Mutual of Omaha Agrees to Sell Medicare Advantage Business Essence Healthcare says it has reached an agreement to acquire Medicare Advantage operations from Mutual of Omaha. Essence Healthcare would end up owning Mutual of Omaha Medicare Advantage Company and Medicare Advantage Company of Omaha. The two Mutual of Omaha Medicare Advantage subsidiaries are offering Medicare Advantage plans in Cincinnati; Dallas; Denver; El Paso, Texas; and San Antonio. The deal would not affect Mutual of Omaha’s other businesses, such as its Medicare supplement insurance business or its Medicare Part D prescription drug plan business. The companies are not saying how much Essence Healthcare is paying for the Medicare Advantage plan business. They hope to complete the deal by the middle of this year, according to Essence Healthcare. Representatives from Mutual of Omaha were not immediately available to comment on the deal announcement. The Companies Essence Healthcare is the St. Louis-based sister company of Lumeris. Essence Healthcare was founded in 2004. It now runs Medicare Advantage plans that provide coverage for about 64,000 people in Missouri and Illinois. Lumeris manages health plans. It also offers systems and services that help health care providers assume care-related financial risk, rather than depending on insurers and public health programs to absorb all of the risk. Mutual of Omaha provides Medicare supplement insurance for 1.4 million people, or 10% of all Medicare supplement insurance users, according to Mark Farrah Associates. Mutual of Omaha moved into the Medicare Advantage plan market in 2018. The company’s Medicare Advantage plan business now offers Medicare Advantage health maintenance organization plans that provide coverage for about 2,500 people, according to enrollment figured posted by the Centers for Medicare and Medicaid Services, the agency that runs Medicare. Lumeris has already been running Mutual of Omaha’s Medicare Advantage plans, and it would continue to run the plans after the transaction is completed, Essence Healthcare says. Essence Healthcare and Lumeris are both subsidiaries of Essence Group Holdings Corp. “Mutual of Omaha is a significant long-term investor in Essence Group Holdings,” according to Essence Healthcare. The Strategy Richard Jones, the chief executive officer of Essence Healthcare, said in a comment accompanying the deal announcement that Essence Healthcare has enjoyed a close working relationship with Mutual of Omaha. “The acquisition of these plans will significantly accelerate our footprint in Medicare Advantage, and materially change our expansion plans,” Jones said. “Accordingly, we will need to reorganize and restructure our business to accommodate this opportunity.” Resources Government reports on Medicare Advantage plan enrollment numbers are available here. An article about the early years of Essence and Lumeris is available here. Source: https://www.thinkadvisor.com/2020/02/26/mutual-of-omaha-agrees-to-sell-medicare-advantage-business ![]() |
Medicare Blog | Medicare News | Medicare Information
Mutual of Omaha Agrees to Sell Medicare Advantage Business
Posted by www.psmbrokerage.com Admin on Thu, Feb 27, 2020 @ 10:27 AM
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The Ultimate Insurance Marketing Guide For 2020
Posted by www.psmbrokerage.com Admin on Wed, Feb 26, 2020 @ 04:10 PM
The Ultimate Insurance Marketing Guide The folks at 321 Web Marketing have put together a great guide that is worth a read. In this insurance marketing guide, you will find information and tips on how to develop a successful insurance marketing strategy online in 2020. 321 have years of experience running successful digital marketing campaigns for insurance agencies and know exactly what to do to take your digital marketing to the next level. They also take a look at what the majority of insurance agencies are doing right and what they are doing wrong, and discuss how to make improvements. Ready to step up your digital marketing game? Read on! Source: https://www.321webmarketing.com/ultimate-insurance-marketing-guide-2020/ ![]() |
Tags: Insurance, Digital Marketing
Some People Will Care No one cares what year your company was founded. No one cares about the map of all your locations. No one cares about the clients you serve. No one cares about the awards your company has won. No one cares about what you believe makes you great. No one cares about your product. No one cares about your service. No one cares about your solutions. No one cares about you.
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High cost of dental coverage means seniors skip needed care
Posted by www.psmbrokerage.com Admin on Tue, Feb 25, 2020 @ 02:44 PM
High cost of dental coverage means seniors skip needed care In 2017, roughly 10% of all Medicare beneficiaries did not get needed dental care because they couldn’t afford it. Traditional Medicare does not cover dental care, which means seniors have to buy it through a Medicare Advantage or other private plan. Check out the dental plans we have available to our agents. ![]() |
Tags: Medicare Advantage, dental plans
Medicare Advantage enrollment swells
Posted by www.psmbrokerage.com Admin on Fri, Feb 21, 2020 @ 01:44 PM
Medicare Advantage enrollment swells Roughly 24.4 million seniors and people with disabilities were enrolled in a Medicare Advantage plan as of this month, a 9.4% jump from the same time in 2019, according to the latest federal data analyzed by Axios. Why it matters: Medicare Advantage, which is run by private health insurers, continues to grow at high rates despite concerns over the program's higher spending and evidence that insurers are making people appear sicker than they are. By the numbers: The 9.4% annual enrollment growth is well above the 6.8% growth rate in 2019, and people flocked to pretty much every insurer selling Medicare Advantage plans this past season — from startups to well-established carriers.
Startups including Devoted Health, Clover Health and Alignment Healthcare still have small MA footprints compared to the traditional insurance carriers, but they recorded sizable enrollment gains for this year.
The elephant in the room: The Congressional Budget Office raised new concerns about MA spending in its latest economic outlook.
