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Enhancing the Healthcare Customer Experience: The Guide to Medicare Advantage Plan Member Engagement

By: John Zimmerer, VP of Healthcare Marketing at Smart Communications

In recent years, the healthcare industry has undergone a slow yet significant transformation, driven by advancements in technology, changes in regulatory policies, and a shift in plan member demographics. As a result, healthcare payers have been faced with the challenge of managing an increasingly complex and demanding customer base. This is especially true for Medicare Advantage plans, where customer communications play a critical role throughout the enrollment process and beyond. Everything from Annual Notice of Change (ANOC) documents to the Appeals and Grievances processes, these communications and customer journeys are crucial in building strong relationships with customers and improving overall Medicare Advantage plan member engagement.  

The U.S. Centers for Medicare & Medicaid Services, or CMS, provides guidelines to help health insurers achieve compliance with US federal laws pertaining to Medicare Advantage (MA), Medicare Advantage Prescription Drug (MA-PD), Prescription Drug (PDP) and 1876 Cost Plans. CMS regulates a wide array of communications due to how broadly 42 CFR parts 417, 422, and 423 set the scope of that term. Because there’s a lot to keep track of here, compliance can be an issue for healthcare payers striving to protect member information while also enabling a streamlined, convenient digital customer experience. 

While it's great to have these guidelines and model materials from CMS, everyone in a health payer's operations or IT departments knows that managing Medicare materials is as much art as it is science, causing an internal struggle between agility and compliance. What both departments need is a sophisticated, cloud CCM solution that can streamline the design, production, and management of Medicare marketing and communications materials.  

In this article, we’ll focus on:  

  • The current state of customer communications for Medicare Advantage plan enrollees. 

  • The link between Medicare member engagement and payers’ administrative operations. 

  • How healthcare payers can bridge the gap between customer experience and agility to enhance Medicare member engagement. 

  • A subset of typical healthcare payer marketing communications. 

RELATED READ | ‘The Ultimate Guide to CCM Software & Strategic Solutions’ 

Customer Communications for Medicare Advantage Plan Enrollment is Ripe for Transformation 

Most payers are in the habit of printing and mailing materials every year. Many are also now posting these to their websites or member portals, most commonly as PDF files. It’s a rare payer that goes ‘all-in’ on digital delivery, even though, per 42 CFR subsections 422.2267(d) and 423.2267(d), all the materials listed above may be delivered electronically provided the enrollee has opted in. Even with this allotment, healthcare payers have historically struggled to manage customer communications effectively, leading to poor customer experiences and friction-filled member engagements.  

The following communication types, which we’ll expand on at the end of this post, are just some of the documents which must be filed with CMS using the HPMS Marketing Module: 

  • Annual Notice of Change (ANOC) 

  • Evidence of Coverage (EOC) 

  • Provider Directory 

  • Pharmacy Directory 

  • Drug Formulary 

  • Explanation of Benefits (EOB) 

  • Appeals and Grievances Notices 

One of the biggest challenges facing healthcare payers is the sheer volume of customer communications they must handle. With so many different channels and touchpoints, it’s tough to ensure every customer receives timely and personalized communications via their channel of choice. This is particularly true during the Medicare Advantage plan enrollment process, where customers are often bombarded with confusing and overwhelming information. 

In addition to the volume of communications, healthcare payers must also contend with the complexity of the information they are communicating. Medicare Advantage plans are notoriously complex, with many different rules, regulations, and benefits that can be difficult for customers to understand. As a result, healthcare payers must find ways to simplify this information and present it in a way that is easy for customers to digest while still providing pertinent information that is required by law, rule, or regulation. 

Healthcare payers currently fall short in their efforts to manage customer communications effectively, leading to frustrated customers who may feel disconnected from their healthcare plan and are less likely to engage with their payer in the future. This has proven to lead to increased member churn and lower overall plan satisfaction. What’s more is that any negative member experiences can impact Star Ratings, which we’ll go over in the next section. 


