CMS Modifies Medicare Advantage to Encompass SDOH Benefits for Plan Members
The federal Centers for Medicare & Medicaid Services (CMS) on April 1 announced that it was changing its polices in the Medicare Advantage program in order to support MA beneficiaries in enhancing their health, including around the social determinants of health (SDOH) elements in health status.
In a press release announced on its website, the agency announced that, “Today, the Centers for Medicare & Medicaid Services (CMS) finalized updates that will take significant steps in continuing the Trump administration’s efforts to increase competition among Medicare Advantage and Part D plans so patients get higher quality care at lower costs. These changes will increase plan choices and benefits, and include important actions to address the opioid crisis.” The press release quoted a statement from CMS Administrator Seema Verma, in which Verma stated that “Today’s changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease. With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy,” she added.
As the announcement noted, “ The final policies will further expand opportunities for seniors to choose Medicare Advantage plans that are providing new supplemental benefits tailored to their specific needs. Last year, CMS empowered patients through expanding the definition of health-related supplemental benefits that Medicare Advantage plans could offer to enrollees, where the primary purpose of the benefits are daily maintenance of health. Beginning in 2019, Medicare Advantage plans can now offer supplemental benefits that are not covered under Medicare Parts A or B, if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization. For example, plans may offer adult day health services, and/or in-home support services under the expanded definition of supplemental benefits when they meet these standards.”
As a practical matter, the press release noted, “For 2020, today’s announcement gives chronically ill patients with Medicare Advantage the possibility of accessing a broader range of supplemental benefits that are not necessarily health-related but have a reasonable expectation of improving or maintaining the health or overall function of the enrollees. These benefits can address social determinants of health for beneficiaries with chronic disease. For example, beneficiaries enrolled in a Medicare Advantage plan could now receive meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services in order to improve their health or overall function as it relates to their chronic illness. For a patient with asthma, for example, a Medicare Advantage plan could cover home air cleaners and carpet shampooing to reduce irritants that may trigger asthma attacks. For someone with heart disease, a plan could provide heart healthy food or produce. And for someone with diabetes, a plan could provide transportation to a doctor’s appointment, diabetes education program or to see a nutritionist.”
Further, the announcement noted, “In addition to expanding opportunities for choice and providing flexibility in offering supplemental benefits, these payment and policy updates include actions that help combat the nation’s opioid crisis. In today’s announcement, CMS encourages Medicare Advantage plans to take advantage of new flexibilities to offer targeted supplemental benefits, cost sharing reductions for patients with chronic pain or undergoing addiction treatment, and encouraging Part D plans to provide at least one opioid-reversal agent on a lower cost-sharing tier. CMS’ overutilization policies have resulted in a 14 percent decrease in the share of Part D beneficiaries using opioids between 2010 and 2017 (36.3 percent to 31.3 percent), with the largest decrease from 2016 to 2017 (5 percent).”
Administrator Verma noted those gains in a telephonic press briefing on Monday afternoon. And, she applauded the fact that, as the press release noted, “Average Medicare Advantage premiums are at their lowest in six years, Part D premiums are at their lowest in three years, and plan choices have increased. Today’s announcement builds in additional flexibilities that will continue to increase choice and competition among Medicare health and drug plans.”
This set of policy changes, Verma emphasized to the press on Monday afternoon, was focused on “strengthening Medicare and unleashing competition,” in order to improve the program and make it better for beneficiaries.
CMS also announced on Monday a set of changes around encounter data and risk adjustment. As the agency noted in a fact sheet published on its website, “CMS calculates risk scores using diagnoses submitted by Medicare Fee-For Service (FFS) providers and by Medicare Advantage organizations. Historically, CMS has used diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS) by Medicare Advantage organizations. In recent years, CMS began collecting encounter data from Medicare Advantage organizations, which also includes diagnostic information. In 2016, CMS began blending 10 percent of risk scores calculated using diagnoses from encounter data with 90 percent of risk scores calculated with diagnoses from RAPS. CMS continued to use a blend to calculate risk scores, by calculating risk scores with 25 percent encounter data and 75 percent RAPS in 2017, 15 percent encounter data and 85 percent RAPS in 2018, and 25 percent encounter data (with RAPS inpatient diagnoses included as a supplement) and 75 percent RAPS in 2019. For 2020, CMS is finalizing the proposal to calculate risk scores by blending 50 percent of the risk score calculated using diagnoses from encounter data, RAPS inpatient diagnoses, and FFS diagnoses with 50 percent of the risk score calculated with diagnoses from RAPS and FFS.”
Further, the agency noted, “In addition, the risk adjustment model we are finalizing builds upon the model implemented for 2019 risk adjustment payments that includes technical updates such as calibrating the model with more recent data, selecting diagnoses with the same method used for encounter data, and including additional condition categories for mental health, substance use disorder, and chronic kidney disease. Consistent with the phase-in of the model in 2019, for 2020 CMS is also finalizing the proposal to implement the phase-in of the new risk adjustment model by calculating the encounter data-based risk scores exclusively with the new risk adjustment model, while continuing use of the risk adjustment model first implemented for 2017 payment for calculating the RAPS-based risk scores.”
