Earlier this month, the Centers for Medicare & Medicaid
Services (CMS) released its 2018 Medicare Advantage and Part D
Advance Notice and Draft Call Letter ("Draft Call Letter"). For the majority of
the letter’s provisions, CMS is proposing to continue its
current course of action and is refraining from introducing new
policies. With that said, however, CMS is proposing several notable
updates, including updates to the use of encounter data for risk
adjustment and the 2018 Star Ratings. This blog is to highlight
some key provisions and changes as MA and Part D plans prepare and
Use of Encounter Data in Risk Adjustment for 2018
CMS is currently transitioning to an Encounter-Based Risk Score
methodology for risk adjustment purposes, which has been met with
some resistances from plans and other stakeholders due to concerns
over its reliability. For the current contract year, encounter data
will account for 25% of the risk score, while data collected
through CMS' Risk Adjustment Processing System (RAPS) accounts
for the other 75%. In the 2017 Call Letter, CMS stated its
intention to increase this ratio to 50% encounter data for contract
year 2018. However, in the 2018 Draft Call Letter, CMS is proposing
to slow down the transition and to keep this ratio at 25%/75%,
rather than increasing it.
Medicare Advantage Employer Group Waiver Plans Bidding
CMS is proposing to continue the waiver of the bidding
requirements for all MA employer/union-only group waiver plans
(EGWPs) for 2018, a policy CMS initially implemented for contract
year 2017. However, CMS is soliciting comments on whether it should
use the weighted average bid-to-benchmark ratio for individual
market plan bids from the prior payment year to calculate base
payments for 2018 Medicare Advantage EGWPs or if it should continue
to use the bid-to-benchmark ratios applied in calculating the 2017
Repricing of DMEPOS based on Competitive Bidding
For 2018, CMS is continuing to "re-pricing Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) claims
from 2011 – 2015 to reflect the most current DMEPOS prices
associated with the Competitive Bidding Program." Of note, CMS
is also determining whether the 21st Century Cures Act may impact
2018 Star Rating Updates
CMS is proposing to add two new 2018 Star Measures and making
technical adjustments to several others. The two new measures
Medication Reconciliation Post
Discharge (Part C). This measure assesses the percentage of
discharges from acute or non-acute inpatient facilities whose
medications were reconciled within 30 days of discharge.
Improving Bladder Control (Part
C). This is a Health Outcomes Survey (HOS) measure, which
assesses the percentage of beneficiaries with urine leakage who
discussed their problem with their provider and received treatment
for the issue.
Of note, CMS is also proposing changes to the Beneficiary Access
and Performance Problems (BAPP) measure, which is based on
sanctions, civil monetary penalties (CMPs), and compliance actions.
CMS calculates this measure by using a 100-point system, where
every contract begins with a BAPP score of 100, but this number is
then reduced based on its sanction status, compliance score, and
each CMP related to beneficiary access. For 2018, CMS is proposing
certain changes to this measure. First, it is proposing to update
the timeframe to July of the measurement year to June of the
following year. Also of note, CMS is proposing to change how the
score is reduced based on CMPs. Currently, the score is reduced 40
points per CMP. CMS proposes to a sliding scale ranging from a
reduction of 10 to 40 points based on "a ratio of the
unadjusted CMP amount to total enrollment of the cited contracts at
the time of the enforcement action."
Further, for 2019 and beyond, CMS indicated that it would
consider removing measures that "topped out," or have
little variation across plans.
Interested stakeholders have until March 3, 2017 to submit
comments in preparation for the final Call Letter to be released
April 3, 2017.
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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