Health Reform WK-EDGE Proposals to increase choice, improve quality for Parts C and D
Thursday, November 1, 2018

Proposals to increase choice, improve quality for Parts C and D

By Patricia K. Ruiz, J.D.

CMS’ proposed updates to Medicare Advantage (MA) and the Medicare prescription drug benefit program (Part D) would implement several sections of the Bipartisan Budget Act of 2018 (P.L. 115-123), promoting flexibility and innovation, and improving the quality of care and availability of plan choices for MA and Part D enrollees. CMS also proposed updates related to program integrity to help recover improper payments made to MA organizations. Over ten years, the changes would result in an estimated $4.5 billion in savings to the Medicare Trust Funds.

Telehealth. The proposal would allow MA plans starting in 2020 to offer telehealth benefits beyond what is currently available to Part A and Part B enrollees. MA plans would have broader flexibility in paying for coverage of telehealth benefits. CMS also proposed to continue authority for MA plans to offer supplemental benefits via remote access and/or telemonitoring for services that do not meet the requirements for telehealth benefits. MA beneficiaries would have greater ability to receive telehealth services from home, rather than having to go to a health care facility to receive telehealth services.

D-SNPs. CMS proposed to establish new minimum criteria for the Medicare and Medicaid integration of MA Dual Eligible Special Needs Plans (D-SNPs) for 2021 and subsequent years. It proposed to require that D-SNPs meet integration criteria by covering Medicaid long-term services and supports and/or behavioral health services through a capitated payment from a state Medicaid agency or notifying the state Medicaid agency of hospital and skilled nursing facility admissions for at least one group of high-risk, full-benefit dual eligible individuals. CMS also proposed unifying Medicare and Medicaid grievance and appeals processes for certain D-SNPs and affiliated Medicaid managed care plans starting in 2021, making the process more straightforward and simple.

Star ratings. CMS proposed several updates to the Star Ratings methodology, including an enhanced methodology for determining cut points that would improve the stability and predictability of ratings and reduce the influence of outliers by implementing a guardrail to keep cut points for increasing or decreasing more than the cap from year to year. Under the proposal, CMS would also implement a policy to adjust ratings in the event of extreme and uncontrollable circumstances, such as hurricanes.

Preclusion list. The proposal would improve the list of providers for which CMS prohibits payment for Part D drugs and MA items or services (preclusion list). CMS seeks to clarify its expectations by revising requirements such as the length of time on the preclusion list for providers or prescribers with a felony conviction, consolidation of the appeals process, effective date for the consolidation of appeals, timeframe for the addition to the preclusion list, beneficiary appeals, beneficiary held harmless, and beneficiary notification.

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