Source: https://www.axios.com/medicare-advantage-2020-enrollment-fefff230-ed08-47dc-b01d-e2921a502508.html ![]() |
Tags: Medicare Advantage, Medicare Part D, CMS
Medicare Managers Hope to Lift Agent Referral Fee Cap
Posted by www.psmbrokerage.com Admin on Mon, Feb 10, 2020 @ 03:41 PM
Medicare Managers Hope to Lift Agent Referral Fee Cap Medicare program managers want to give health insurers more flexibility over pay for agents and brokers. Officials at the Centers for Medicare and Medicaid Services (CMS) have proposed lifting the current $100 limit on Medicare Advantage plan enrollment fees. Instead, an insurer would have to keep a producer’s total Medicare plan sales compensation under the “fair market value” compensation limit for the year. This year, for example, the annual producer compensation limit for a Medicare Advantage plan enrollment in most of the country is $510 for a new sale and $255 for a renewal sale. Resources
CMS would lift the prescription drug plan referral fee limit, which is now $25. Instead, a Medicare drug plan issuer would have to keep all producer compensation for a sale, including referral fee payments, under the fair market value limit, which is $78 per year for a new sale, and $39 per year for a renewal sale. The PacketCMS announced the proposal last week, in an 895-page packet of Medicare program draft regulations and regulation notes. Along with the producer comp provisions, the packet includes:
The real-time benefit tool would give a drug plan enrollee a simplified version of the drug benefits information that the enrollee’s doctor sees. CMS is preparing to publish the packet in the Federal Register, the government’s official rulemaking publication, Feb. 18. Comments on the draft regulations are due April 6. Medicare PlansThe Medicare Part A program covers enrollees inpatient hospital bills. The Medicare Part B program pays physician and outpatient services bills. Medicare Part C lets private insurers offer consumers alternatives to using Original Medicare Part A and Part B coverage as is. The biggest Medicare Part C program, the Medicare Advantage program, provides access to plans that look somewhat like employer-sponsored health maintenance organization, preferred provider organization and fee-for-service plans. The Medicare Part D program lets private plans offer Medicare enrollees prescription drug coverage. Medicare Producer CompensationCMS uses the terms “referral fee” and “finder’s fee” to refer to money paid to an agent or broker in exchange for the producer’s help with locating someone who needs Medicare coverage, without the producer having to complete a sale. CMS officials say in the introduction to the new draft regulations that CMS uses the term “compensation” to refer to commissions, bonuses, gifts, prizes, awards, and referral or finder fees. “By eliminating the individual referral fee limit, we are restructuring the regulation to only provide for referral fees within the scope of fair market value,” officials say. Officials acknowledge that efforts to regulate referral fees generated a great deal of discussion in 2009, when they were developing the official Medicare Advantage “call letter” for 2010. “We solicit comment on whether removing the limit on referral/finder’s fees would generate concerns such as those” that cropped up in 2009, officials say. “Fair Market Value”Officials explain in the introduction to the new draft regulations what the term “fair market value” means in connection with Medicare plan producer compensation. Medicare program managers based the original Medicare Advantage fair market value producer comp caps on 19,000 producer compensation 2006 and 2007 records that plans submitted around 2008, according to CMS. The original Medicare Advantage plan cap was $400 per year in most of the country. Since then, CMS has adjusted the producer comp caps for inflation using a Medicare Advantage “growth rate,” or inflation adjustment rate. CMS started out setting the Medicare drug plan fair market value limit at $50 per year, and it has used a Medicare drug plan inflation adjustment rate to adjust the drug plan fair market value limit for inflation, officials say. Medicare Communications & Marketing GuidelinesCMS officials say they also want to put a reorganized version of marketing rules given in a manual, the Medicare Communications & Marketing Guidelines, into federal regulations. “CMS does not intend to change policy expressed in those regulations,” officials say. But officials do define the term “marketing” in the proposed regulations, and they list information about enrollee rewards and incentives programs as a type of content that must comply with CMS Medicare plan marketing guidelines. The Medicare plan marketing guidelines apply to any communications developed by the insurers’ “downstream entities,” such as distributors or agents, but only the insurers, not the downstream entities, can submit materials to CMS for review and approval for use, officials say. CMS already has a regulation that keeps agents and others from making unsolicited calls to Medicare plan enrollees. Officials say they want to update that regulation to apply to unsolicited direct messages from social media platforms. In a section that updates the rules for Medicare Advantage-related events and marketing appointments, CMS seems to make room for Medicare Advantage agents to provide holistic reviews of consumers’ needs. A Medicare Advantage agent may not “market non-health-related products, such as annuities,” to consumers, according to the draft regulations. But an agent who has a personal marketing appointment with a consumer may “review the individual needs of the beneficiary including, but not limited to, health care needs and history, commonly used medications, and financial concerns,” according to the draft regulations. Source: https://www.thinkadvisor.com/2020/02/10/medicare-managers-hope-to-lift-agent-referral-fee-cap ![]() |
Women and Lower-Income Enrollees Are Most Likely to Change Medicare Advantage Plans
Posted by www.psmbrokerage.com Admin on Mon, Feb 10, 2020 @ 03:05 PM
Women and Lower-Income Are Most Likely to Change Medicare Advantage Plans According to a survey of Medicare Advantage enrollees released today by eHealth, Inc., 40% of women had changed from one Medicare Advantage plan to another, compared to 33% of men. eHealth's survey also found that 40% of those with incomes below $25,000 had changed plans, compared to 29% of those with incomes over $100,000.
