MICHAEL BRADY February 05, 2020 05:30 PM
The CMS on Wednesday proposed increasing the baseline Medicare Advantage
payment rates for 2021 by 0.93%, well below the 2.53% rate increase that plans
got this year.
The agency also proposed new steps to reduce
out-of-pocket drug costs for Part D beneficiaries, promote generic drug usage
and allow enrollees to know more about their prescription drug costs in
advance. The proposed rule also implements changes under the 21st Century Cures
Act that allows people with end-stage renal disease to freely enroll in
Advantage plans. Comments on the proposed changes are due March 6.
The CMS estimated that the proposed changes
could save the federal government $4.4 billion over a decade. Much of those
savings would stem from the Part D star ratings and Medicare Advantage changes,
according to a fact sheet.
Under the proposal, insurers that offer
Advantage plans may be able to count telehealth services for specialties like
psychiatry or cardiology towards their network adequacy standards. The Trump
administration claims the change would increase access to care for seniors in
rural areas and lower the costs of Advantage plans. Increasing access to
telehealth services had been a key part of the administration's attempts to
expand access to care and rein in costs.
Dual-eligible special needs plan
"look-alikes" could soon be an endangered species because the CMS
wants to refuse to contract with them if there's a true D-SNP in the state.
These look-alikes try to attract patients eligible for both Medicare
and Medicaid to Medicare Advantage by promising additional care
coordination. But enrollees often may go without important benefits because
these plans can't integrate with Medicaid, according to some experts.
The CMS plans to implement several provisions of
the Substance Use-Disorder Prevention that Promotes Opioid Recovery and
Treatment for Patients and Communities Act that mandate Part D plans address
the opioid crisis through beneficiary education. The agency also wants to
mandate drug management programs and make other changes aimed at preventing and
reducing over usage of opioids.
Medicare Advantage and Part D star ratings could
get a minor overhaul under the proposed rule. The CMS wants to weigh patient
experience and complaints and access measures more heavily in the ratings. It's
another step in the consumerization of healthcare.
The rate announcement is part two of the 2021
Medicare Advantage Advance Notice. Last month, the CMS said that it wanted to use more encounter data to
decide federal payments to Advantage plans. The agency is increasingly
using this data to calculate patient risks scores, which it uses to increase or
decrease payments to insurers.
But insurers have complained that encounter data
is unreliable and makes their patients look healthier than they are, leading to
lower federal payments to Advantage plans.
Congress repealed the health insurance tax in December. The tax was supposed
to help pay for the Affordable Care Act, but it was only in effect for 2018 and
2020 thanks to heavy lobbying from the insurance industry. Analysts say that
the repeal will lead to smaller premium increases and more benefits for
Advantage plans, and boost payer profits because insurers won't have to pay the
tax or pass it onto consumers.
Flat premiums and enhanced supplemental benefits
could boost Advantage plan enrollment, an important policy goal for the Trump
administration. Roughly one-third of Medicare enrollees— about 22 million
people—participate in Medicare Advantage.
Continuing the Trump administration's efforts to
reduce healthcare spending through increased transparency and lower drug costs,
the CMS wants Part D prescription drug plans to give beneficiaries access to
patient-specific drug costs in real time by January 1, 2022.
"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," the CMS said in a statement.
It proposed giving Part D plans the ability to
create a "preferred" specialty tier of high-cost drugs with lower
cost-sharing for enrollees. That change could help plans negotiate lower prices
for expensive drugs with drugmakers by promising them access to the so-called
preferred tier.
The CMS requested feedback on how it could use
measures of generic and biosimilar drug utilization to influence Part D star
ratings. The agency thinks that rewarding plans for steering consumers and
providers toward generics and biosimilars could reduce healthcare costs.
End-stage renal disease patients on dialysis
will be able to enroll in Advantage plans in 2021 for the first time. In the
past they could only participate in an Advantage plan and seek dialysis
treatment if they were diagnosed with ESRD after enrollment.
ESRD patients aren't usually profitable for Advantage
plans because they pay higher rates for dialysis than original, fee-for-service
Medicare. Advantage plans also have caps on out-of-pocket contributions that
increase insurers' responsibility for the cost of dialysis and related
treatments.
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