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Read more about this in the commissioned report from Forrester: ‘Disjointed Experiences Cost Insurers Members and Money: The Bleak Reality of Member Experience with US Health Insurers’ 

Cloud-based Customer Communications Software Enhances Medicare Member Experience 

To address these challenges, healthcare payers are increasingly turning to cloud-based customer communications management (CCM) software. This allows payers to manage all their customer communications from a single platform, providing greater visibility and control over the entire process and making possible a seamless omnichannel approach for members. With cloud-based customer communications management software, payers ensure that every customer receives timely and personalized communications on their preferred channel, while also simplifying the information they are presenting. 

By leveraging cloud-based customer communications management software, payers can improve member engagements, reduce churn, and ultimately provide a better healthcare experience that has the possibility to enhance Medicare Advantage plan member engagement. As the healthcare industry continues to evolve, and member engagement remains a growing area of focus for leaders, customer communications will only become more important. That’s why it’s essential to invest in the right tools and technologies to stay ahead of the curve. 

The Importance of Star Ratings and How CCM Software Can Help Medicare Member Engagement

When healthcare payers fail to engage with their members and make them feel seen and heard as individuals, it can lead to disenrollment and negatively impact Star Ratings. Additionally, the CMS Star Rating system is placing more emphasis on member experience and payer administrative operations rather than solely on clinical outcomes. These ratings have significant implications for healthcare payers as they can result in bonus payments for high-performing plans and influence the decisions of future members. According to a report from McKinsey, 56 percent of seniors reported that Star Ratings were one of the top features they considered when shopping for Medicare Advantage plans. 

Check out our short video below to see how Grace, a Medicare Advantage enrollee, engages with her plan throughout the customer lifecycle, and see how SmartCOMM™ and SmartIQ™, two products in the Conversation Cloud from Smart Communications, make life better for her and her chosen Medicare Advantage Organization (MAO).

Below, we dig into the use cases featured in the video.


Annual Notice of Change (ANOC) 

The Annual Notice of Change (ANOC) is a critical document for Medicare Advantage members as it informs them about any changes in their plan for the upcoming year. For health payers, managing the creation and distribution of ANOC can be a challenging, time-consuming task. Below are some of the common pain points, plus, how a leading cloud CCM solution can help alleviate them. 

One of the most significant challenges of delivering and managing ANOC is the repetitive nature of the content across different plan types. Modern customer communications management (CCM) solutions employ a layered model that separates content from styling and branding, maximizing the use of reusable objects. This allows payers to create the content once to use across multiple plan documents, simplifying the translation efforts and minimizing the effort to comply with accessibility standards. With this ability to create personalized ANOC documents that reflect the unique needs of their members, while also minimizing redundant content, health payers can ensure their Medicare members feel empowered to manage their plans. 

As many health payers have plans in multiple jurisdictions, which can complicate the ANOC process, having a solution that accounts for these variations is key. SmartCOMM’s Editions feature allows payers to create tailored ANOC documents for each jurisdiction they serve, ensuring that members receive accurate and relevant information as per their region. 

Finally, the ANOC process often requires reviews and approvals from multiple stakeholders, which can lead to delays and errors. With a built-in workflow feature, payers can streamline the process of managing and tracking reviews and approvals in a centralized system. Ultimately, this reduces the risk of errors without sacrificing agility, ensuring that ANOC documents are delivered on time. 

Though managing the ANOC can be a complex and time-consuming process, the right technology and tools help healthcare payers streamline the process of creating and delivering personalized, accurate ANOC documents to members. This helps improve the overall Medicare member engagement, leading to more renewals and higher Star Ratings in the long run. 

Evidence of Coverage (EOC)

Providing members with accurate and comprehensive information about their healthcare benefits is crucial for payers. However, managing the Evidence of Coverage (EOC) is a complex and lengthy process as relevant details and data may exist across multiple core systems. Even more frustrating is the limited access to real-time eligibility and coverage information coupled with the fact that data which is available could be incorrect due to data entry errors.  