Additional highlights from eHealth's survey:
eHealth's findings are based on a voluntary survey of consumers who enrolled in Medicare Advantage plans purchased from eHealth. The survey was conducted in January 2020 and a total of 1,086 responses were received. Read the full report. ![]() |
Tags: Medicare Advantage
CMS Releases Advance Notice For Medicare Advantage And Part D Plans
Posted by www.psmbrokerage.com Admin on Mon, Feb 10, 2020 @ 01:52 PM
CMS Releases Advance Notice For Medicare Advantage And Part D Plans Last week, the Centers for Medicare & Medicaid Services (CMS) released Part II of its Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part D Payment Policies for Calendar Year (CY) 2021 (fact sheet). The agency also released its proposed rule on policy and technical changes to MA and Part D for CYs 2021 and 2022 (fact sheet). A press release for both developments is available here. This post focuses on summarizing the Advance Notice component of this package of policies. The topline takeaway for you from this raft of rulemaking is that the Medicare Advantage program is stronger than ever. Since I wrote a post on these pages in 2014 about its inexorable rise, over six million more seniors enrolled in the program, now accounting for 34 percent of all Medicare beneficiaries. Growth has remained strong despite reimbursement cuts to MA plans under the Affordable Care Act that brought their payment into parity with traditional Medicare. Overall, the changes in the Advance Notice will likely continue to fuel this trend. Payments are expected to rise modestly, a newly refined risk adjustment methodology continues to be phased in, and an array of next-generation quality measures are presented for potential adoption. The trend and positive implications for the Part D prescription drug benefit track a similar path CMS already released Part I of the Advance Notice on January 6, 2020 (fact sheet). Today’s Part II addresses a wider array of MA and Part D-related policies and includes the estimated net rate update for MA plans. The Agency includes additional updates for both the MA and Part D programs, including the continued phase-in of using encounter-based risk scores for determining MA payment adjustments. An important change from the proposed rule on policy changes that we want to briefly note is the inclusion of beneficiaries with end-stage renal disease (ESRD) in the program for the first time, per the requirements of the 21st Century Cures Act. Payment Update For MA Plans CMS estimates that, based on the proposed policies in the Advance Notice, net year-over-year revenue to MA plans will increase by 0.93 percent in CY 2021 compared with CY 2020, reflecting an almost three percent growth in underlying costs of care, modest adjustments due to the quality Star ratings program and revisions to the risk model, and an approximate 2.5 percent decrease to account for the relative risk of MA enrollees compared to other Medicare beneficiaries. This projection does not include an adjustment for current coding behavior of MA plans, which CMS says would yield an additional 3.5 percent increase for 2021. Risk Adjustment And Other MA Changes CMS is continuing implementation of a new approach to its MA risk adjustment methodology. In 2021, 75 percent of this factor will be based on the new model, up from 50 percent in 2020, while 25 percent will be based on the old model. The primary difference is that the new methodology relies on real patient counter data to calculate risk. The Advance Notice makes other changes to MA policy, including exclusion of organ procurement costs from plan payments, establishing the basis for payment for beneficiaries with ESRD, imposition of a statutorily mandated 5.9 percent reimbursement cut to counterbalance historical increases in coding intensity, and maintenance of a cap on MA benchmarks that, despite some stakeholder objections, also applies to quality bonus payments. An open question for comment is whether to extend a 4.7 percent increase to plans in Puerto Rico to reflect the fact that over three times the proportion of Puerto Ricans do not use any Medicare services at all as compared to the national average. Prescription Drug Benefit Changes As it does annually, CMS proposes updates to the benefit parameters for Part D prescription drug plans indexed to an annual increase of 2.85 percent. For example, standardized Part D plan deductibles would increase from $435 to $445 and the coverage limit is set to increase from $4020 to $4130. CMS proposes to continue the phase-in of a new risk adjustment model for Part D as well, advancing usage of the new, encounter-based methodology to 75 percent of the factor for 2021. The Agency also floats the concept of shifting more risk to Part D plans, while stopping short of a formal proposal, while noting that plans will pay 75 percent of dispensing and vaccine administration fees in the coverage gap, while beneficiaries pick up the balance. This discussion may be related to the fact that Congress is contemplating reforms to the Part D benefit as well. Star Ratings CMS proposes several new measure concepts for potential incorporation into the Star ratings quality measurement program. For MA plans, they explore including new measures relating to ESRD, prior authorization, health outcomes, osteoporosis screening, cardiac rehabilitation, diabetes overtreatment, and home health. For Part D, new measures are proposed for generic drug utilization, initial opioid prescribing, and net promotor score (a measure of customer satisfaction). Next Steps Comments on Advance Notice are due by Friday, March 6 at 6pm ET. CMS will publish the Final Call Letter no later than April 6, 2020. CMS also states it will no longer be publishing a Call Letter for 2021, stating that it plans to codify much of what it has traditionally included in the Call Letter instead in the CY 2021 and 2022 MA and Part D proposed rule, a change consistent with the Administration’s goal of reducing the overall number of regulations issued. CMS will issue MA and Part D bidding instructions separately. All-told, as noted above, these policy changes are a net improvement for the Medicare Advantage and Part D programs, which are likely to continue their stability and consistent growth in the years to come. Source: https://www.healthaffairs.org/do/10.1377/hblog20200210.336746/full/ ![]() |
Tags: Medicare Advantage, Medicare Part D, CMS
2021 Medicare Advantage and Part D Advance Notice Part II Fact Sheet
Posted by www.psmbrokerage.com Admin on Mon, Feb 10, 2020 @ 01:42 PM
2021 Medicare Advantage and Part D Advance Notice Part II Fact Sheet The Centers for Medicare & Medicaid Services (CMS) released Part II of the Calendar Year (CY) 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (the Advance Notice). CMS released Part I of the Advance Notice on January 6, 2020. CMS will accept comments on all proposals in the Advance Notice through Friday, March 6, 2020, before publishing the final Rate Announcement by April 6, 2020. The proposed updates will continue to modernize and maximize competition among MA and Part D plans. 2021 Advance Notice Through the CY 2021 Advance Notice, CMS is proposing updates and changes to the methodologies used to pay Medicare Advantage plans, PACE organizations, and Part D sponsors. Net Payment Impact The chart below indicates the expected impact of the proposed policy changes on plan payments relative to last year.
