CMS Medicare Advantage Rule Features Highlights for Health Plans

by Lauren Flynn Kelly

CMS on Feb. 5 issued a 900-page proposed rule containing a slew of non-rate-related changes to the Medicare Advantage and Part D programs for contract years 2021 and 2022.

"There are not game-changers in this regulation, but there are another series of program tweaks that are, in total, pretty helpful to MAOs," observes Michael Adelberg, a principal with Faegre Drinker Consulting.

One of the more interesting proposals includes CMS's first attempt to regulate imitators of Dual Eligible Special Needs Plan (D-SNPs), points out Adelberg. CMS in the 2020 draft Call Letter had discussed the proliferation of so-called "D-SNP look-alike" plans, and the agency maintained that they may undermine state efforts to promote further integration of Medicare and Medicaid benefits.

CMS in the new proposed rule said it would not enter into or renew an MA contract for a non-SNP plan if: (1) a plan projected in its bid that 80% or more of its total enrolled population is also eligible for Medicaid benefits, or (2) 80% of its actual enrollment are dual eligibles. MA plans whose membership exceeds this threshold would be able to transition their membership into a D-SNP or another $0 premium plan offered by the MAO, suggested CMS.

"CMS could have twisted itself and everyone else into pretzels seeking to define a D-SNP look-alike," points out Adelberg. "But instead, they propose an enrollment threshold, which is a much more straightforward approach."

Meanwhile, one plan-friendly change was a proposal around network adequacy and telehealth. CMS in the new rule proposed allowing MA plans to receive a "10 percent credit" on meeting published time and distance standards when contracting with telehealth providers for five specialty types.

Another piece of good news for plans was a proposal to include in their medical loss ratio (MLR) calculation covered services delivered by entities that do not meet the definition of "provider." As CMS codifies subregulatory guidance and statutory changes that have expanded the types of supplemental benefits that MA plans may include in their plan benefit packages, the agency said that such benefits need not be delivered by an individual or entity that falls under the provider standard.

From RADAR on Medicare Advantage