The right cloud CCM software simplifies the process of managing and storing EOC documents as it enables easy access to member eligibility data, plan coverage details, and benefit limits in real-time. With the right integrations in place, customer communications management solutions can minimize errors and reduce administrative costs for payers. SmartCOMM, for instance, can seamlessly integrate with a wide range of core systems, such as policy systems and CRM, allowing for the easy personalization of information based on members' needs. 

We understand that complex tables can be a pain point when it comes to managing EOC documents. Modern CCM solutions easily create complex tables that span multiple pages, including repetition of header and footer rows. This helps members easily comprehend their healthcare benefits, including what's covered, what's not, the costs, and their right to appeal. 

Provider Directory 

It is crucial to provide members with a comprehensive Provider Directory that is easy to access and find information in. However, traditional directories present several challenges that negatively impact satisfaction. These include: 

  • The directory's size makes it costly and challenging to print 

  • It can be difficult to keep the directory current as provider networks change 

  • There’s a sub-par user experience especially when the directory is printed 

  • High customer burden as members must sift through numerous listings to find the right provider 

To provide the best possible outcomes and experience for members, payers should invest in a leading cloud CCM solution that enhance the Provider Directory for both members and providers. This means minimizing the number of directories that need to be printed, honoring member channel preferences, and creating one template that can be used for both print and digital versions which ensures consistency across all channels. 

Our technology allows you to integrate data from various sources to create on demand the most up-to-date and personally relevant version of the Provider Directory. SmartCOMM can potentially present only the providers that match specific criteria (such as specialty area or location) as HTML versions may differ from print versions. This allows for a tailored web experiences to meet members' needs, such as only showing, for example, in-network acupuncture providers within 10 miles if that is what the member is seeking. 

Pharmacy Directory 

A Pharmacy Directory is a unique list of participating pharmacies, including preferred pharmacies where members receive the best prices. It is typically organized by state and then sorted by zip code, like a phone book. Providing members with an accurate and up-to-date Pharmacy Directory is a great way to prioritize Medicare Advantage plan member engagement. 

Realistically, Pharmacy Directories present various challenges that can negatively impact member satisfaction. Just like the Provider Directories, members must wade through large documents to find out if their pharmacy is preferred, which can be challenging and time-consuming. 

Payers should provide different experiences per channel, such as PDF or print versus web or mobile. This flexibility allows members to access Pharmacy Directory information in a way that is most convenient for them, leading to improved member satisfaction. By improving the Pharmacy Directory experience, members are empowered to easily find the pharmacies they need, ultimately leading to better health outcomes and less frustration toward health insurers. 

Of course, this level of customization and personalization will require partnering with a CCM vendor who understands the nature of the health insurance industry. For more information on why Smart Communications is uniquely positioned to do so, read the report from Aspire, naming Smart Communications as a leader in Vendor Hosted SaaS Customer Communications Management (CCM). 


Drug Formulary 

Providing a comprehensive and up-to-date drug formulary to their members is a necessity for health insurers looking to enhance the member experience. The drug formulary is a high priority for the average Medicare Advantage, supplemental or prescription plan member, especially when they are on multiple maintenance medications. However, many common pain points can detract from the member experience, causing members to disengage altogether. 

Like is the case with Provider and Pharmacy directories, one major pain point with a drug formulary is the lack of access to the most up-to-date list of drugs. With drugs being added, deleted, and changing tiers, it can be challenging for members to stay informed about the latest formulary. Additionally, traditional drug formularies can be a terse volume that lists medications categories (e.g., NSAIDs under analgesics), making it hard for individuals to navigate and find the information they need. SmartCOMM solves these problems by integrating with back-office systems and triggering the automatic generation of a new version of the drug formulary as soon as a drug is added, deleted, or changes tiers. This is particularly important for the HTML version, ensuring that web visitors have an up-to-the-minute drug formulary to reference that is always correct. 

