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CMS Continues Expansion of Supplemental Benefits in Medicare Advantage Plans

Posted by www.psmbrokerage.com Admin on Thu, Apr 18, 2019 @ 04:18 PM

CMS Continues Expansion of Supplemental Benefits in Medicare Advantage Plans


By JD Supra – April 15, 2019

The CMS’s recent announcement of increased flexibility for Medicare Advantage plans to offer supplemental benefits (benefits not covered under Parts A or B) are complicated. Beginning in 2020, M/A plans may offer chronically ill enrollees supplemental benefits not necessarily health-related but reasonably expected to improve or maintain health and function. CMS provided the following examples of supplemental benefits that would qualify as primarily health related:

  • Compression garments as part of an over-the-counter benefit;
  • Cooking classes as part of a nutritional/dietary benefit;
  • Fall prevention kits as part of home and bathroom safety devices;
  • Implantable hearing aids, such as middle ear implants.

These changes are incorporated into the 2020 Medicare Advantage and Part D Rate Announcement and Final Call Letter. Your supervisors will provide details and elaboration of new M/A plans’ benefits as the evolution of plans’ components continues.

Source: https://www.jdsupra.com/legalnews/cms-continues-expansion-of-supplemental-75237/

Image: www.Canva.com

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Tags: Medicare Advantage, Medicare

UnitedHealth CEO says 'Medicare for All' would destabilize the nation's health system

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 04:51 PM

Medicare for all

  • UnitedHealth Group CEO David Wichmann warns that "Medicare for All" would "destabilize the nation's health system."
  • Vermont Sen. Bernie Sanders unveiled a new bill that would create a government-run system to provide health insurance for all Americans.
  • Freshman Rep. Alexandria Ocasio-Cortez is pushing a similar plan.



UnitedHealth Group
CEO David Wichmann warned investors on Tuesday that "Medicare for All" proposals pushed by Democratic lawmakers and presidential candidates would "destabilize the nation's health system."

A number of Democratic proposals call for eliminating private health insurance and replacing it with a universal Medicare plan, claiming it would help reduce administrative inefficiencies in the health-care system. Most recently, Sen. Bernie Sanders of Vermont unveiled a bill that would create a government-run system to provide health insurance for all Americans. Freshman Rep. Alexandria Ocasio-Cortez is pushing a similar plan.

Wichmann, who rarely discusses politics, told investors on a post-earnings conference call Tuesday such measures would "surely jeopardize the relationship people have with their doctors, destabilize the nation's health system and limit the ability of clinicians to practice medicine at their best."

"And the inherent cost burden would surely have a severe impact on the economy and jobs — all without fundamentally increasing access to care," he added.

The executive noted that health costs have grown less quickly than overall inflation for 16-straight months, saying "it has lessened considerably due to better management of price inflation and earlier and more effective management of care in lower cost settings."

Despite concerns from UnitedHealth, public support for a single-payer system has grown. According to a survey from the Kaiser Family Foundation last month, 56% of respondents supported a national health plan in which all Americans would get insurance from a single government plan, versus 39% who said they oppose it.

Health care has been the worst-performing sector in the stock market this year, rising by just 4.17% as of Monday's close, significantly lagging the broader market indexes. The Dow Jones Industrial Average is up 13.35% over the same period, and the S&P 500 is 16.12% higher.

The biggest decliners have been from insurers, which are under threat from "Medicare for All" proposals. Investors are also watching the Trump administration's legal challenge to former President Barack Obama's signature health insurance law, the Affordable Care Act.

A federal appeals court in New Orleans said last week that it will hear arguments in July on a lawsuit backed by President Donald Trump to overturn Obamacare. Dismantling the health-care law would lead to 32 million more uninsured people in the U.S. by 2026, according to an estimate from the Congressional Budget Office.

Earlier Tuesday, UnitedHealth reported first-quarter earnings and revenue that beat Wall Street's expectations. It was driven by strength in its pharmacy benefit management business and higher enrollment for its health plans.

The industry bellwether, which is the first health insurer to report quarterly results, also raised its full-year adjusted earnings forecast to between $14.50 and $14.75 per share from its prior projection of $14.40 to $14.70 a share.

