New Medicare Advantage Codes, Supplemental Benefits May Improve Dementia Treatment

By Lauren Flynn Kelly

With the addition of two new codes to the Medicare Advantage risk adjustment payment system and expanding flexibility in MA benefit design, Alzheimer's disease advocates are hopeful that such changes will lead to increased diagnoses, improved treatment and greater awareness of clinical trials for disease-modifying therapies.

Starting Jan. 1, 2020, CMS will incorporate into its risk score calculation for MA plans an alternative payment condition count model that includes additional Hierarchical Condition Category (HCC) codes for dementia: HCC51 — Dementia With Complications and HCC52 — Dementia Without Complications. Plans will therefore have a financial incentive to capture the appropriate diagnosis codes, and by assigning equal weights to the two codes, CMS has minimized the chance of upcoding, observes Catherine Murphy-Barron, a principal and consulting actuary with Milliman.

"I think anytime you add conditions to the HCC, obviously it gets a higher priority. From an MA-PD plan perspective, coding is crucially important to its success, and part of the challenge with dementia is that it’s not always coded," Murphy-Barron points out.

John Dwyer, president and founding board member of the Global Alzheimer's Platform, says his organization is hopeful that the availability of new MA supplemental benefits and the new risk adjustment codes will do more to raise awareness of dementia treatment options, including enrolling in clinical trials, since one of the biggest challenges with drug research and development is recruitment.

At the same time, MA organizations may be able to use newly expanded supplemental benefits to address brain health.

"Memory fitness programs are a largely undefined nonspecific clinical benefit that plans are starting to slowly roll out," explains Dwyer. These could range from discounts to online "brain training" exercises that are incorporated into a fitness or overall wellness benefit to something more substantial that is dedicated to brain health.

From RADAR on Medicare Advantage