CMS Announces Changes to Medicare Advantage Plans
In April 2018, the Centers for Medicare and Medicaid Services (CMS) issued instructions that encouraged more flexibility and addressed specific issues facing Medicare Advantage recipients. The changes will take place in 2019 and are designed to compensate for physical impairments, diminish the impact of a sudden injury or illness, and reduce the use of emergency rooms by Medicare patients. CMS is finalizing changes to Medicare Advantage that will take effect in 2019. These changes include an expansion of health-related supplemental benefits, substance abuse disorder treatment and better flexibility throughout Medicare Advantage plans.
Expansion of Health-Related Supplemental Benefits
Some Medicare Advantage plans offer supplemental benefits that allow patient access to services that could be available to them under Medicare fee-for-service. In an effort to reduce costs and allow patients better coverage under Medicare Advantage, CMS plans to develop a rebate and premium plan that would make supplemental benefits more affordable. CMS defines a supplemental benefit as one that is not covered by original Medicare, is health related and one in which Medicare Advantage would incur a direct medical cost.
CMS changes to Medicare Advantage plans will also address the current opioid crisis. Some of the changes being implemented include a hard safety edit to limit the initial fills of opioid prescriptions to no more than a 7-day supply for patients who have not been prescribed the drugs in the past. For high-risk opioid users, CMS plans to expand the Overutilization Monitoring System (OMS) to identify patients who are using high levels of opioids and obtaining them from multiple prescribers or pharmacies. Real-time safety alerts are also to be implemented at the time a prescription is filled to engage providers and patients. In addition, CMS plans to implement the Comprehensive Addiction and Recovery Act of 2016 to limit at-risk beneficiary coverage for drugs that are frequently abused. There will also be enhanced metrics to track high use of opioids.
One of the benefits that consumers have requested from Medicare Advantage is better flexibility when it comes to benefit and service access. Using targeted cost sharing and supplemental benefits, CMS hopes to increase benefit flexibility for specific enrollee populations. Much of these changes will be based on health status or disease, and will ensure that all individuals are provided benefits uniformly.
Other changes proposed by CMS include risk scores related to encounter data, adjustments to plan payments that reflect differences in diagnosis coding, and Medicare Employer Retiree Plans. Adjustments will also be made to risk assessments for Medicare Advantage recipients in Puerto Rico who were impacted by hurricanes during 2017.
Medicare Advantage Plans to Add Telehealth Coverage
In February 2018, Congress passed the Bipartisan Budget Act, which included the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act. Included in the CHRONIC Care act are provisions that allow Medicare Advantage plans to cover telehealth services, reducing the number of office visits a patient must make when ill.
What Are Telehealth Services?
Initially known as telemedicine, telehealth is now how healthcare providers refer to healthcare that is delivered using technology. It is a growing trend in healthcare, with many walk-in clinics and other healthcare organizations using technology to diagnose and treat illness. Telehealth may be conducted through live two-way video, similar to Skype, which allows the doctor and patient to interact directly. It’s also the transmission of recorded videos or digital images, such as X-rays or photos, that a healthcare provider can use to diagnose an illness. Personal health and medical information can also be collected remotely along with texts or email messages that provide patient education.
Benefits of Telehealth Services
Telehealth affords a variety of benefits, especially to patients with chronic health conditions. It expands access to care, allowing healthcare providers to connect with patients outside the traditional delivery system, and provides care to those in rural settings. There is no need to spend money on gas, parking or public transportation in order to ask your doctor a question. For working adults, telehealth allows them to be examined by a doctor without missing time as the appointment can be scheduled on a break or after hours. Access to specialists, especially for patients in rural areas, are improved as someone who lives in remote areas may need to drive a significant distance to see a specialist. Because waiting rooms are often filled with people who are sick, some with contagious illnesses, there is no risk of “catching” something from someone else if patients can see a doctor in the comfort of their own home.
In the past, Medicare has put up barriers to telehealth services, preferring that patients visit a doctor face-to-face. When patients have chronic illnesses, however, a visit to the doctor each time they have a question or need care can be risky, especially during flu season. Using telehealth services, a patient can speak to a doctor directly from home who can then determine if a visit to the office is necessary. Healthcare providers can receive real-time test results like blood pressure, temperature and other routine examination information electronically while they are speaking to the patient.
One reason that Medicare Advantage plans are efficient is that they often require patients to obtain services from a provider network. This limits patient choice and, in some areas of the country, has led to substandard care. However, patients find the supplemental benefits and lower cost of Medicare Advantage plans to outweigh these problems. With the addition of telehealth benefits, care will improve and encourage even more consumers to purchase the private option of Medicare.
Additional Telehealth Services
In addition to routine telehealth care offered through Medicare Advantage, all Medicare beneficiaries will be eligible for tele-stroke evaluations. If an EMT suspects that a patient is having a stroke, a doctor can evaluate the symptoms remotely so that the patient may receive treatment on the way to the hospital. In the past, only patients who lived in remote areas were eligible for telehealth services if they were receiving at-home dialysis. With the new changes, all patients will be eligible for those services if they are being treated at home, reducing the number of times they must visit a doctor or clinic during treatment.