Source: https://www.cnbc.com/2019/04/16/unitedhealth-warns-medicare-for-all-would-destabilize-us-health-system.html

Image: Justin Sullivan | Getty Images

 
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Tags: Medicare Advantage, Medicare, UnitedHealthcare, Medicare For All

CMS Finalizes Medicare Advantage, Part D Payment Policies

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 04:04 PM

CMS finalizes payment policies

The 2020 payment updates will increase competition among Medicare Advantage and Part D health plans

By Jessica Kent – HealthPayerIntelligence – April 9, 21019

CMS finalized new Medicare Advantage and Part D payment policies for 2020 that will increase competition among health plans, leading to higher quality care at lower costs.  

The changes will increase plan choices and benefits, enabling seniors to choose Medicare Advantage plans that are offering supplemental benefits tailored to their specific needs. The updated policies will also give chronically ill patients with Medicare Advantage the option of accessing a range of benefits that aren’t necessarily health-related, but can improve or maintain the overall health of beneficiaries.

These benefits may address the social determinants of health for beneficiaries with a chronic disease. For example, more Medicare Advantage enrollees may now receive meal delivery, transportation for non-medical needs like grocery shopping, and home environment services.

For beneficiaries with asthma, a Medicare Advantage plan could cover home air cleaners or carpet shampooing to reduce irritants that cause asthma attacks. Plans could also cover healthy food or produce for enrollees with heart disease, or education programs for those with diabetes.

“Today’s changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease,” said CMS Administrator Seema Verma. “With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy.”

The new policy updates will also include actions to help curb the opioid epidemic. Medicare Advantage plans can now offer targeted supplemental benefits to beneficiaries, as well as cost sharing reductions for patients with chronic pain. With the new policies, CMS is also encouraging Part D plans to offer at least one opioid-reversal agent on a lower cost-sharing tier.

CMS’s past efforts to reduce opioid use have had positive results. The agency reports that between 2010 and 2017, its overutilization policies have led to a 14 percent decrease in the share of Part D beneficiaries using opioids.

CMS first proposed these policy changes in January 2019, aiming to expand coverage opportunities for beneficiaries.

“CMS is committed to modernizing Medicare and our top priority is to ensure that seniors have more choices and affordable options in receiving their Medicare benefits,” Verma said at the time.

“Medicare Advantage enrollment is at an all-time high as more and more seniors are choosing to enroll in private Medicare health and drug plans, and we need to maximize competition by providing plans the flexibility to meet patients’ needs.”

The new updates will expand on last year’s Medicare Advantage and Part D policy changes. Released in April 2018, these policy changes expanded the health-related benefits Medicare Advantage plans could offer, with benefits mainly supporting the daily maintenance of health.

Because of these changes, Medicare Advantage plans can now offer supplemental benefits that aren’t covered under Parts A and B, if these benefits compensate for physical impairments, diminish the impact of injuries or health conditions, or reduce avoidable emergency room utilizations.

The 2020 policy changes will enable Medicare Advantage plans to tailor benefits to suit beneficiaries’ needs and combat the opioid crisis, which will become increasingly important as Medicare Advantage and Part D plan enrollment continues to grow.

“Medicare Advantage remains a popular choice among beneficiaries and has high satisfaction ratings. Average Medicare Advantage premiums are at their lowest in

six years, Part D premiums are at their lowest in three years, and plan choices have increased,” CMS concluded.

“Today’s announcement builds in additional flexibilities that will continue to increase choice and competition among Medicare health and drug plans.”

Source: https://healthpayerintelligence.com/news/cms-finalizes-medicare-advantage-part-d-payment-policies

Image: www.Canva.com

 
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Tags: Medicare Advantage, Medicare

More Telehealth Benefits Coming To Medicare Advantage Plans In 2020

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 03:53 PM

telehealth benefits coming to medicare advantage


By Bruce Jepsen – Forbes – April 8, 3029

Access to telehealth services for seniors got another boost Friday when the Centers for Medicare & Medicaid Services said it would allow private Medicare Advantage plans to offer additional access to virtual doctors in their basic benefit packages.

The so-called final rule will bring new benefits to seniors in 2020 as part of their Medicare Advantage plans. Such coverage is growing rapidly and expected to account for half of Medicare beneficiaries in the coming years, some analysts say.

