Lower pay hike proposed for Medicare Advantage plans in 2021
INSURERS ARE HOPEFUL about getting some much-desired flexibility to tweak their Medicare Advantage offerings, but they’re pushing back against a lower pay hike.
The CMS last week proposed increasing baseline Medicare Advantage payment rates for 2021 by 0.93%, well below the 2.53% rate increase that plans received this year.
Under the proposal, Advantage plans may be able to count telehealth services for specialties like psychiatry or cardiology toward their network adequacy standards. The Trump administration claims the change would increase access to care for rural seniors and lower the costs of Advantage plans. Increasing access to telehealth services had been a key part of the administration’s attempts to expand access and rein in costs.
“We are encouraged by proposals for additional flexibility that would allow health insurance providers to tailor benefits, design high-quality provider networks, and continue to innovate,” said Matt Eyles, CEO of America’s Health Insurance Plans. “However, we are concerned that some proposals could undermine the critical funding that protects millions of Americans’ access to the benefits and care they need, including individuals with kidney disease who are newly eligible to enroll in Medicare Advantage.”
The CMS estimated that the rule could save the federal government $4.4 billion over a decade, largely from the Part D star ratings and Advantage changes.
Dual-eligible special needs plan “look-alikes” could soon be an endangered species because the CMS wants to refuse to contract with them if there’s a true dual-eligible special needs plan in the state. These look-alikes try to attract patients eligible for both Medicare and Medicaid to Medicare Advantage by promising additional care coordination. But enrollees often may go without important benefits because these plans can’t integrate with Medicaid, according to some experts.
The CMS plans to implement several provisions of the Support Act that mandate Part D plans address the opioid crisis through beneficiary education. The agency also wants to mandate drug management programs and make other changes aimed at preventing and reducing overuse of opioids.
Medicare Advantage and Part D star ratings could get a minor overhaul under the proposed rule. The CMS wants to weigh patient experience and complaints and access measures more heavily in the ratings.
The rate announcement is part two of the 2021 Medicare Advantage Advance Notice. Last month, the CMS said that it wanted to use more encounter data to determine federal payments to Advantage plans.
The agency is increasingly using this data to calculate patient risks scores, which it uses to increase or decrease payments to insurers.
But insurers have complained that encounter data is unreliable and makes their patients look healthier than they are, leading to lower federal payments to Advantage plans.
Continuing the Trump administration’s efforts to reduce healthcare spending through increased transparency and lower drug costs, the CMS wants Part D prescription drug plans to give beneficiaries access to patient-specific drug costs in real time by Jan. 1, 2022.
“If a doctor recommends a specific cholesterol-lowering drug, the patient could easily look up what the copay would be and see if a different, similarly effective option might save the patient money,” the CMS said in a statement.
It proposed giving Part D plans the ability to create a “preferred” specialty tier of high-cost drugs with lower cost-sharing for enrollees. That change could help plans negotiate lower prices for expensive drugs by promising drugmakers access to the so-called preferred tier.
End-stage renal disease patients on dialysis will be able to enroll in Advantage plans in 2021 for the first time. In the past they could only participate in an Advantage plan and seek dialysis treatment if they were diagnosed with endstage renal disease after enrollment.
End-stage renal disease patients usually aren’t profitable for Advantage plans because they pay higher rates for dialysis than fee-for-service Medicare. Advantage plans also have caps on outof-pocket contributions that increase insurers’ responsibility for the cost of dialysis and related treatments. Comments on the proposed changes are due March 6. ●