The proposed rule released Friday, October 26 would give 2020 MA plans the option of offering government funded telehealth benefits to all MA members regardless of their rural or urban zip code.
Also included in the pitch from The Centers for Medicare & Medicaid Services (CMS) is a plan to unify the appeals processes across Medicare and Medicaid for dual eligible beneficiaries, a methodology update for calculating the agency’s star ratings and makes significant changes on how it audits MA insurers in risk adjustment audits. Finally, CMS proposes updates to its payment prohibition against prescribers and providers on a “preclusion list”.
CMS Administrator Seema Verma,
An increasing number of seniors are voting with their feet and choosing to receive their Medicare benefits through private plans in Medicare Advantage. Today’s proposed changes would give Medicare Advantage plans more flexibility to innovate in response to patients’ needs.
CMS says the changes will 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.
According to CMS, 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.
The agency is proposing an enhanced cut point methodology for data collected during the 2020 measurement year and associated 2022 Star Ratings to improve stability and predictability and reduce the influence of outliers by implementing a guardrail so cut points don’t increase or decrease more than the cap from one year to the next.
CMS proposes to modify the following existing measures used for its star rating:
- Controlling High Blood Pressure (Part C) to align with new clinical guidelines related to hypertension.
- Medicare Plan Finder Price Accuracy (Part D) to better measure the reliability of a contract’s advertised prices.
- Plan All-Cause Readmissions (Part C) to include observation stays and remove individuals with high frequency hospitalizations.
- Improvement measures (Part C and D) to exclude from the improvement calculation any measure that receives a measure-level Star Rating reduction for data integrity concerns for either the current or prior year.
FierceHealthcare points out a portion of the CMS proposal should make all MA insurers nervous because of a significant change to the way it audits MA insurers that would extrapolate data generated from risk adjustment audits.
“Unlike provider audits for traditional Medicare payments, data from RADV audits are not extrapolated. For example, if CMS audits 100 members and 12 are found to have improper payments, the plan is only responsible for paying back overpayments in those 12 identified cases. The proposed rule would change that to extrapolate those findings, meaning insurers could be on the hook for much higher recoupments, reported FierceHealthcare.
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Read the proposed rule from CMS
Read more about the RADV audit issue from FierceHealthcare