“Historically, Medicare Advantage plans have been able to offer more telehealth services, compared to Original Medicare, as part of their supplemental benefits,” the Centers for Medicare & Medicaid Services (CMS) said Friday. “But with the final rule, it will be more likely that plans will offer the additional telehealth benefits outside of supplemental benefits, expanding patients’ access to telehealth services from more providers and in more parts of the country than before, whether they live in rural or urban areas.”

It could be a huge boon to companies like American Well, MDLive and Teladoc and an array of startups getting into the business of offering access to physicians and patients via smart phone, tablet or computer. Employers and private insurers are already embracing the trend as a way to make healthcare more convenient and avoid costly and unnecessary trips to the emergency room or a more expensive physician’s office.

"This is a bold and important move by CMS, signaling to the rest of the healthcare system that telehealth based care is simply another form of care and should be treated as such,” MDLive’s chief medical officer and executive vice president of product strategy, Dr. Lyle Berkowitz said. “This is a rare win for providers, patients and payors.”

Increasingly popular Medicare Advantage plans contract with the federal government to provide extra benefits and services to seniors, such as disease management and nurse help hotlines, with some even providing vision and dental care and wellness programs. Medicare Advantage enrollment is projected to rise to 38 million, or 50% market penetration, by the end of 2025, L.E.K. Consulting projects.

“With these new telehealth benefits, Medicare Advantage enrollees will be able to access the latest technology and have greater access to telehealth,” CMS Administrator Seema Verma said Friday in a statement. “By providing greater flexibility to Medicare Advantage plans, beneficiaries can receive more benefits, at lower costs and better quality.”

ARTICLE based on CMS NOTICE

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Tags: Medicare Advantage, Medicare

Medicare Trends and Recommendations

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 03:28 PM

medicare trends and recommendations

 

DOWNLOAD REPORT

Introduction and Summary

In 2017, Medicare Rights staff and volunteers addressed more than 15,000 questions and issues through the organization’s national helpline. In addition, over 2.8 million questions were answered for people with Medicare, their caregivers, and professionals serving them through Medicare Interactive, Medicare Rights’ free and independent online reference tool thoughtfully designed to help older adults and people with disabilities navigate the complex world of health insurance. This report will feature select helpline trends and highlight the most commonly searched for Medicare Interactive answers, providing a glimpse into the information and coverage needs of Medicare beneficiaries and their families.

As in previous years, helpline callers and users of Medicare Interactive were geographically and socioeconomically diverse, and needed help with a wide array of complex Medicare-related issues. Medicare Rights served clients in all 50 states. Approximately 30% of helpline callers were living on incomes of less than $19,000 per year. This number includes people dually eligible for Medicare and Medicaid, who represented 10% of all callers. Caregivers helping to resolve issues and asking questions for family members accounted for 20% of helpline callers. And around 25% of helpline callers were under 65 and eligible for Medicare due to disability. Medicare Rights has less robust demographic data on users of Medicare Interactive but knows that these users represent both beneficiaries and the professionals serving them, and the most popular sections in 2017 included one on Medicare-covered services and one that introduces Medicare eligibility and coverage topics.

Medicare Rights produces this report so that advocates, policymakers at the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA), and other stakeholders can better understand the needs of beneficiaries and work toward greater accessibility and affordability in Original Medicare and Medicare Advantage. For instance, in order to streamline and increase consumer awareness around Part B enrollment, the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act, supported by Medicare Rights and further discussed in this report, was introduced in Congress in 2017. In 2018, additionally, Medicare Rights led advocacy efforts with CMS to extend the Medicare Part B time-limited equitable relief opportunity for Medicare beneficiaries who are enrolled in Marketplace health insurance instead of Medicare. Medicare Rights applauds CMS for extending and providing this relief opportunity through 2019 and beyond for those eligible in 2019 or prior years.

Around two-thirds of Americans receive their Medicare benefits through Original Medicare, and it is critical to protect Original Medicare as an important coverage option, even while Medicare Advantage may be the right choice for some beneficiaries. Medicare Rights expressed its concerns with CMS education and outreach materials prepared for the 2018 Medicare Annual Coordinated Election Period, which many perceived promoted Medicare Advantage over Original Medicare. CMS listened to Medicare Rights’ and other advocates’ concerns, and the final version of the 2019 “Medicare & You” handbook—the primary educational resource for those new to Medicare—was more balanced and accurate. Medicare Rights hopes that additional recommendations made in this report to increase Medicare’s responsiveness to beneficiary needs will be similarly heeded and acted on.

