Medicare Compliance & Reimbursement

Hint: Risks may outweigh the advantages.

CMS continues to churn out notices, proposals, and final rules at lightning speed. With new offerings and overhauls coming weekly, it’s tough to keep up.

Among the many policy changes, payment models seem to be a hot topic. In recent months, the Center for Medicare and Medicaid Innovation (CMMI) has presented several payment models to facilitate value and quality while improving care and cutting Medicare costs.

Read on to see what’s on the table — and what’s ahead in years to come.

See the VBID Model Adjustments

Last month, CMS made changes to the Value-Based Insurance Design (VBID) model, which was introduced for use in certain states in 2017 and is facilitated through Medicare Advantage.

“Until now, the VBID model has only been tested in select states,” counsels attorneys Xavier G. Hardy and Bridgette A. Keller of national law firm Mintz, Levin, Cohn, Ferris, Glovsky, and Popeo, PC in a Mintz Healthcare Viewpoints post. “However, beginning in CY 2020, MA plans in all 50 states and in U.S. territories are eligible to apply for the innovations being tested through the VBID model, including Regional Preferred Provider Organizations (RPPO) and all categories of Special Needs Plans (SNPs).”

Facts: Starting in calendar year (CY) 2020, CMS announced it will offer a “non-uniform benefit design to provide reduced cost-sharing or additional supplemental benefits for enrollees based on condition and/or certain socioeconomic,” noted the VBID model fact sheet. The changes also promote the use of telehealth and bolster enhanced care planning. In 2021, the agency wants to test the model for Medicare hospices, according to the release.

Applications are being accepted through March 1, 2019 for the CY 2020 start date.

See the VBID model fact sheet at www.cms.gov/newsroom/fact-sheets/value-based-insurance-design-model-vbid-fact-sheet-cy-2020.

Add This Part D Option to Your Checklist

To cut Medicare spending and revise Part D, CMMI introduced the Part D Payment Modernization model. The “voluntary” five-year model addresses “cost and quality” as well as the “the high list price” of Medicare Part D drugs, a CMS fact sheet said. The two-sided risk model would offer incentives and rewards to “manage [a] catastrophic phase federal reinsurance subsidy,” the fact sheet stressed.

“Part D Plans who participate in the model will take on more risk for spending in the catastrophic phase but can share in the savings generated with CMS,” explains attorney Matthew W. Horton of King & Spalding LLP in a News & Insights blog post. “CMS will calculate savings by estimating what governmental spending would have been without the incentives of the Part D Model and will compare that to actual spending.

Risk and reward: Horton adds, “If actual spending is lower than the target, Part D Model participants will have an opportunity to share in the savings. Conversely, if they exceed the target, Part D Model participants will also share in the losses.”

CMS promises the Part D model application will be a competitive process. Interested parties may request an application through March 1, 2019 for CY 2020. Currently, the payment model is available for application only to “eligible standalone Prescription Drug Plans (PDPs) and Medicare Advantage-Prescription Drug Plans (MA-PDs) that are approved to participate,” but CMS may open it up in the future, the agency fact sheet advised.

Find out more about the Part D model at www.cms.gov/newsroom/fact-sheets/part-d-payment-modernization-model-fact-sheet.

Emergency Care Gets a Boost

Last week, CMMI issued a payment model, specifically to pinpoint issues with emergency healthcare after a 911 call. According to CMS, the voluntary, five-year plan named the Emergency Triage, Treat, and Transport (ET3) model aims to “pay participating ambulance suppliers and providers” for the following three items:

• “Transport to a hospital emergency department (ED);
• “Transport to an alternative location; [and]
• “Provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth.”

CMMI released the ET3 model to streamline emergency medical services (EMS) for Medicare fee-for-service beneficiaries, making emergency access more efficient and accessible. The patient-centered model has three central themes:

• Offer payment options that promote quality and are tied to performance.
• Boost regional markets to “ensure appropriate use of EMS resources,” the fact sheet adds.
• Utilize methods that measure accountability with monitoring and enforcement.

“This model will help make how we pay for care more patient-centric by supporting care in more appropriate settings while saving emergency medical services providers precious time and resources to respond to more serious cases,” said CMS Administrator Seema Verma in a release.

Looking ahead: Expect a forthcoming request for application (RFA) in summer 2019, the agency said.

Review the ET3 model fact sheet at www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model.