create isn’t captured by the ACO, but by its payor partners.
Starting a provider-sponsored Medicare Advantage plan could be an opportunity for both health systems and ACOs to capture more of the value themselves, create alternative revenue sources, and strengthen their position with payors.
Whether you’re just contemplating starting a Medicare Advantage plan, trying to determine if it’s right for you, or full-on committed to pursuing Medicare Advantage, Naya Advisors can help you understand not only the opportunity, but if the opportunity is right for you and what it will take to win.
How much value will you capture?
Making the decision to start a Medicare Advantage plan is complex and requires a deep and thorough assessment, and without the right partner, due to the Centers for Medicare and Medicaid (CMS) application and filing timelines (table 1 below), delaying your decision by just a few months could delay your MA plan launch by more than a year.
Choosing your partner on this journey is as important as the decision itself. The right partner provides the data and insight needed to make your MA decision with confidence, and an experienced partner will aggressively manage the assessment and implementation timelines to maximize your investment and ensure you get to market quickly.
Our detailed Market Assessment and Feasibility Study leverages market and company data, our advanced analytic approach, and our deep industry insights to help you understand not just the opportunity, but what it will take to not just enter the market, but win.
Market Assessment summary:
Key CMS Steps and Milestone Dates
Requirement that prospective plans notify CMS of their intent to
offer Medicare Advantage plan(s) during the following year’s Open Enrollment period.
Notice of Intent to Apply (NOIA) deadline
CMS applications are posted in January for the following January plan effective dates, e.g.; Applications posted in January 2019 for plans with January 1, 2020 effective dates.
Applications posted by CMS
CMS applications must be submitted in February for the following
January plan effective dates, e.g.; Applications are submitted for both
Part C (medical) and Part D (pharmacy) in February 2019 for plans with January 1, 2020 effective dates.
Application submission deadline
Plan designs and pricing for all plans to be offered in the following year must be actuarially certified and submitted by the June deadline.
Bid submission to CMS
August - September 2021
CMS review and requests for additional detail will take place between
June and August/September when plans are notified of plan approval.
Plans Approved and CMS contracts executed
October - December 2021
Medicare beneficiary enrollment period. While many consider the plan effective date, 1/1, as the Plan’s official launch date, Pinocchio is a
real boy the day you start selling!
Annual enrollment period (AEP) Launch
First date of coverage for the plan year.
Plan effective date
Given the 14-month CMS timeline-- from the Notice of Intent to Apply to the plan’s first effective date-- Naya Advisory recommends starting the Assessment process as early as practical. Unlike our competitors however, our knowledge and expertise allow us to shorten assessment and implementation timelines and reduce cost while maintaining the highest quality standards.
In addition to the initial Market Assessment and Feasibility Study, once the decision has been made to launch an MA plan, Naya Advisory Services collaborates with our clients to develop a detailed implementation plan unique to the needs of the client. While client needs and implementation complexity vary, table 2 below highlights two key functions we propose starting immediately following the go/no go decision.
Additional Areas of Focus
Network Development and Contracting
Establishing provider partnerships will be a key to your plan’s success. Not only is network adequacy a CMS requirement, but providing the right care in the right location at the right price starts with the care giver. Building strong provider relationships takes time and should be started once the decision to enter the MA market has been made.
Product Assessment and Strategy
Understanding how Medicare Advantage products are performing in your market is part of Naya’s overall Market Assessment, but once you’ve decided to move forward, a deeper dive is required to develop product and benefit features and align product positioning with your company’s strategy.
Market Assessment and Feasibility Study including;
Network / Network Adequacy
Capabilities Assessment (Build/Buy/Partner)
Financial Pro Formas, capital requirements
Legal / Regulatory requirements
While the Market Assessment and Feasibility Study can be completed in 60 – 90 days, if leadership or Board approvals are required, Naya recommends starting the process in the Spring of the year prior to plan's first open enrollment.
As early as:
No later than: September/October2019
Medicare Advantage Timeline
Where to start
Starting and operating a Medicare Advantage Health Plan is difficult and complex. While the market opportunity can be significant for both commercial health plans and health systems, 25% of new market entrants exit the market within three years due to underperformance.
In order to succeed, you need to quickly develop expertise in a number of key areas, from development of strong provider partnerships, to sustained membership growth, to compliance with a myriad CMS regulations, to the transactional basics. Naya Advisory Services will help you assess the opportunity and develop a strategy– from licensing an insurance company and securing capital to building and leading ongoing plan operations.
Naya Advisory Services, through its Synovia Health division, can provide a full-suite of Business Process Outsourced services across the spectrum of key capabilities required for success. We perform functions on our clients’ behalf and teach them along the way to ensure they not only succeed, but excel.