1Rebasing/re-pricing impact is dependent on finalization of the average geographic adjustment index and will be available with the publication of the CY 2021 Rate Announcement. 2021 Part C Risk Adjustment Model Proposals As previously discussed in Part I of the Advance Notice, we are proposing to continue the phase-in of the 2020 CMS-Hierarchical Condition Categories (HCC) model. The 21st Century Cures Act requires that CMS phase-in changes to risk adjustment payments based on section 1853(a)(1)(I) of the Social Security Act over a three-year period, beginning with 2019, with such changes being fully implemented for 2022 and subsequent years. In order to continue phasing in the model that meets the statutory requirements (the 2020 CMS-HCC model), CMS is proposing to calculate risk scores for CY 2021 payment to MA organizations and certain demonstrations as the sum of:
This proposal represents a change from the blend for CY 2020 of 50% of the risk score calculated with the 2020 CMS-HCC model and 50% of the risk score calculated with the 2017 CMS-HCC model. Using Encounter Data Also as previously discussed in Part I, CMS calculates risk scores using diagnoses submitted by MA organizations and from original Medicare fee-for-service (FFS) claims. Historically, CMS has used diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS) by MA organizations for the purpose of calculating risk scores for payment. In recent years, CMS began collecting encounter data from MA organizations, which also includes diagnostic information. CMS began using diagnoses from encounter data to calculate risk scores for CY 2015 and, for CY 2016, CMS blended 10% of the encounter data-based risk score with 90% of the RAPS-based risk score. CMS has continued to use a blend to calculate risk scores by calculating risk scores with 25% encounter data and 75% RAPS data for CY 2017, 15% encounter data and 85% RAPS data for CY 2018, and 25% encounter data and 75% RAPS data for CY 2019. For CY 2020, CMS is continuing to use a blend to calculate risk scores, by calculating risk scores with 50% encounter data and 50% RAPS data. For CY 2021, CMS proposes to calculate risk scores for payment to MA organizations and certain demonstrations by summing 75% of the encounter data-based risk score with 25% of the RAPS-based risk score. CMS proposes to calculate the encounter data-based risk scores with the 2020 CMS-HCC model and the RAPS-based risk scores with the 2017 CMS-HCC model. For Programs of All-Inclusive Care for the Elderly (PACE) organizations for CY 2021, CMS proposes to continue calculating risk scores by pooling risk adjustment-eligible diagnoses from encounter data, RAPS data, and FFS claims to calculate a single risk score (with no weighting) using the 2017 CMS-HCC model. Medicare Advantage Coding Pattern Adjustment Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between MA organizations and FFS providers. For CY 2021, CMS proposes to apply a coding pattern adjustment of 5.90 percent, which is also the minimum adjustment for coding intensity required by the statute. Exclusion of Kidney Organ Acquisition Costs from MA Benchmarks The 21st Century Cures Act amended the Social Security Act to allow all Medicare-eligible individuals with ESRD to enroll in MA plans beginning January 1, 2021. With this new enrollment option, the Cures Act also made related payment changes in the MA and FFS programs. Effective January 1, 2021, MA organizations will no longer be responsible for organ acquisition costs for kidney transplants for MA beneficiaries, and such costs will be excluded from MA benchmarks and covered under the FFS program instead. CMS is implementing these payment provisions through the Advance Notice. PACE organizations will continue to cover organ acquisition costs for kidney transplants, and CMS will continue to include the costs for kidney acquisitions in PACE payment rates. Puerto Rico A far greater proportion of Medicare beneficiaries receive benefits through MA in Puerto Rico than in any other state or territory. The policies proposed and under consideration for 2021 would continue to provide stability for the MA program in the Commonwealth and to Puerto Ricans enrolled in MA plans. These policies include basing the MA county rates in Puerto Rico on the relatively higher costs of beneficiaries in FFS who have both Medicare Parts A and B, continuing the statutory interpretation that permits certain counties in Puerto Rico to qualify for an increased quality bonus adjusted benchmark, and applying an adjustment to reflect the nationwide propensity of beneficiaries with zero claims. Part C and D Star Ratings As part of the Administration’s effort to increase transparency and seek public comment on the Part C and D Star Ratings program, CMS codified the methodology for the Part C and D Star Ratings program in the CY 2019 Medicare Part C and D Final Rule, published in April 2018 for the 2021 Star Ratings. The Advance Notice provides updates that those regulations require us to make through the process described for changes in, and adoption of, payment and risk adjustment policies in section 1853(b) of the Act. In addition, we are soliciting input on future measures and concepts as we continue to enhance the Star Ratings over time. The Advance Notice includes information about the date by which plans must submit their requests for review of the appeals and complaints measures data, and lists the measures included in the Part C and D Improvement measures and the values for the Categorical Adjustment Index for the 2021 Star Ratings. The policy for adjustments to Star Ratings in the event of extreme and uncontrollable circumstances, such as major hurricanes, is the same as the one implemented for the 2020 Star Ratings and codified in regulation for the 2022 Star Ratings and beyond. Additionally, as part of our efforts to lower prescription drug costs for Medicare beneficiaries and strengthen competition for generic products, CMS is soliciting feedback on a generic utilization Part D measurement concept through the 2021 Advance Notice. CMS encourages Part D sponsors to leverage favorable tier placement and effective formulary management tools to incentivize beneficiaries to fill generic alternatives over branded products. Our goal is to ultimately propose to adopt measures that reward sponsors for high rates of generic utilization. Other measurement concepts that CMS is soliciting feedback on include:
2021 Call Letter CMS will not be publishing a Call Letter for 2021. CMS is proposing to codify much of the guidance typically included in the annual Call Letter through the CY 2021 and 2022 MA and Part D Proposed Rule. CMS will also separately issue Part C and Part D bidding instructions and information previously provided through the Call Letter. Process Comments on the proposals set forth in Part I and Part II of the Advance Notice must be submitted by Friday, March 6, 2020. The final 2021 Rate Announcement will be published by Monday, April 6, 2020. To submit comments or questions electronically, go to www.regulations.gov, enter the docket number “CMS-2020-0003” in the “search” field, and follow the instructions for ‘‘submitting a comment.’’ The 2021 Advance Notices (Part I and Part II) may viewed by going to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents and selecting “2021 Advance Notices.” ![]() |
Tags: Medicare Advantage, Medicare Part D, CMS
CMS to Add MA Telehealth Coverage for Kidney Disease, Specialty Care
Posted by www.psmbrokerage.com Admin on Mon, Feb 10, 2020 @ 10:00 AM
CMS to Add MA Telehealth Coverage for Kidney Disease, Specialty Care In a proposed rule issued this week, CMS is boosting telehealth coverage in Medicare Advantage plans for members with end-stage renal disease and giving MA members more telehealth coverage for specialist care.