DOWNLOAD REPORT

Source: https://www.medicarerights.org/2017-medicare-trends-recommendations

Image: www.Canva.com

 
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Tags: Medicare Advantage, Medicare

Humana launches nationwide value-based cancer care program

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 03:17 PM



As part of its effort to shift more of its business towards value-based care arrangements, Louisville-based insurer Humana has launched a national Oncology Model of Care program meant to drive better treatment of cancer patients across the country.

Through the program – which targeted at both Medicare Advantage beneficiaries and commercial members – Humana will support better care coordination and health outcomes through financial incentives.

The insurer said it will provide compensation for better care navigation based on quality and cost metrics across various parts of the patient journey ranging from inpatient admissions, ED visits, prescription drugs, diagnostics and radiology.

Humana lists 16 providers as inaugural participants in the program including multiple members of The US Oncology Network, along with health systems and practices like Cincinnati-based Tri Health and Kentucky’s Baptist Health Medical Group.

While the CMS Innovation Center has developed its own Oncology Care Model, the program is focused on episodes of care surrounding chemotherapy administration.

Humana is hoping to improve general cancer care for patients over the period of a year by emphasizing more face time between physicians and patients, access to proactive health screenings and the increased use of data analytics to better coordinate care around patients.

The new oncology program is the payer’s fourth specialty-care payment model, alongside bundled payment programs for Medicare Advantage spinal fusion patients and total joint replacement patients, as well as maternity care bundled payment programs for commercial group members with low-to-moderate risk pregnancies.

Humana has more than 2 million Medicare Advantage members and around 115,000 commercial plan members who are cared for by primary care physicians in value-based payment relationships.

In the company’s 2018 report on its value-based care practices, Humana found that MA members with physicians in value-based care relationships experienced 7 percent fewer emergency room visits and 5 percent fewer hospital admissions

Medical costs for patients who were affiliated with physicians in Humana MA value-based agreements were also 15.6 percent lower than traditional Medicare.

Humana’s recent activities are indicative of the larger payer industry making a full-scale business transition to value-based care.

Case in point, UnitedHealthcare is launching a Care Bundles program next year that will offer providers across 30 states the option of participating in bundled payment arrangements for eight medical procedures for MA patients.

Source: https://medcitynews.com/2019/04/humana-launches-nationwide-value-based-cancer-care-program/

 
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Tags: Humana, Medicare Advantage, Medicare

Medicare Advantage is nudging aside ‘Old Medicare’

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 02:47 PM

medicare advantage nudging aside medicare

 

By Michael Adelberg – STAT – April 4, 2019

Nearly a quarter century ago, then Speaker of the House Newt Gingrich said this about the original Medicare program: “We believe it’s going to wither on the vine because we think people are voluntarily going to leave it — voluntarily.”

Gingrich argued that original Medicare — based on a 1960s-style fee-for-service benefit package with a confusing set of deductibles, co-insurance, and copays — was stuck in the past. He saw a day when Medicare-contracted private health plans would prove so attractive that Medicare beneficiaries would have to choose them.

It’s taken a generation, but Gingrich is on the verge of being right about Medicare.

Medicare began experimenting with managed care as an alternative to the original program in the 1970s, and annually contracted health plans — called Medicare+Choice — were made a permanent part of the program in the 1990s. Because of funding reductions, it initially floundered.

That changed in 2003 with the passage of the Medicare Prescription Drug, Improvement, and Modernization Act, which renamed the program Medicare Advantage, raised payment rates, and added risk adjustment to the payment methodology. Leading managed care companies, such as UnitedHealth Group, Humana, Aetna, and Blue Cross Blue Shield companies, began marketing Medicare Advantage products every fall. So did dozens of smaller and health system-owned health plans.

Enrollment in these plans has increased every year since then. Today, more than 22 million beneficiaries choose Medicare Advantage, about 35 percent of all people

with Medicare, up from about 11 million people a decade ago. This has occurred despite a gradual phase down in funding put in place by the Affordable Care Act.

