With Medicare Advantage enrollment at an all-time high, CMS offers greater plan flexibility in 2020, with payment policies designed to enhance coverage and increase competition.
CMS has released it 2020 Medicare Advantage (MA) and Part D Rate Announcement and Final Call Letter. The Rate Announcement portion finalizes the methodologies for 2020 payments by CMS to MA plans and Part D sponsors. The Final Call Letter updates various actions, including those designed to help combat the opioid crisis and to give chronically ill MA enrollees access to a broader range of supplemental benefits that are not necessarily health-related but may improve or maintain the health or overall function of the enrollee.
The 2020 Medicare Advantage (MA) and Part D Rate Announcement and Final Call Letter finalizes CMS’ 2020 Advance Notice and Draft Call Letter, which was published in two parts on December 20, 2018 (Part I) and January 30, 2019 (Part II) (see 2020 changes to the MA risk adjustment model proposed, December 21, 2018; and CMS issues Part II of its 2020 Advance Notice and Draft Call Letter, January 31, 2019).
2020 Rate Announcement. The 2020 payment changes are expected to result in an effective MA payment growth rate of 5.62 percent, resulting in an average MA plan revenue increase of 2.53 percent over 2019 revenue.
With regards to the MA risk adjustment model, an alternative payment condition count model has been added for 2020 that includes additional condition categories for pressure ulcers and dementia, as well as additional variables that count the number of conditions a beneficiary may have, and makes an adjustment as the number increases.
CMS calculates risk scores using diagnoses submitted by Medicare fee-for service (FFS) providers and MA organizations. In recent years, CMS began collecting encounter data from MA organizations, including diagnostic information. For 2020, CMS will calculate risk scores by blending 50 percent of the risk score calculated using diagnoses from encounter data, CMS’ Risk Adjustment Processing System (RAPS) inpatient diagnoses, and FFS diagnoses with 50 percent of the risk score calculated with diagnoses from RAPS and FFS. In addition, for 2020, CMS will apply a coding pattern adjustment of 5.9 percent to reflect differences in diagnosis coding between MA organizations and FFS providers.
In 2019, CMS transitioned to administratively-set rates for Employer Group Waiver Plans (EGWPs). For 2020, CMS will continue that payment policy.
In 2020, CMS policies to stabilize the MA program in Puerto Rico will continue. These include: (1) basing the MA county rates in Puerto Rico on the relatively higher costs of beneficiaries in FFS Medicare who have both Medicare Parts A and B; (2) continuing the statutory interpretation that permits certain counties in Puerto Rico to qualify for an increased quality bonus adjusted benchmark; and (3) applying an adjustment in the calculation of the per capita cost estimate used in the benchmark to reflect the nationwide propensity of beneficiaries with zero claims.
2020 Final Call Letter. The Final Call Letter provides that new policies implemented in 2019 to help plan sponsors prevent prescription opioid overuse will continue in 2020. These include the Part D drug management programs for high risk opioid users and improved safety alerts, such as the 7-day supply limit for opioid naïve patients. In addition, CMS is finalizing several other opioid policies, including: (1) new flexibilities to offer targeted benefits and cost-sharing reductions for patients with chronic pain or undergoing addiction treatment; (2) lower cost-sharing for opioid-reversal drugs, such as naloxone; and (3) updating the specifications for the use of opioids at high dosage and/or from multiple providers, and the concurrent use of opioids and benzodiazepines measures.
For 2020, chronically ill MA patients will be allowed access to a broader range of supplemental benefits. For example, MA beneficiaries could receive meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services. Under these supplemental benefits, CMS suggests that an asthma sufferer could be offered coverage for home air cleaners and carpet shampooing to reduce irritants that may trigger asthma attacks; a heart disease patient could be offered coverage for heart healthy food or produce; and a diabetic patient could be provided with coverage for transportation to a doctor’s appointment, a diabetes education program, or to see a nutritionist.
The methodology for the 2021 Part C and D Star Ratings program was codified in the calendar year 2019 Medicare Part C and D final rule, published on April 3, 2019 (see CY 2019 Medicare Part C and D policy changes and updates finalized, April 3, 2018 ). As such, CMS announced that 2020 is the final year when all changes to the methodology for calculating the ratings and any changes in the measurement set will be addressed using the Call Letter process.
For 2020, CMS will adjust the Star Ratings in the event of extreme and uncontrollable circumstances, such as the hurricane that struck Puerto Rico, and will expand the number of measures used in the determination of the Categorical Adjustment Index to include all Star Ratings measures that remain after applying the exclusion criteria for a candidate measure for adjustment.
CMS is also removing the Adult BMI Assessment (Part C), the Appeals Auto-Forward (Part D), and the Appeals Upheld (Part D) measures from the 2022 Star Ratings program due to low statistical reliability. In addition, the Controlling High Blood Pressure (Part C) measure is being temporarily removed from the 2020 and 2021 Star Ratings due to a change aligning with the release of new hypertension treatment guidelines from the American College of Cardiology and American Heart Association.
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