In a proposed rule issued on February 5, the Centers for Medicare & Medicaid Services announced that it is following through with mandates included in the 21st Century Cures Act by eliminating barriers to enrollment in MA plans for people with ESRD. “This proposed rule takes an important step in improving the lives of beneficiaries with ESRD, which is a priority in alignment with the Executive Order on Advancing American Kidney Health,” CMS said in a fact sheet accompanying the proposed rule. “By removing the barrier that beneficiaries with ESRD now face in terms of enrolling in MA plans, we are empowering them to choose the type of Medicare coverage that best meets their needs.” The telehealth-specific changes are part of a larger proposed rule targeting prescription drug programs. The rule references an executive order issued last July by President Donald Trump that aimed to change how people living with ESRD are treated and how care providers are reimbursed for that treatment. The order opens the door to, among other things, home-based dialysis programs that use remote patient monitoring technology for care management and transplant programs that use telehealth to improve organ procurement and post-operative recovery. “For decades, across all of American healthcare, and kidney care in particular, the focus has been on paying for procedures, rather than paying for good outcomes,” Health and Human Services Secretary Alex Azar noted in a press release. “We need to flip that around: We’re going to start paying providers for better health outcomes, rather than procedures, and we’re going to pay for health, rather than simply paying once people are already sick.” Roughly 30 million Americans, or 15 percent of the adult population, are affected by chronic kidney disease. Of that number, more than 660,000 have kidney failure, and almost 470,000 are on dialysis. More than 193,000, meanwhile, have a functioning kidney transplant, which requires them to follow a very strict daily medication regimen. According to the National Kidney Foundation, telemedicine offers a promising alternative to in-person care, most often delivered in a doctor’s office or dialysis clinic. Clinicians can remotely monitor a patient’s blood pressure and other vital signs, as well as offering resources for medication adherence and diet plans. More importantly, nephrologists and nephrology nurses can coordinate care online with a patient’s primary care provider (a model now being used by the Indian Health Service) and interact at home with patients undergoing hemodialysis and peritoneal dialysis, offering on-demand care between regularly scheduled office visits. In its proposed rule this week, CMS also announced that it’s giving MA beneficiaries access to new telehealth benefits not available in Medicare fee-for-service plans for a number of specialty care services. “CMS proposes to strengthen network adequacy rules for MA plans by codifying our existing network adequacy methodology, but we are also proposing new policies to improve access in rural areas and encourage the use of telehealth in all areas,” the agency said. “In rural areas, we are proposing to reduce the required percentage of beneficiaries that must reside within the maximum time and distance standards from 90 percent to 85 percent and inviting comment regarding additional changes to improve MA access in rural areas. To encourage and account for telehealth providers in contracted networks, we are proposing that MA plans receive a 10 percent credit towards the percentage of beneficiaries that must reside within required time and distance standards when the plan contracts with telehealth providers for Dermatology, Psychiatry, Cardiology, Otolaryngology, and Neurology.” CMS also said that it would solicit comments on whether the credit should be expanded to other specialties. ![]() |
Tags: Medicare Advantage, CMS, Telehealth
Contract Year 2021 and 2022 Medicare Advantage and Part D Proposed Rule
Posted by www.psmbrokerage.com Admin on Fri, Feb 07, 2020 @ 10:48 AM
Contract Year 2021 and 2022 Medicare Advantage and Part D Proposed Rule Fact Sheet On February 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates Medicare Advantage (MA or Part C) and the Medicare prescription drug benefit (Part D) program to give seniors more choices and lower out-of-pocket costs, and to encourage price transparency. The proposed rule is another step in lowering drug costs for seniors, increasing competition, and further advancing the agency’s efforts to strengthen and modernize the popular MA and Part D programs. The proposed rule implements several changes stemming from federal laws related to the Part C and D programs—including the Bipartisan Budget Act of 2018 (BBA of 2018), the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (the SUPPORT Act), and the 21st Century Cures Act (the Cures Act). The proposed rule also addresses the opioid epidemic across CMS programs and continues CMS’s Patients Over Paperwork initiative to reduce “red tape” that depletes resources from our healthcare system. If finalized, the proposed changes would result in an estimated $4.4 billion savings to the federal government over ten years, largely arising from proposed refinements to the MA and Part D Quality Star Rating system. We expect some savings will also be passed onto beneficiaries in the form of increased benefit offerings and reduced premiums or cost sharing. As part of the Patients Over Paperwork initiative to reduce unnecessary burden to increase efficiencies and the beneficiary experience, CMS is seeking comment from the public on proposals to codify many longstanding policies on the MA and Part D programs that have been previously adopted through sub-regulatory guidance such as the annual Call Letter and other guidance documents. CMS will not publish a Call Letter for 2021. We believe that codifying the policies in regulation provides additional transparency and program stability, and allows MA organizations and Part D plan sponsors to develop more innovative plan designs. In addition, CMS will issue HPMS memoranda to communicate instructions, such as those around bidding, in advance of the bid deadline. Through this regulation, the final Rate Announcement, the bid pricing tool materials and bidding instruction memoranda, plans will have all of the information needed to prepare Part C and D bids for 2021. This fact sheet discusses the major provisions of the proposed rule, including a number of changes to strengthen and improve the MA and Part D programs and the Programs of All-Inclusive Care for the Elderly (PACE), and other changes for contract year 2021 and 2022. The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/current. Implementing Certain Cures Act Provisions Medicare Advantage (MA) Plan Options for End-Stage Renal Disease (ESRD) Beneficiaries The Cures Act amended the Social Security Act (the Act) to allow all Medicare-eligible individuals with ESRD to enroll in MA plans beginning January 1, 2021. CMS is proposing to codify this statutory change in regulation. This proposed rule takes an important step in improving the lives of beneficiaries with ESRD, which is a priority in alignment with the Executive Order on Advancing American Kidney Health. By removing the barrier that beneficiaries with ESRD now face in terms of enrolling in MA plans, we are empowering them to choose the type of Medicare coverage that best meets their needs. This proposed rule also implements related MA and Medicare FFS payment changes made by the Cures Act—FFS coverage of kidney acquisition costs for MA beneficiaries and exclusion of such costs from MA benchmarks.” Enhancements to the Part C and D Programs Medicare Advantage (MA) and Part D Prescription Drug