SmartCOMM also offers layout tools that make it easy to manage the large volume of information included in the drug formulary and create tables inside a PDF/print version. This creates a better member experience, making it easier for members to find the information they need quickly and without frustration. For health payers, being able to offer a customized drug formulary experience for their members, with easy access to the most up-to-date information in a user-friendly format can make or break the overall member experience. 

Explanation of Benefits (EOB) 

Payers know how critical the Explanation of Benefits (EOBs) are to a members' experience yet EOBs are often difficult for members to understand. This often leads to frustration, appeals, and grievances which are time-consuming and costly to the business. These bad experiences can also lead to a diminished brand reputation, lower Star Ratings, and even disenrollment. 

That's where SmartCOMM comes in. Our platform offers a solution that improves the information architecture of EOB documents, making it easier for members to understand the reasons behind the insurer's payments or non-payments. By integrating charts and graphs, our platform visualizes where the member is in their out-of-pocket maximum or deductible, providing a clearer picture of the financial responsibilities. Additionally, you can include related education materials when generating EOBs based on claims included, which further educates members on what was or wasn’t paid and why or why not. 

Moreover, our connected claims abilities will boost self-serviceability and help deflect calls from call centers, allowing Customer Service Representatives to focus on providing the highest level of service to members who need more attention. SmartCOMM's platform also offers various delivery options for EOBs, such as digital and print versions. This flexibility ensures that members receive their EOBs in the format they prefer, which can increase engagement and understanding. 

By leveraging SmartCOMM's technology, payers can enhance the EOB experience for members, reduce appeals and grievances, and improve overall member satisfaction. Health insurers can also use the platform to generate clear and concise EOBs, increasing transparency and fostering trust between members and the organization. 

Appeals and Grievances

For Medicare Advantage providers, Appeals and Grievances (A&G) are an inevitable part of the healthcare member experience. Members have the right to appeal how a claim was paid or file grievances for various reasons. Managing appeals and grievances can be a time-consuming and costly process for both the payer and the member. Not only do payers have mandated response times, which can be challenging to meet, there can also be a lack of transparency and high customer burden for members, including forms to fill out and mail/fax to the payer. For A&G employees, switching contexts between different tools can lead to reduced productivity and further delays. 

SmartCOMM streamlines the appeals and grievances process, reducing costs and improving member satisfaction. Our platform integrates with systems of record, such as PegaSystems, allowing for quicker processing times and reducing the need for third parties in the review process. 

Our flexible templates enable payers to generate all possible permutations of response, including acknowledgments, requests for more information, denials, and approvals, all based on input from a system of record or an A&G employee. This approach streamlines the communication process and ensures that the member receives clear and concise information about their appeal or grievance. 

We also honor the member's preferred channel for generating the communication, which can improve member satisfaction and reduce the burden on your A&G employees. Additionally, SmartCOMM can integrate within other applications (e.g., Salesforce, Pega), helping employees to stay in context and improving their productivity. 

Moving Medicare Advantage Communications to the Cloud 

In addition to the use cases highlighted above, SmartCOMM is a great solution for managing other Medicare Advantage materials and marketing communications, including ID cards, Summary of Benefits and plan booklets. In fact, many healthcare payers use SmartIQ, our forms automation software, to help manage provider and partner contracts, group plan development, and enrollment. 

By moving your communications to the cloud and utilizing SmartCOMM, you can transform your communications into engaging conversations that will help you meet your members' needs and reduce costs. From directories of participating pharmacies to drug formularies, from explanations of benefits to appeals and grievances, having the right systems and solutions in place can help health insurers save money, remain agile, and—most importantly—improve the medicare member experience

With SmartCOMM, health insurers can improve Medicare member engagement and streamline communication processes, all while meeting regulatory requirements and staying ahead of the competition. So, why wait? Make the move and start reaping the benefits today!

If you’d like to learn more about how to member engagement, visit our Medicare Advantage page