Proposed 2023 MA and Part D Advance Notice
Recently, the Centers for Medicare and Medicaid Services (CMS) published the Proposed Rule on 2023 contract policy and technical changes to the Medicare Advantage (MA) and Medicare Prescription Drug Benefit Programs, also referred to as the Proposed Rule. Per CMS, the goal of the Proposed Rule is to reduce out-of-pocket prescription drug costs, improve price transparency and market competition under the Part D program, fortify protections for MA and Part D beneficiaries so they can better access information about their health plan choices, strengthen CMS oversight of MA and Part D plans, and improve the integration of Medicare and Medicaid programs for individuals enrolled in dual eligible special needs plans, commonly known as D-SNPs.
The following is a brief summary of the proposed changes to risk adjustment, Star Ratings, and the agency’s plans to advance health equity. If concluded, these proposed changes could take effect January 1, 2023.
Enrollee Participation
The Proposed Rule would require MAO’s that offer one or more D-SNPs in any given state to have one or more enrollee advisory committees made up of beneficiaries to act as advisory to the D-SNP served by the MAO in that state. The MAO has the option to create one advisory committee per D-SNP or multiple committees per state. These advisory committees are required to have an even representation of members based on the population enrolled in the D-SNP. The representation of members is designed to include all characteristics of the enrollee population of the D-SNP served by the committee. The makeup of the committee is to include, but also not limited to, service area, geography and demographics. It is CMS’s belief that these committees will offer valuable beneficiary protection and ensure enrollee feedback is taken into serious consideration, with the goal of providing improved and better coordinated care. The idea being, when enrollees are involved in designing and participating in defining their own care, there’s a better chance for engagement and collaboration between enrollee and plan.
Questions on Health Risk Assessments
Starting in 2024 and after, CMS is proposing to include standardized questions on the topics of housing, food security, and transportation access as part of the health risk assessment process. This is based on CMS’s past experience with model tests from other programs. The idea here is that the series of questions based around these issues will assist SNPs to gather comprehensive information for risk assessment based on physical, psychosocial and functional needs. It will serve to assist in designing individualized care plans that better meet the needs of enrollee and meet regulation standards. Also, rather than outlining the language of the questions in regulation, sub-regulatory guidance will specify the language used for the questions so that CMS can maintain consistency with other programs and make changes as needed while still providing straightforward requirements to MAOs. Of note, CMS does plan to orient the selected questions, to some degree, with Social Determinants of Health Assessment data accepted as part of the United States Core Data for Interoperability Version two when complete and where seen fit.
Refining Definitions for D-SNPs
In the Proposed Rule, CMS mentions its intent to enhance the incorporation of Medicare and Medicaid programs for those enrolled in D-SNPs. One method is to use contracting strategies for dual eligible enrollees that align enrollment between D-SNP and MCO offered by the same company, in the same geographic area. The proposed D-SNP arrangement is designed to better align and blend benefits for dual eligible beneficiaries.
For 2025 and after, CMS is proposing that fully integrated dual eligible special needs plans, known as FIDE SNPs, have aligned enrollment. What this means is that Medicaid beneficiaries will also be enrolled in an aligned ACO, that through a capitated contract with the State Medicaid agency, covers behavioral health services, Medicaid home health, and durable medical equipment. In addition, CMS is proposing for 2025 and after to require that every highly integrated dual eligible special needs plan, known as HIDE SNP, that contracts with the State apply a service area equal to the D-SNP.
State Medicaid Contracts Integration
CMS is proposing to create new avenues for coding through which states access contracts between D-SNPs and their Medicaid agencies. The requirement would be that certain D-SNPs, with uniquely aligned enrollment, integrate messaging and materials for enrollees. While also creating contracts that include just one or more D-SNPs within a State, as to better help members get a sense of their benefits. Also, since Star Ratings are designated at the contract level, it is CMS’s goal to have better clarity into quality ratings for the D-SNPs. This should allow CMS and States to distinguish any care gaps between dually eligible beneficiaries and other beneficiaries and mediate as needed.
Systems to better align State and CMS oversight of certain D-SNPs is proposed by CMS when a State has chosen to call for an added level of integration, which includes giving access to selected CMS data systems. It is CMS’s belief that such proposals would enhance Federal and State oversight of D-SNPs and their affiliated MCOs through better sharing of data between government regulators.
Requirements During a Disaster
MAOs have to comply with regulations that ensure access to care services for enrollees even during a period of disaster or emergency. Since we’re now entering the third year of the COVID-19 pandemic, CMS is looking to outline exact dates pertaining to this emergency period. As it stands now, current regulation fails to state with clarity, updated disaster declarations to balance service on a national scale. It mentions that a disaster/emergency declaration is over when any of the following criteria are met. First, the origin that announced the declaration says that it’s over, or secondly 30 days have gone by since the announcement and no end date has been identified. As you may imagine, CMS has been pressed with questions on this since the COVID-19 pandemic and is taking steps to classify advice to mitigate any vagueness.
