A bipartisan group of lawmakers is concerned about proposed policy and payment changes in the Medicare agency's 2019 advance notice for Medicare Advantage and Part D programs.
The congressmen, in a letter (PDF) to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma, listed numerous concerns regarding the advanced notice, which was released in two parts in late 2017 and early 2018, including risk-adjustments and cost plan transitions.
The agency proposed an MA risk adjustment model that included additional mental health, substance use disorder and chronic kidney disease conditions. The agency also outlined a “Payment Condition Count model" for risk adjustment, which takes into account the number of conditions that a beneficiary has, but only among the conditions that are included in the payment model.
Lawmakers urged the agency to work with health plans in order to receive the most robust feedback and understand the full impact of the changes.
The proposed Program of All-Inclusive Care for the Elderly normalization factor is likely to reduce payments to PACE programs by 6% next year. The program provides comprehensive care and social services to frail, elderly patients, many of whom are dual eligibles.
"PACE remains a successful program and reductions of this magnitude may jeopardize the care being provided to our most frail seniors by some PACE providers," the letter said. The lawmakers encouraged the CMS to rethink the impact of the proposed reductions.
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Additionally, the lawmakers asked the agency to provide detailed plans for engaging and informing seniors before the 2019 open-enrollment season regarding certain cost plans that are required to transition to MA plans. For 2019 coverage, open enrollment will run from Oct. 15 to Dec. 7.
Following the devastation caused by Hurricane Maria that has created challenges for providers and patients, the committees also encouraged the agency to provide more equitable benchmarks for MA plan payments in Puerto Rico. More than 75% of Medicare patients in Puerto Rico are enrolled in an MA plan.
"Yet MA rates on the island are below those of the mainland," the lawmakers said. "There are numerous valid approaches the agency should further consider to ensure MA rates on the island are more fair and thus sustain MA plans' to provide care."
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The lawmakers, however, praised the CMS head for implementing certain provisions of the 21st Century Cures Act and the Bipartisan Budget Act of 2018, including improvements to MA risk adjustment and expanded supplemental benefits for seniors, as well as updates to the Star Ratings Program.
The letter was signed by House Ways and Means Committee Chairman Rep. Kevin Brady, R-Texas, House Ways and Means Ranking Member Rep. Richard Neal, D-Mass., House Energy and Commerce Chairman Rep. Greg Walden, R-Ore., and House Energy and Commerce Ranking Member Rep. Frank Pallone, Jr., D-NJ.
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Industry response to the advance notices has also been mixed.
The Alliance of Community Health Plans praised the agency for addressing the opioid crisis by capping initial opioid prescriptions at seven days and flagging beneficiaries who may be at risk for abuse.
The American Hospital Association, however, said it is concerned about the use of encounter data in determining risk scores, as such data is "not designed to support MA risk adjustment calculations." Using encounter data in these calculations could lead to inaccurate scores, the association said in early March.