In 2019, Medicare Advantage plans stepped up their coverage to include the delivery of meals, rides to physician appointments and pharmacies, home safety improvements, and a host of other new benefits. As described in a new report on Medicare Advantage plans that one of us (M.A.) co-authored, 153 Medicare Advantage plans are now leveraging new Trump administration guidance and experimenting with 842 “flex benefits” this year. These benefits fall into two broad categories: reducing costs to encourage members to receive preventive care, such as free primary and podiatry care for people with diabetes; and non-medical benefits, such as home-delivered meals following a hospital discharge, home safety interventions, and non-skilled in-home caregiving.

Medicare beneficiaries select Medicare Advantage for a variety of reasons. These include catastrophic cost protection, care management programs, and a range of mainly health-related supplemental benefits such as dental checkups, eyeglasses, hearing aids, over-the-counter drugs, and gym memberships. The trade-off for these extras is limited choice of providers and managed care tools like prior authorization. These limitations put off some Medicare beneficiaries, but have not dampened the high overall satisfaction with Medicare Advantage or its continued growth.

Medicare Advantage’s competitive edge over original Medicare will take another step forward in 2020 when plans are expected to gain additional flexibilities in offering non-medical benefits for people with chronic diseases. The next wave of new benefits can include anything that the Centers for Medicare and Medicaid Services deems “has a reasonable expectation of improving or maintaining the health or overall function” of enrollees with chronic diseases. While CMS has not yet offered its final guidance, this will likely include meals, transportation, pest removal, and activities that combat social isolation and depression, which could include companionship services and pet therapy.

Some of the brightest minds in managed care are working to determine whether relatively inexpensive, newly permissible benefits like these will pay for themselves by reducing the number of expensive medical procedures. Actuaries at Wakely Consulting, for example, have modeled the value of a falls reduction benefit. Using Medicare claims data, they determined that injury-causing falls are associated with spikes in medical costs that average about $10,000 compared to pre-fall costs. So an intervention that reduces falls by even 10 percent would likely pay for itself if it costs less than $1,000 per fall-prone member receiving the service. Hiring a handyman for a couple hundred dollars to install grip bars in a shower or modify cabinetry would be a bargain.

How does original Medicare stack up in comparison to Medicare Advantage? The Affordable Care Act and the Medicare Access and CHIP Reauthorization Act (MACRA) introduced value-based reimbursement reforms into original Medicare. These may make the program a more efficient payer, but they do not necessarily improve benefits for Medicare beneficiaries. Medicare Supplement Insurance (Medigap) continues to be purchased by roughly 13 million Medicare beneficiaries. It plugs gaps and simplifies original Medicare’s idiosyncratic coverage, but it is too expensive for lower-income beneficiaries. In addition, state and federal laws prevent Medigap from keeping up with Medicare Advantage.

A 2017 report by the National Association of Insurance Commissioners demonstrates that only a handful of states permit Medigap carriers to offer any “innovative” benefits. And the modest flexibilities permitted — such as eye exams — pale in comparison to the richness and diversity of Medicare Advantage benefits.

In subtle and unsubtle ways, the Trump administration has seeded the ground for massive gains in Medicare Advantage enrollment. These include loosened restrictions on marketing Medicare Advantage plans, new consumer tools that accentuate the advantages of these plans, greater use of telehealth than permitted in original Medicare, the elimination of “meaningful difference” tests that limit the number of Medicare Advantage plans in a given market, and extra time for plan sponsors to secure a provider network. Meanwhile, the administration has finalized a regulation that may substantially lessen the number of accountable care organizations participating in original Medicare — the original Medicare reform with the greatest potential to align providers in reimbursement systems outside of Medicare Advantage.

Congress has also quietly added tools to Medicare Advantage that aren’t available in original Medicare. A little-noticed MACRA provision will remove two of the most popular Medigap plans from the market in 2020, further weakening its value proposition versus Medicare Advantage. This is not an accident: Many conservatives have long disliked original Medicare’s centralized pay schedules and the perverse incentives of fee-for-service medical care. And many liberals are willing to strengthen Medicare Advantage if that’s the only way to offer more generous health care coverage to seniors.

Intentionally or not, Congress and various administrations have created two Medicare programs: the original fee-for-service program with rules and coverage that the private market largely abandoned decades ago, and a managed care program that has just benefited from another set of favorable legislative and regulatory tweaks. Maybe it is unfair that policy makers are favoring Medicare Advantage. But if this is the only way to deliver modern and more generous health benefits to Medicare beneficiaries, then a thumb on the scale is better than denying beneficiaries access to 21st-century benefits.