Program Quality Rating System The Part C and D Star Ratings support CMS efforts to improve the level of accountability for the care provided by health and drug plans, physicians, hospitals, and other Medicare providers. In addition to routine measure updates and technical clarifications to the Star Ratings, CMS proposes to further increase the predictability and stability in the Star Ratings by directly reducing the influence of outliers on cut points. We also propose to further increase measure weights for patient experience/complaints and access measures from 2 to 4, reflecting CMS’s commitment to put patients first and to empower patients to work with their doctors to make healthcare decisions that are best for them. Permitting a Second, “Preferred”, Specialty Tier in Part D Part D sponsors and pharmacy benefit managers have requested a second specialty tier option, suggesting this would encourage the use of more preferred, less expensive agents, reduce enrollee cost sharing, and reduce costs to CMS. In response, with a proposed effective date of January 1, 2021, we propose to: allow Part D sponsors to establish a second, “preferred” specialty tier with lower cost sharing than the current specialty tier; codify the maximum cost sharing for the higher specialty tier; codify the methodology that determines and increases the specialty tier cost threshold; require sponsors to permit tiering exceptions between the two specialty tiers; and permit sponsors to determine which drugs go on either tier subject to the proposed cost threshold. This proposal supports the agency’s commitment to lowering drug prices for the Medicare population. Beneficiary Real Time Benefit Tool (RTBT) CMS proposes that each Part D plan implement a beneficiary RTBT that will allow enrollees to view plan-provided, patient-specific, real-time formulary and benefit information by January 1, 2022. Plans would be able to use existing secure patient portals, develop a new portal, or use a computer application to fulfill this requirement. Plans would be required to also make this information available to enrollees who call the plan’s customer service call center. In order to encourage enrollees to use the beneficiary RTBT, we also propose to allow plans to offer rewards and incentives to their enrollees who log onto the beneficiary RTBT or seek to access this information via the plan’s customer service call center. Establishing Pharmacy Performance Measure Reporting Requirements Under the Part D program, plans currently do not have to disclose to CMS the measures they use to evaluate pharmacy performance in their network agreements. The measures used by plans potentially impact pharmacy reimbursements. Therefore, CMS proposes to require Part D plans to disclose such information to enable CMS to track how plans are measuring and applying pharmacy performance measures. CMS will also be able to report this information publicly to increase transparency on the process and to inform industry in their recent efforts to develop a standard set of pharmacy performance measures. CMS is also seeking comment on the Part D pharmacy performance measures more broadly, including recommendations for potential Part D Star Ratings metrics to incentivize the uptake of a standard set of measures. Medical Loss Ratio (MLR) CMS proposes to amend the MA MLR regulations to allow MA organizations to include in the MLR numerator as “incurred claims” all amounts paid for covered services, including amounts paid to individuals or entities that do not meet the definition of “provider” as defined at § 422.2, in alignment with changes to MA supplemental benefits in recent years. In addition, CMS proposes to add a deductible-based adjustment to the MLR calculation for MA medical savings account (MSA) contracts receiving a credibility adjustment. The proposed adjustment would remove a potential deterrent to the offering of MSAs by MA organizations that may be concerned about their inability to meet the MLR requirement as a result of random variations in claims experience, the risk of which is greater under health insurance policies with higher deductibles. This proposal aligns with President Trump’s Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors for the Department of Health and Human Services to propose regulatory changes that reduce barriers to obtaining MSAs. Implementing Several Opioid Provisions of the SUPPORT Act Continuing the fight against the opioid epidemic, the proposed rule implements several provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act that require Part D plans to educate beneficiaries on opioid risks, alternate pain treatments, and safe disposal of opioids. The proposed rule also expands drug management programs and medication therapy management programs, through which Part D plans review with providers opioid utilization trends that may put beneficiaries at-risk and provide beneficiary-centric interventions. These provisions will help prevent and treat opioid overuse. Codifying Existing Part C and D Program Policy Medicare Advantage (MA) and Cost Plan Network Adequacy CMS proposes to strengthen network adequacy rules for MA plans by codifying our existing network adequacy methodology, but we are also proposing new policies to improve access in rural areas and encourage the use of telehealth in all areas. In rural areas, we are proposing to reduce the required percentage of beneficiaries that must reside within the maximum time and distance standards from 90% to 85% and inviting comment regarding additional changes to improve MA access in rural areas. To encourage and account for telehealth providers in contracted networks, we are proposing that MA plans receive a 10% credit towards the percentage of beneficiaries that must reside within required time and distance standards when the plan contracts with telehealth providers for Dermatology, Psychiatry, Cardiology, Otolaryngology, and Neurology. We are soliciting comment regarding whether to expand this credit to other specialty provider types. Supplemental Benefit Requirements We are proposing to codify existing policy with respect to supplemental benefits, including the Managed Care Manual (Chapter 4) definition of a supplemental benefit, the expanded definition of “primarily health related,” and the reinterpreted uniformity requirements, including that reductions in cost sharing are an allowable supplemental benefit. Special Election Periods (SEPs) for Exceptional Conditions We are proposing to codify a number of SEPs that we have adopted and implemented through sub-regulatory guidance as exceptional circumstances SEPs. Among the proposed SEPs are the SEP for Individuals Affected by a FEMA-Declared Weather-Related Emergency or Major Disaster, the SEP for Employer/Union Group Health Plan elections, and the SEP for Individuals Who Disenroll in Connection with a CMS Sanction. Two SEPs that do not currently exist in guidance are also being proposed: the SEP for Individuals Enrolled in a Plan that has been identified by CMS as a Consistent Poor Performer and the SEP for Individuals Enrolled in a Plan Placed in Receivership. Codifying our current policy for these SEPs will provide transparency and stability for stakeholders about the MA and Part D programs and about the nature and scope of these SEPs by ensuring that the SEPs are changed only through additional rulemaking. Implementing Certain BBA of 2018 Provisions Special Supplemental Benefits for the Chronically Ill (SSBCI) CMS is proposing a minor policy modification to SSBCI. Previously, CMS limited the chronic conditions an enrollee must have to be eligible under SSBCI to those conditions outlined in the Medicare Managed Care Manual (Chapter 16b). However, the agency recognizes that there