Patient advocates say that telehealth services are more efficient and effective, especially for patients with chronic conditions. These services are also less expensive and can improve patient outcome. Telehealth will especially help patients who have multiple chronic conditions like heart disease, diabetes, stroke or cancer. Since many of these patients are older and suffer from mobility issues, allowing a doctor to treat them remotely at home provides a huge benefit.
Medicare Advantage Plans to Provide Non-Medical Services
The Centers for Medicare & Medicaid Services (CMS) recently expanded its definition of primarily health-related benefits that can be covered by Medicare Advantage plans. These supplemental benefits are designed to help those on Medicare Advantage plans live healthier, more independent lives. The new rules will take effect in 2019.
Prevent or Treat Injuries
Starting in 2019, Medicare Advantage plans will be permitted to cover devices that prevent or treat injuries as well as those that compensate for impairments, reduce emergency room visits or address psychological effects of sickness or injury. This could include grab bars in bathrooms or home health aides that can help with daily activities. Home health aides provide services that may include helping people get dressed, preparing meals or assisting with personal care. All benefits must be medically appropriate and recommended by a licensed healthcare provider, but a doctor’s prescription is not necessary.
Current Medicare Advantage plans cover some additional benefits, including eyeglasses, hearing aids, dental care and gym memberships. The new rules will allow plans to expand coverage significantly. Medicare Advantage recipients who have been diagnosed with asthma could have an air conditioner covered by their policy. Some recipients could receive home-delivered meals or healthy groceries that can help alleviate symptoms of illness. Transportation to medical appointments may also be covered when the rules are implemented in 2019. Experts say that when the official benefit packages are released in the fall after approval by CMS, however, the supplemental services will not be available in all plans since needs vary tremendously across the U.S.
Promote Independent Living
The new rules are designed to promote independent living among Medicare Advantage recipients. The idea is to keep people on the plans healthy by providing them with the tools they need to achieve that goal. Many advocates of the new rules say that Medicare benefits should not be viewed as “one-size-fits-all.” They argue that designing plans with greater flexibility allows for a more personalized healthcare experience and promotes well-being. However, some patient advocates are concerned that Medicare Advantage recipients are receiving supplemental services while original Medicare recipients are being left behind.
Not a New Concept
The Institute on Aging, a California nonprofit organization that offers services for senior citizens as well as adults with disabilities, currently provides services that enable patients who had been living in nursing homes to return to their own homes. The Institute says that they have seen as much as a 30 percent savings by taking a more integrated approach to meeting social and healthcare needs.
Although the CMS has not yet released official information on what may or may not be covered by Medicare Advantage plans in 2019, all indications are that plans will include benefits that are health-related but not necessarily medical supplies or treatments. These changes are an effort to promote healthier living among senior citizens and adults with disabilities.
CHRONIC Care Act Addresses MA Special Needs
The passage of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act, which was included in the bipartisan budget bill, addresses the long-term status of the Medicare Advantage Special Needs (SNP) program. The program was created by Congress in 2004 but was time-limited, designed to end in December 2008. The SNP was extended 7 times but without clear support, which made investors leery of supporting the program.
Changes to the Program
With the passage of the CHRONIC Care Act, Congress created changes that would affect dual eligible recipients who are covered by both Medicaid and Medicare Advantage plans. Some of these changes include:
- Increasing integration for coordinating information between state partners
- More stringent standards to demonstrate integration
- A unified grievance and appeal process
The law also broadens the definition of who qualifies as a “chronic special needs” recipient, imposes stringent care management standards and authorizes special needs enrollees to receive some supplemental benefits.
Coordination of Benefits
Another area where the new legislation helps those who are enrolled in both Medicare Advantage and Medicaid is with coordination of benefits. These changes are designed to eliminate frustrations many patients dealt with when they tried to get coverage under the two programs. Before this change, Medicare did not issue a denial letter for a service that was not considered a benefit, yet Medicaid would not pay without that denial letter. In addition, senior citizens often had to carry multiple identification cards that demonstrated coverage for different services. The new legislation eliminates these barriers to coverage.
Chronic Care Working Group
Along with better coordination of care between Medicare Advantage and Medicaid, CMS adopted four policies presented by the Chronic Care Working Group designed to assist beneficiaries with chronic illnesses. Providers may receive a higher payment if they spend time actively coordinating care for their patients with chronic illnesses. In addition, integrated mental health care is included along with better care for patients suffering from cognitive impairments like Alzheimer’s. Finally, patients who are at risk of developing diabetes can receive coverage for education and prevention services. Patients who are suffering from end-stage renal disease may now have access to Medicare Advantage plans.
Many patients who were enrolled in a Medicare Advantage SNP reported frustration in getting services covered by Medicare and Medicaid due to the lack of communication between the two agencies. With these changes as well as additional coverage designed for prevention care, patients who are enrolled in both Medicare Advantage plans and Medicaid can live healthier, more independent lives.
