Center for Medicare and Medicaid Services proposed bumping up the Medicare Advantage payment rates for 2019 by 3.4% on average, this would impact more than 20 million elderly or disabled people.
The CMS said the average Medicare Advantage payment rate will have a total increase of 6.5% after considering the way health plans code their members diagnoses. This is almost double the amount previously proposed.
This 2019 payment proposal expands the benefits that insurers can offer in the plans; items like wheelchair ramps and devices to diminish the impact of health conditions. Thus, this opportunity is a positive one for insurers competing with Traditional Medicare for members.
Things to know about Medicare Advantage plans:
- Medicare Advantage plans are typically low cost to the consumer.
- The Government pays a percentage of the Medicare recipients Part B premium to the Private Insurance company.
- Medicare no longer assumes risk of the Medicare beneficiaries’ healthcare cost.
- Medicare Advantage plans are not standardized by the government.
- One-Third of all Medicare beneficiaries are in a Medicare Advantage plan.
Medicare Advantage Plan Changes for 2019
CMS is moving to increase the use of encounter data to determine risk scores. A 2017 Government Accountability Office report found encounter data to often not be accurate information. CMS believes it is appropriate to move forward.
CMS administrator Seema Verma says two policies released in April will directly lower costs for Medicare beneficiaries starting January 1, 2019. The agency also announced policies to target opioid abuse. Therefore, the Medicare Part D program would establish a ceiling for opioid doses at 90mg morphine equivalent units (MME).
Any prescription at or above that would trigger a “hard edit” requiring the pharmacists to talk to the insurance company and doctor about the dose.
Encounter data is a record of healthcare services for which Managed Care Organizations(MCO) pay, in many states, the amount MCOs pay to providers of those services.
This data is detailed and generated by healthcare providers; documenting both the clinical conditions they diagnose as well as the services and items delivered to the beneficiaries to treat these conditions.
- In the proposed notice, the agency suggested that 25% of risk scores are based on encounter data.
- In 2018 the agency used a risk score blend of 85% of fee-for-service and 15% of encounter data.
CMS believes the quality of encounter data has improved and they are moving forward with the increased percentage of encounter data in the blend.
Lower Cost Prescriptions
There are two policies going into effect the first day of 2019. One of these policies will lower the cost of biosimilar drugs for low-income patients. Another will enable Medicare beneficiaries to get access to new generic drugs faster.
CMS estimates the biosimilar provision will save $10 million in 2019. Currently, Medicare beneficiaries must wait until the next open enrollment period before newly approved generic drugs would be covered with their insurance.
Once this change goes into effect, insurance plans can choose to make them available sooner. According to an analysis by CMS the proposed rule would indeed have patients paying less, but the government would pay more.
Policies to Target Opioid Abuse
The agency said they are requiring at-risk beneficiaries to use only selected prescribers or pharmacies for opioid prescriptions. Thus, limiting opioid prescriptions for acute pain to no more than seven days.
Critics say the regulations could force many high-dose pain patients to be abruptly tapered to lower doses. Doing this could lead these patients to severe pain, withdrawal symptoms, or even illegal drug use.
The CMS deputy administrator, Demetrios Kouzoukas says “We are proposing important new actions to reduce seniors’ risk of being addicted to or overdoing it on opioids while still having access to important treatment options, we believe these actions will reduce the oversupply of opioids in our communities.”
- 1.6 million Medicare beneficiaries meet or exceed the opioid doses of 90mg MME for at least one day in 2016.
- Many suffer from chronic or intractable pain and have been on high doses for years
- Combining opioids and “potentiator” drugs (gabapentin and pregabalin) increases the risk of an overdose.
The Center for Medicare and Medicaid Services
Further insight on these changes can be found at the Center for Medicare and Medicaid Services website. CMS is working hard to make sure quality plans, quality care, and low-cost prescriptions are available to Medicare beneficiaries. CMS also wants to address the opioid epidemic and help combat this public health emergency.
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