Medicare Compliance & Reimbursement

CMS wants to waive the bid requirements for MA EGWPs.

In addition to the opioid use provision, the 2017 Advance Notice and Draft Call Letter for the Medicare Advantage (MA) and Part D programs also contains a variety of other proposed policy and payment changes.

According to a Feb. 29 analysis by attorneys Susan Berson, Jordan Cohen, Bridgette Keller, and Lauren Moldawer of the law firm Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C., these changes include:

• Net Payment Increase: The Advance Notice policy changes to improve payment accuracy will increase MA and Part D plan revenue by 1.35 percent, the Centers for Medicare & Medicaid Services (CMS) predicts. And when combined with the annual anticipated growth in risk scores, total plan revenue could increase by as much as 3.55 percent.
• Revised Risk Adjustment Model: CMS proposes to update the CMS-Hierarchical Condition Categories (CMS-HCC) model for Part C payments for aged/disabled beneficiaries to better account for costs associated with dual eligibility. The model would divide the community into six subgroups:

                  1. Non-dual aged;
                  2. Non-dual disabled;
                  3. Full benefit dual aged;
                  4. Full benefit dual disabled;
                  5. Partial benefit dual aged; and
                  6. Partial benefit dual disabled.

• Updated RxHCC Model for Part D: CMS proposes an updated version of the Part D Prescription Drug HCC (RxHCC) risk adjustment model it used to adjust direct subsidy payments for stand-alone Prescription Drug Plans (PDPs) and Medicare Advantage-Prescription Drug Plans (MA-PDs) Part D benefits.
• Bid Requirements Waiver: CMS proposes to waive the bid requirements for MA Employer Group Waiver Plans (EGWPs) and create a new payment methodology. CMS wants to use non-EGWP plan bids to establish Part C county-level payment amounts, instead of EGWPs submitting bids. The proposal also would bar MA EGWPs from buying down Part B premiums for their enrollees.
• Blended Risk Scores: CMS wants to continue to use a blend of encounter-data and Risk Adjustment Processing System (RAPS)-based risk scores, as a reasonable progression toward eventually relying exclusively on encounter data for plan-submitted diagnosis information. In 2017, CMS proposes to use a higher percentage of encounter data-based risk scores versus RAPS-based risk scores.
• Adjusted Star Rating Measures: CMS proposes to implement an interim analytical adjustment for a subset of MA and Part D Star Rating measures, which would adjust for plans serving dual eligible enrollees and/or enrollees receiving the low income subsidy (LIS), as well as those with disabilities. This proposal is in response to MA organizations’ and PDP sponsors’ concerns that enrolling a high percentage of these types of enrollees limits their plans’ ability to achieve high Star Ratings. CMS is also considering adding new measures in 2018, including those for care coordination, depression, pain management, opioid use, and antipsychotic use in persons with dementia.