Health Reform WK-EDGE CY 2020-2021 MA and Part D final rule provides flexibility to organizations and sponsors
Friday, April 19, 2019

CY 2020-2021 MA and Part D final rule provides flexibility to organizations and sponsors

By Harold Bishop, J.D.

Medicare Advantage (MA) and Part D updates for 2020-2021 include the expansion of telehealth benefits, new specifications for the calculation of Star Ratings, and additions to the preclusion list provisions for MA providers and Part D prescribers.

A final rule updating the Medicare Advantage (MA or Part C) and the Medicare prescription drug benefit (Part D) programs for 2020 and 2021 has been issued by CMS based on its continued experience and to implement certain provision of the Bipartisan Budget Act of 2018 (BBA). The final rule also implements certain BBA provisions by revising the appeals and grievances requirements for certain Medicaid managed care and MA special needs plans (SNPs) for dual eligible individuals (Final rule, 84 FR 15680, April 16, 2019).

Expansion of telehealth benefits. Section 50323 of the Bipartisan Budget Act of 2018 (P.L. 115-123) adds section 1852(m) to the Social Security Act, allowing MA plans in 2020 to provide "additional telehealth benefits" to enrollees as part of their basic benefit package. These additional telehealth benefits are limited to services for which benefits are available under Medicare Part B, but that are not currently payable as telehealth services under section 1834(m) of the Soc. Sec. Act, and have been identified as clinically appropriate to furnish through electronic information and telecommunications technology. Despite covering a Part B service as an MA additional telehealth benefit, the MA plan must also continue to provide access to such service through an in-person visit. In providing additional telehealth benefits, MA plans must also comply with non-discrimination provisions contained in section 1557 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

MA plans will also be allowed to continue offering MA supplemental benefits via remote access technologies for those services that do not meet the requirements for coverage under original Medicare or the requirements for MA "additional telehealth benefits."

MA and Part D quality rating system. As part of an effort to increase transparency regarding enhancements to the Part C and D Star Ratings program, in its 2019 final rule (see CY 2019 Medicare Part C and D policy changes and updates finalized, April 16, 2018) CMS codified the methodology for the Star Ratings system for the MA and Part D programs. In this 2020-2021 final rule, CMS is finalizing enhancements to the cut point methodology for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. The enhanced cut point methodology will improve stability and reduce the influence of outliers through the implementation of a cut point guardrail, ensuring that cut points do not increase or decrease more than 5 percent from year to year. It also makes substantive updates to the specifications for a few measures for the 2022 and 2023 Star Ratings, and finalizes rules for calculating Star Ratings in the case of extreme and uncontrollable circumstances, such as hurricanes.

Preclusion list requirements. In its 2019 final rule, CMS decided that the best way to safeguard its payment objectives was to focus on MA providers and Part D prescribers that were demonstrably problematic, rather than increasing the enrollment burden on all providers and prescribers. As a result, the 2019 final rule placed the problematic MA providers and Part D prescribers on a "preclusion list," with MA services and Part D drugs provided or prescribed by these precluded individuals paid or rejected as required by the circumstances. The 2020-21 final rule will continue this payment approach and make several revisions and additions to the preclusion list provisions.

MA and Medicaid managed care SNPs. Section 50311(b) of the BBA amended section 1859 of the Soc. Sec. Act to require the development of unified grievance and appeals processes for dual eligible (e.g. individuals eligible for both Medicare and Medicaid) SNPs, and the establishment of new standards for integration of Medicare and Medicaid benefits for dual eligible SNPs. The BBA required CMS to establish these unified grievance and appeals procedures by April 1, 2020, and for dual eligible SNP contracts with state Medicaid agencies to use the unified procedures by 2021.

Under the final rule, the unified grievance and appeals processes must use the grievances and appeals provisions from MA and Medicaid that provide the greatest protection to the beneficiary and take into account differences in state Medicaid plans to the extent necessary. The unified processes must be easily navigable by a beneficiary, include a single written notification of all applicable grievance and appeal rights, and provide a single pathway for resolution of a grievance or appeal. The processes must also provide clear beneficiary notices, employ unified timeframes for grievances and appeals, and establish requirements for how the plan must process, track, and resolve grievances and appeals. For benefits covered under Medicare Parts A and B and Medicaid, the processes must provide continuation of benefits pending appeal for these items and services.

Regarding the establishment of new standards for integration of Medicare and Medicaid benefits, the final rule requires that all dual eligible SNPs meet certain new minimum criteria for such integration for plans years 2021 and forward, either by covering Medicaid benefits through a capitated payment from a state Medicaid agency or notifying the state Medicaid agency of hospital or skilled nursing facility admissions for a least one group of high-risk full-benefit dual eligible individuals.

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