Proposed rule would strengthen the popular system for private health insurance plans to provide Medicare coverage, increase plan flexibility to offer telehealth benefits, and improve coordination for dual-eligible beneficiaries
In a proposed rule issued today, the Centers for Medicare & Medicaid Services (CMS) took action to build upon the Administration’s ongoing efforts to modernize the Medicare Advantage and Part D programs, which provide seniors with Medicare health and prescription drug coverage through private plans. The changes proposed today would allow plans to cover additional telehealth benefits and would make other much-needed updates, including for individuals who are eligible for Medicare Advantage special needs plans.
Medicare Open Enrollment for 2019 is currently underway and runs through December 7, 2018, so seniors can review their coverage options and decide how they would like to receive their Medicare benefits in 2019. CMS offered new flexibilities to Medicare Advantage plans starting in the 2019 plan year, and plans are making additional benefits available including adult day care services, in-home support services, and benefits tailored for patients with chronic diseases like diabetes. The average Medicare Advantage premium will decline by 6.1 percent, enrollment is projected to grow by 11.5 percent, and there will be approximately 600 more plans available across the country next year.
Today’s proposed changes for plan year 2020 would leverage new authorities provided to CMS in the Bipartisan Budget Act of 2018, which President Trump signed into law earlier this year. With respect to telehealth, the proposed changes would remove barriers and allow Medicare Advantage plans to offer “additional telehealth benefits” not otherwise available in Medicare to enrollees, starting in plan year 2020 as part of the government-funded “basic benefits.”
This proposal will allow Medicare Advantage plans broader flexibility in how coverage of telehealth benefits is paid to meet the needs of their enrollees. As Medicare beneficiaries become more tech savvy, CMS is working across the agency to promote beneficiary access to telehealth, but the Medicare fee-for-service program telehealth benefit is narrowly defined and includes restrictions on where beneficiaries receiving care via telehealth can be located. The proposed rule would give MA plans more flexibility to offer government-funded telehealth benefits to all their enrollees, whether they live in rural or urban areas. It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places like their homes, rather than requiring them to go to a health care facility to receive telehealth services. Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.
Today’s proposed changes are a major step towards expanding access to telehealth services because the rule would eliminate barriers for private Medicare Advantage plans to cover such additional telehealth benefits under the MA plan. While MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that MA plans will offer them and that more enrollees will be able to use the benefits.
Additional changes proposed today would improve the quality of care for dually-enrolled beneficiaries in Medicare and Medicaid who participate in “Dual Eligible Special Needs Plans” or D-SNPs. These beneficiaries generally have complex health needs. Today’s proposed changes would unify appeals processes across Medicare and Medicaid to make it easier for enrollees in certain D-SNPs to navigate the system. The proposed rule would also require plans to more seamlessly integrate benefits across the two programs to promote coordination.
Today’s proposed rule also improves accountability and bolsters program integrity within the Medicare Advantage and Part D programs. The proposed changes would update the methodology for calculating Star Ratings, which provide information to consumers on plan quality. The new methodology would improve stability and predictability for plans, and would adjust how the ratings are set in the event of extreme and uncontrollable events such as hurricanes.
The proposed rule also includes critical updates with respect to program integrity. First, CMS is making revisions to an earlier regulation that made available to Part D sponsors and Medicare Advantage plans a list of precluded providers and prescribers that have engaged in behavior that bars their enrollment in Medicare. Under the earlier regulation, plans would be required to deny payment for any prescription, service, or item that is prescribed or furnished by an individual or entity on the Preclusion List.
Second, the proposed rule would take steps to help CMS recover improper payments made to Medicare Advantage organizations. CMS conducts Risk Adjustment Data Validation audits to confirm that diagnoses submitted by Medicare Advantage Organizations for risk adjusted payments are supported by medical record documentation. CMS recovers improper payments based on these audits. The proposed rule would strengthen CMS’s ability to return dollars to the Medicare Trust Funds as a result of these audits. If finalized, the proposed changes would result in an estimated $4.5 billion in savings to the Medicare Trust Funds over a ten year period, largely from the recovery of improper payments to Medicare Advantage plans through contract- level Risk Adjustment Data Validation audits. In addition, CMS released an analysis on the application of a Fee-For-Service adjuster in determining the Medicare Advantage payment recoveries. The analysis can be accessed at: https://www.cms.gov/Research-Statistics-Data-and- Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation- Program/Resources.html (the Fee-For-Service Adjuster executive summary and technical appendix are available in the “Downloads” section of the webpage).
For a fact sheet on the CY 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P), please visit: https://www.cms.gov/newsroom/fact-sheets/contract-year-cy-2020- medicare-advantage-and-part-d-flexibility-proposed-rule-cms-4185-p.