CMS is proposing to only accept the application of the special requirement when there is a major disturbance to accessible care. That disturbance is specifically defined by CMS as “an interruption or interference in access to health care throughout the service area such that enrollees do not have the ability to access contracted providers or contracted providers do not have the ability to provide needed services causing MA organizations to fail to meet the prevailing patterns of community health care delivery in the service area under § 422.112(a).” The duty to assess what’s considered a disturbance in care would be left up to the MAOs themselves.
MA Network Adequacy Rules
Starting in 2019, CMS no longer required MAOs demonstrating network adequacy as a qualifying factor for CMS approval of their service area growth applications. At this time CMS plans to resume network adequacy reviews starting in 2024 as part of the application process. It’s CMS’s belief that resuming the review of provider networks will safeguard bid integrity, protect members and enhance product offerings.
Star Ratings Given Impacts of COVID-19
CMS maintains and makes publicly available a 5-star rating designation for MA and Part D plans that is generally based on a performance period of two years before the Star Rating has been assigned.
In the provisional rules known as “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” published in early April of 2020, CMS integrated updates to the 2021 and 2022 Star Ratings in an effort correct any disruptions in data collection and performance for the 2020 period brought on by the COVID-19 pandemic. Since the COVID-19 emergency has taken on such vast duration than anticipated, CMS changed the 2022 Star Rating criteria in the provisional rule known as “Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” published in early September 2020, which changed the disaster policy rules and calculations of performance for 2022 Star Ratings.
Past Performance Accountable
CMS has a responsibility to make sure the healthcare organizations it contracts with provide the highest quality care and services to beneficiaries. To eliminate low quality providers, CMS has regulations allowing them to turn down applications from low quality providers. The Proposed Rule looks to increase the ability for application denial by using two strategies.
Star Ratings History - CMS has decided that an application denial with a one year history of below a 2.5 Star Rating aligns with CMS’ practice of graduated enforcement. CMS does not want to enable an organization with low quality Star Ratings to increase in size if it’s going to be terminated in two years.
Bankruptcy Proceedings - CMS believes that allowing an organization to grow while in the midst of bankruptcy litigation would not be in support of MA or Part D program, since bankruptcy often ends in the closure of the organization. Applications from organizations that have filed or are in bankruptcy will be denied.
Third-Party Marketing Organizations
With a major spike in the marketing of MA and Part D plans by third party marketing organizations known as “TPMOs”, and after complaints from beneficiaries related to these marketing efforts, CMS is proposing new regulation to add oversight to the actions of TPMOs and their related partners. CMS is proposing to define TPMOs as organizations that perform lead generation, marketing, sales, and enrollment related functions as a part of the chain of enrollment (the steps taken by a beneficiary from becoming aware to making an enrollment decision). CMS would require MAOs and Part D sponsors to make it mandatory for the TPMO in which they do business to prominently display a disclaimer on their website, marketing materials, and any and all electronic communications depending on the interaction. Additionally, plans that do business with TPMOs are responsible for that TPMO to follow all requirements that apply to the plan. And lastly, plans would be responsible for TPMOs that are managing lead generation to make it known to the beneficiary that their information is being shared with a licensed agent for future contact, who can assist them with enrollment.
Loss Ratio Reporting
CMS reduced the MA and Part D MLR reporting standards for calendar year 2018 to 2022, whereas MAOs and Part D sponsors had to only report MLR and the remittance amount of each contract, if anything. However, MAOs and Part D sponsors had to still record details and calculations on the MLR, and remittance, and were subject to audit on those calculations. So it seemed the change didn’t relax any standards as originally intended. What it did do was create issues for CMS and the public related to MLR compliance of the MAO and Part D sponsors without the assistance of audits. CMS also mentions there has been an uptick in the annual number of contracts since 2018 that haven’t met the required MLR and were subject to penalties.
Drug Prices at the Point of Sale
It’s a requirement that Part D sponsors allow beneficiaries access to what’s known as “negotiated prices” for covered Part D drugs. The term “negotiated prices” defined by CMS is “the price paid to the network pharmacy or other network dispensing provider for a covered Part D drug dispensed to a plan enrollee that is reported to CMS at the point-of-sale by the Part D sponsor”. The price paid at the point of sale is used to determine beneficiary cost-sharing, determined plan and CMS liability during a payment year cycle, subject to final appeasement following the end of the covered year. At this time, “negotiated prices” have to include all pharmacy prices except those amounts that can’t “reasonably be determined” at sale, like performance-based pharmacy price concessions that decrease the price a sponsor has to pay for a certain drug.
For healthcare organizations looking to succeed in the transition to value-based care delivery models, ForeSee Medical is a specialized software platform designed to increase the profitability of Medicare Advantage risk contracts. Using A.I. including natural language processing, ForeSee Medical perfects HCC risk adjustment scores, empowering providers to positively influence health outcomes.
Blog by: The ForeSee Medical Team