may be other chronic conditions that may meet the statutory definition of a chronic condition, but are not included in Chapter 16b. Therefore, beginning in contract year 2021, CMS is proposing that plans be allowed to target other chronic conditions. “Look-Alike” Dual Eligible Special Needs Plans CMS proposes to limit MA plans that are Dual Eligible Special Needs Plan (D-SNP) “look-alikes.” These “look-alike” plans, which have similar levels of dual eligible enrollment as D-SNPs but are not subject to the federal regulatory and state contracting requirements applicable to D-SNPs, circumvent federal regulatory and state contracting requirements that otherwise apply to D-SNP products. The Medicare Prescription Drug, Improvement, and Modernization Act created D-SNPs to allow for Medicare Advantage (MA) products that exclusively serve individuals dually eligible for Medicare and Medicaid. D-SNPs must meet a number of additional requirements, relative to non-SNP MA plans, related to health risk assessments, models of care, and Medicaid integration. Most recently, the Bipartisan Budget Act (BBA) of 2018 required CMS to establish additional requirements related to Medicaid integration for D-SNPs. The “look-alike” D-SNPs impede the ability of states and CMS to meaningfully implement existing and new statutory requirements for D-SNPs that Congress created in the BBA by allowing plans that fail to meet the requirement to create look-alikes instead. Under the proposed rule, CMS proposes to not enter into or renew a contract for an MA plan that is a non-SNP plan that either:
Under the proposed rule, MA plans exceeding this threshold would be able to transition their membership into a D-SNP or another zero-premium plan offered by the MA organization. Proposed Changes to the Programs of All-Inclusive Care for the Elderly (PACE) CMS proposes to reduce the administrative burden for PACE organizations by proposing to allow service delivery requests be approved in full by an interdisciplinary team (IDT) member at the time the request is made. This proposal eliminates the requirement that the IDT conduct a reassessment of the participant for service delivery requests that can be approved. We are also proposing to enhance participant protections by improving the participant appeals process, adding additional participant rights, increasing requirements related to the provision of services, and ensuring PACE organizations appropriately document care in the medical record while maintaining original communications from caregivers and others. CMS is also proposing to bolster CMS’s ability to access records, improve the regulatory framework relating to required services in PACE, and set out appeal processes for PACE organizations following certain enforcement actions. ![]() |
Tags: Medicare Advantage, Medicare Part D, CMS
Proposed Changes to Medicare Advantage and Part D Will Provide Better Coverage, More Access and Improved Transparency for Medicare Beneficiaries
Posted by www.psmbrokerage.com Admin on Fri, Feb 07, 2020 @ 10:35 AM
Proposed Changes to Medicare Advantage and Part D Will Provide Better Coverage, More Access and Improved Transparency for Medicare Beneficiaries Proposed rule and Advance Notice continue to strengthen the popular private Medicare health and drug plans Today the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule and the Advance Notice Part II to further advance the agency’s efforts to strengthen and modernize the Medicare Advantage and Part D prescription drug programs. The changes proposed today would lower beneficiary cost sharing on some of the most expensive prescription drugs, promote the use of generic drugs, and allow beneficiaries to know in advance and compare their out-of- pocket payments for different prescription drugs. Together, these proposed changes advance President Trump’s Executive Orders on Protecting and Improving Medicare for Our Nation’s Seniors and Advancing American Kidney Health as well as several of the CMS strategic initiatives. The proposed changes described in the Advance Notice are expected to increase plan revenue by 0.93%. “Whether you’re a senior dealing with kidney disease, living in a rural area, facing high costs because you need a specialty drug, or just want a better sense of what you’ll owe for prescription drugs, these new CMS proposals will improve your Medicare experience,” said HHS Secretary Alex Azar. “President Trump has been laser-focused on strengthening and protecting Medicare for our seniors, and these proposed improvements are the latest measures taken under the President’s Medicare executive order.” As part of President Trump’s commitments to promoting price transparency and lowering prescription drug prices, the proposed rule would require Part D plans to offer real-time drug price comparison tools to beneficiaries starting January 1, 2022, so consumers could shop for lower-cost alternative therapies under their prescription drug benefit plan. For example, beneficiaries would be able to compare drug prices at the doctor’s office to find the most cost- effective prescription drugs for their health needs. In addition, if a doctor recommends a specific cholesterol-lowering drug, the patient could easily look up what the copay would be and see if a different, similarly effective option might save the patient money. With this tool, patients would be better able to know what they’ll need to pay before they’re standing at the pharmacy cash register, and pharmaceutical companies and plans would have to compete on the basis of the costs that patients face for their prescription drugs. “In addition to giving those with kidney disease more choices, today’s proposals shed desperately needed light on previously obscured out of pocket costs for prescription drugs, “said CMS Administrator Seema Verma. “At the same time, it strengthens plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal. The Trump Administration will stop at nothing to protect America’s seniors.” In the Medicare Part D program, beneficiaries choose the prescription drug plan that best meets their needs. Many plans offering prescription drug coverage place drugs into different “tiers” on their formularies. Today, all drugs on a plan’s specialty tier – the tier that has the highest-cost drugs – have the same level of cost sharing. The proposed rule would allow a second, “preferred” specialty tier in Part D with a lower cost sharing amount. This proposal is designed to give Part D plans more tools to lower out of pocket costs for enrollees. Plans would be able to demand a better deal from manufacturers of the highest-cost drugs in exchange for placing their products on the “preferred” specialty tier. Under the Part D program, plans currently do not have to disclose to CMS the measures they use to evaluate pharmacy performance in their network agreements. CMS has heard concerns from pharmacies that the measures plans use to assess their performance are unattainable or otherwise unfair. The measures used by plans potentially impact pharmacy reimbursements. Therefore, the proposed rule would require Part D plans to disclose such information to enable CMS to track how plans are measuring and applying pharmacy performance measures. CMS will also be able to report this information publicly to increase transparency on the process and to inform the industry in its new efforts to develop a standard set of pharmacy performance measures. CMS is also seeking comment on Part D pharmacy performance measures more broadly, including stakeholders’ recommendations for potential Part D Star Ratings metrics that could incentivize the uptake of a standard set of measures once the industry establishes one. One way to help lower drug prices for beneficiaries is