It’s no wonder that Medicare beneficiaries are voluntarily leaving original Medicare — voluntarily.

Source: https://www.statnews.com/2019/04/03/medicare-advantage-nudging-aside-old-medicare/

Image: www.Canva.com

 
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Tags: Medicare Advantage, Medicare

Re-calibrating Medicare Advantage Risk Adjustment

Posted by www.psmbrokerage.com Admin on Wed, Apr 17, 2019 @ 01:29 PM

The Implications Of Re-calibrating Medicare Advantage Risk Adjustment Using Encounter Data

Med-Adv-Re-calibratingMA plans play an increasingly important role in the Medicare program, with enrollment growing from about a quarter of all Medicare beneficiaries (or 11 million) in 2010 to 34 percent of beneficiaries (approximately 20 million) in 2018. And, according to the Congressional Budget Office, enrollment in MA is projected to exceed 40 percent (32 million) of the total Medicare population by 2028.

MA’s popularity indicates that it works well, and one of the reasons the system functions as well as it does is that plan payments are adjusted for the health risks of enrollees.

Until now, the Centers for Medicare and Medicaid Services (CMS) has estimated its MA risk-adjustment models using data from traditional Medicare, but the agency has signaled in the past its interest in using encounter data from MA to estimate (or recalibrate) the model. CMS reiterated this interest in its fiscal year 2020 performance budget.

Under such recalibration, CMS would recalculate the coefficients for the demographic characteristics and health conditions based on MA encounter data, instead of on traditional fee-for-service Medicare claims.

Read the full article: https://www.healthaffairs.org/do/10.1377/hblog20190412.299173/full/

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Tags: Medicare Advantage

UnitedHealthcare, AMA unveil more medical codes for social determinants

Posted by www.psmbrokerage.com Admin on Fri, Apr 05, 2019 @ 03:59 PM

UnitedHealthcare, AMA unveil more medical codes for social determinants-1

 By Shelby Livingstone – ModernHealthCare – April 3, 2018

UnitedHealthcare and the American Medical Association said Tuesday they want to expand the set of ICD-10 diagnostic codes to include more specific diagnoses related to a person's social determinants of health.

The hope is that these codes would allow clinicians to document patients' social determinants in a standardized way, which would allow them to better tailor care plans or refer patients to community organizations that could meet those social needs.

"If someone has a transportation barrier and they are unable to get to their doctor's appointment or to pick up their prescription, today in the ICD-10 codes, there isn't a way to diagnose that," said Sheila Shapiro, senior vice president for national strategic partnerships in UnitedHealthcare's clinical services team. "There is no common way for the system to communicate around not only that barrier, but the solutions that can be brought to assist that individual."

Today, a clinician may use medical code that identifies a patient as low-income, but that's as granular as it gets. UnitedHealthcare's proposed set of codes would more specifically identify the person as unable to pay for transportation for medical appointments of prescriptions, for instance.

That would then tell the healthcare provider they should order prescriptions mailed to the home or possibly provide some form of transportation, explained Dr. Tom Giannulli, chief medical officer at the AMA's Integrated Health Model Initiative, which is supporting UnitedHealthcare's proposal.

Expanding diagnostic codes related to social determinants of health is another step in the healthcare industry's journey to address those factors outside of the doctor's office that often have a greater impact on outcomes than clinical care. In recent years, social determinants have become a buzzword in the healthcare industry as insurers and providers have looked for new ways to control health spending. Now insurers and health systems are moving beyond initial pilot projects to address those factors in a sustainable, scalable way.

The existing ICD-10 family of diagnostic and procedural codes includes 11 codes that identify social and environmental barriers to a patient's care, but they are broad categories. UnitedHealthcare's proposal would add 23 more codes to that list. Some of those codes would indicate a patient's inability to pay for prescriptions, inadequate social interaction, or fears about losing housing.

Trenor Williams, the founder of Socially Determined, a company that uses data to help organizations build programs to address their patients' social needs, said expanding the codes to include more specific diagnoses is a good start and an opportunity to better document social risk factors among a population.

It also could prompt more discussion among stakeholders about providing reimbursement that is risk-adjusted based on a patient's social determinants, Williams said. Some groups, including the National Academy of Medicine and the Medicare Payment Advisory Commission, have explored the feasibility of adjusting Medicare payments for socioeconomic status. Congress has also commissioned reports on the subject. But so far Medicare payments remain unadjusted for social factors.