to encourage greater use of lower price generics and biosimilars. In general, plans are already achieving high utilization rates, but there is room to do better. In the Advance Notice, CMS is seeking comment on potentially developing measures of generic and biosimilar utilization in Medicare Part D as part of a plan’s star rating. This would reward plans based on the rate at which they encourage market adoption of these competitor products and lower costs for patients. Currently, beneficiaries with End-Stage Renal Disease (ESRD) are only allowed to enroll in Medicare Advantage plans in limited circumstances. Today’s proposed rule implements the 21st Century Cures Act requirements to give all beneficiaries with ESRD the option to enroll in a Medicare Advantage plan starting in 2021. This will give patients with ESRD access to more affordable Medicare coverage choices and extra benefits such as transportation or home- delivered meals. Starting this year, Medicare Advantage beneficiaries are able to access additional telehealth benefits not offered under Medicare Fee-for-Service, giving patients the option to receive health care services from more convenient locations, like their homes, rather than requiring them to go to a health care facility. CMS is proposing to build on the current benefits and give Medicare Advantage plans more flexibility to count telehealth providers in certain specialty areas like psychiatry, neurology, or cardiology towards network adequacy standards, which would encourage greater use of telehealth services as well as increase plan choices for beneficiaries. These proposed changes aim to give seniors more plan choices in rural areas, increase competition between plans, and allow providers to take advantage of the latest healthcare technologies and innovations. CMS is also proposing to enhance the Medicare Advantage and Part D Star Ratings to further increase the impact that patient experience and access measures have on a plan’s Star Rating. The Star Ratings system helps people with Medicare, their families, and their caregivers compare the quality of health and drug plans being offered. One of the best indicators of a plan’s quality is how its enrollees feel about their coverage experience. This proposal reflects CMS’s commitment to put patients first and improves incentives for plans to focus on what patients value and feel is important. Continuing the fight against the opioid epidemic, the proposed rule implements several provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act that require Part D plans to educate beneficiaries on opioid risks, alternate pain treatments, and safe disposal of opioids. The proposed rule also expands drug management programs and medication therapy management programs, through which Part D plans review with providers opioid utilization trends that may put beneficiaries at-risk and provide beneficiary-centric interventions. These provisions will help prevent and treat opioid overuse. And finally, as part of our Patients Over Paperwork initiative to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience, in the proposed rule, CMS is seeking comment on many longstanding policies on the Medicare Advantage and Part D programs that have been adopted through sub-regulatory guidance such as the annual Call Letter and other guidance documents. CMS looks forward to feedback on the proposed rule. Comments may be submitted electronically through our e-Regulation website at: https://www.cms.gov/Regulations-and-Guidance/Regulations-and- Policies/eRulemaking/index.html?redirect=/eRulemaking. CMS will accept comments on all proposals in the Advance Notice through Friday, March 6, 2020, before publishing the final Rate Announcement by April 6, 2020. To submit comments or questions electronically, go to www.regulations.gov, enter the docket number “CMS-2020-0003” in the “search” field, and follow the instructions for ‘‘submitting a comment.’’ For a fact sheet on the CY 2021/2022 Medicare Advantage and Part D Proposed Rule (CMS- 4190-P), please visit: https://www.cms.gov/newsroom/fact-sheets/contract-year-2021-and-2022-medicare-advantage-and-part-d-proposed-rule-cms-4190-p-1 The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/2020/02/18/2020-02085/medicare-and-medicaid- programs-contract-year-2021-and-2022-policy-and-technical-changes-to-the The 2021 Medicare Advantage and Part D Advance Notice Part II Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-advantage-and-part-d-advance-notice-part-ii-fact-sheet-0 Medicare Advantage and Part D Advance Notice Part II, please visit: https://www.cms.gov/files/document/2021-advance-notice-part-ii.pdf A blog about Increasing Access to Generics and Biosimilars in Medicare will be available at https://www.cms.gov/blog/increasing-access-generics-and-biosimilars-medicare ![]() |
Tags: Medicare Advantage, Medicare Part D, CMS
Deft Research: Medicare Shopping and Switching Study
Posted by www.psmbrokerage.com Admin on Fri, Feb 07, 2020 @ 10:20 AM
Deft Research: Medicare Shopping and Switching Study Deft's Medicare Shopping and Switching Study is now available! The 2020 Medicare Shopping and Switching Study uses responses from over 3,200 seniors to provide trends in consumer activity and decision making during the fall Annual Election Period. Special reporting includes:
An Executive Research Brief zeroing in on $0 PPO's and supplemental benefits is available, "Two Powerful Forces Have Permanently Changed the Medicare Landscape: #1 $0 PPOs and #2 Supplemental Benefits" Review the research brief here Source: https://www.deftresearch.com/ ![]() |
7 Things You Need to Know About Medicare Advantage
Posted by www.psmbrokerage.com Admin on Tue, Feb 04, 2020 @ 03:29 PM
7 Things You Need to Know About More than 23 million seniors and people with disabilities choose Medicare Advantage. Unlike traditional Medicare, Medicare Advantage delivers better services, better care, and better value, and continues to receive high rates of satisfaction from members who use it. Providing Better Financial Security Medicare Advantage caps out-of-pocket costs each year. These caps help protect seniors and people with disabilities financially in addition to their physical health. By doing so, vulnerable seniors—like those who make less than $30,000 a year, who overwhelmingly choose Medicare Advantage — have access to stable, high-quality health care. Reducing Costs for Taxpayers Medicare Advantage also helps drive down costs for taxpayers: the more people who enroll in Medicare Advantage, the slower costs grow for traditional Medicare. Helping People Stay Healthy Medicare Advantage performed better than traditional Medicare on 16 out of 16 clinical quality measures, including hospital readmissions, breast and colon cancer screenings, and medication adherence. Popular and Growing Medicare Advantage plans cover more than 23 million Americans. That’s 35% of all Medicare-eligibles in the nation. People are choosing Medicare Advantage plans because they deliver better services, better care, and better value. Medicare Advantage Delivers Better Services Medicare Advantage provides the same benefits as traditional Medicare—and so much more. Examples include:
Today, the Medicare program spends the same amount on average for Medicare Advantage as it does for traditional Medicare. But because Medicare Advantage plans deliver more benefits and better value than traditional Medicare, Americans are getting more for less. Seniors Give Medicare Advantage High Marks Affordability, competition, additional benefits, broader choice, flexibility… No wonder those who choose Medicare Advantage are overwhelmingly satisfied (93%) with their plans!
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Tags: Medicare Advantage