UnitedHealthcare presented its recommendation to expand the codes at the ICD-10 Coordination and Maintenance Committee meeting in March. Following a 60-day comment period, the committee will determine whether to act on UnitedHealthcare's recommendation in the early summer. The new codes would be available to use as early as 2020, if the committee approves them, Shapiro said.

Source: https://www.modernhealthcare.com/technology/unitedhealthcare-ama-unveil-more-medical-codes-social-determinants?utm_source=modern-healthcare-daily-dose-tuesday&utm_medium=email&utm_campaign=20190402&utm_content=article3-headline

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Tags: Medicare Advantage, UnitedHealthcare

CMS rule gives Medicare Advantage plans an edge over traditional Medicare

Posted by www.psmbrokerage.com Admin on Thu, Apr 04, 2019 @ 09:52 AM

man on mountain

 

The Centers for Medicare and Medicaid Services today finalized payment updates to Medicare Advantage and Part D plans for 2020.

MA rates increase 2.53 percent. This includes the phasing-in of a risk adjustment model that takes into account the number of chronic conditions a person has, according to CMS Administrator Seema Verma.

CMS originally had released a rate increase of 1.59 percent.

The effective growth rate increased from 4.59 percent in the advance notice, to 5.62 percent today. Verma said the reason for the change is that CMS is continually updating information.

However, the biggest changes for Medicare Advantage insurers is in their ability to offer additional, non-health benefits to members who have a chronic condition, if there is a reasonable expectation of improving or maintaining the health or overall function of the enrollee. Plans can address the social benefits of health in these tailored benefits.

For example, beneficiaries could now receive transportation for non-medical needs like grocery shopping and home environment services to cover home air cleaners and carpet shampooing for asthma sufferers.

WHY THIS MATTERS

Today's supplemental benefit flexibility gives Medicare Advantage plans an edge in competition over traditional Medicare fee-for-service.

The flexibility in today's rule is due to legislation in the Bipartisan Budget Act, Verma said.

Asked why Congress would allow MA plans to have an edge in offering benefits over traditional Medicare fee-for-service, Verma said fee-for-service is an open-ended benefit program while MA is capped and is a value-based payment systems. CMS supports allowing the flexibility for plans to address the social determinants of health in a value-based arrangement, she said.

The varying benefits are also expected to spur competition between MA plan offerings.

Medicare Advantage is a growing program both for seniors and for insurers, with CMS not-so-subtly promoting the private health insurance option.

Average Medicare Advantage premiums are at their lowest in six years, Part D premiums are at their lowest in three years, and plan choices have increased, CMS said today.

WHAT ELSE YOU NEED TO KNOW

CMS calculates risk scores using diagnoses submitted by Medicare fee-for-service providers and by MA organizations.

CMS is including encounter data in  calculating the risk scores despite objections by some stakeholders. For 2020, CMS will blend 50 percent of the risk score calculated using diagnoses from encounter data, the RAPS Risk Adjustment Processing System inpatient diagnoses and FFS diagnoses, with 50 percent of the risk score calculated with diagnoses from RAPS and FFS.

For 2020 CMS expects the underlying coding trend to increase risk scores, on average by 3.3 percent.

PART D

The payment and policy updates include actions to address the opioid crisis,  encouraging Part D plans to provide at least one opioid-reversal agent on a lower cost-sharing tier.

CMS said its overutilization policies have resulted in a 14 percent decrease in the share of Part D beneficiaries using opioids between 2010 and 2017 (36.3 percent to 31.3 percent), with the largest decrease from 2016 to 2017 (5 percent).

TREND

Starting this year, Medicare Advantage plans could offer supplemental benefits that are not covered under Medicare Parts A or B, such as adult day health services, and/or in-home support services under an expanded definition of supplemental benefits.

The updates released today continue the Trump administration's efforts to increase competition among Medicare Advantage and Part D plans. CMS said.

ON THE RECORD

"Today's changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease," Verma said. "With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy." 

Source: https://www.healthcarefinancenews.com/news/cms-rule-gives-medicare-advantage-plans-edge-over-traditional-medicare

Photo by eberhard grossgasteiger from Pexels

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Tags: Medicare Advantage, Medicare Part D

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