Medicare Advantage Value-Based Insurance Design Change
In November 2017, the Centers for Medicare and Medicaid (CMS) announced that they would expand the Medicare Advantage value-based insurance design (V-BID) to all 50 states by 2020 in order to provide more options for patients. This would mean greater plan flexibility for Medicare Advantage recipients.
Obama Administration Project
Medicare Advantage V-BID programs debuted in 2015 as a demonstration project. The plans were launched in seven states with the goal to provide Medicare Advantage plans that were flexible and would provide supplementary benefits for people with specific health problems, such as high blood pressure, diabetes or congestive heart failure. The program was expanded to three additional states in 2018. With this expansion, the Trump administration is adding additional flexibility. The new regulation also allows Chronic Condition Special Needs plans to be eligible, something that was not permitted in the past.
Under the new regulation, enrollee identification can be determined by each individual plan. This allows Medicare Advantage companies to offer coverage to people with chronic conditions, such as people with chronic kidney disease or those who use tobacco. By increasing the number of people who are eligible for the plans, more consumers will be eligible for customized care and additional choices over traditional Medicare.
The basic premise of Medicare Advantage V-BID plans is to use consumer cost-sharing and plan elements to encourage enrollees to use high-value medical services, especially for those with chronic conditions. There is increasing interest in this type of insurance market because it’s proven to reduce costs and quality of care. In the first year, a report released by Manatt Health found that patients received reduced cost-sharing for benefits and that the plans focused on diabetes, congestive heart failure and chronic obstructive pulmonary disease (COPD). Under the new regulations, the plans will be available for patients with:
- Congestive heart disease
- Coronary artery disease
- History of stroke
- Mood disorders
- Rheumatoid arthritis
Starting in 2019, participants will be permitted to identify enrollees with chronic conditions other than those listed or modify the chronic condition category to include a different subset of existing chronic conditions.
One of the benefits of Medicare Advantage V-BID plans is that patients with multiple chronic conditions, who had historically received too little high-value care, might comply more with recommended medical treatments. Research from the test states indicated that by changing to the V-BID model, the use of both nonessential and essential care decreased, implying that those patients were more likely to comply with doctor recommendations. This leads to a better quality of life and improved health for those who are enrolled in such plans. The main focus of the V-BID model is an intervention approach to healthcare. Patients are encouraged to use medical services that have the greatest positive impact on their health. Expansion of the Medicare Advantage V-BID model will allow patients with chronic conditions to obtain better coverage while also reducing the costs to Medicare Advantage recipients.
Medicare Advantage News
Among the changes bought by the Affordable Care Act are cuts to the Medicare Advantage program. Those cuts are certain to be one of the hottest issues of this year’s congressional campaign. Medicare Advantage is very popular especially in areas like New York where 35 percent of Medicare beneficiaries participate in a plan under the program.
More than 1.1 million seniors in New York are enrolled in this healthcare program. In Duchess County alone, a total of 9,220 individuals are currently registered for the Medicare Advantage plan. That is about 18 percent of Medicare recipients.
Medicare Advantage – A Unique Healthcare Plan
Medicare Advantage Plans that private companies provide Medicare subscribers with a substitute for traditional Medicare for medical and hospital expenses. Health networks such as Health Maintenance Organizations operate these plans for senior citizens. Baby boomers are often attracted to these healthcare plans because they offer things like health club memberships and discounts on hearing aids and eyeglasses.
However, all of these benefits are under threat. The 2010 healthcare law is cutting a whopping $156 billion from Medicare Advantage over ten years. The political debate that is currently happening is centered on whether the phased-in reductions of reimbursement rates will be a threat to the services that Medicare Advantage provides or simply reduce the profits that private insurers make from offering Medicare Advantage plans.
Could Higher Premiums Could Be the Solution?
Some Medicare Advantage subscribers believe that insurance companies that offer this plan should start charging their enrollees higher premiums or decreasing their coverage in order to offset the rate cuts. However, GOP representatives who are running in competitive re-election races have made it known that they clearly oppose further reduction in Medicare Advantage.
Aside from that, these concerns have been made into a campaign issue. Some lawmakers think that it is definitely growing as an issue due to the constant attacks from people who are opposed to the cuts. These people believe that the program without the cuts is structured toward healthy living.
They believe that further cuts will be detrimental to the plan’s overall capability to offer subscribers a good quality of life and health. Medicare Advantage has already survived significant changes in federal reimbursement rates. When the Affordable Care Act was implemented in 2010, Medicare Advantage Plans were obtaining 14 percent more in reimbursements than traditional Medicare. This disparity is only six percent this year.
An Increase in Medicare Advantage Enrollment
Amidst the looming Medicare Advantage cuts, enrollment in these plans continues to rise. The nonpartisan Congressional Budget Office issued an April 14 forecast that predicted national enrollment in Medicare Advantage will reach the 19 million mark in 2017 despite the full phase-out of what healthcare law calls overpayments to health care insurers who are offering the plans. Aside from that, Medicare Advantage plans increased nationally by 1.4 million individuals to 15.7 million from 2013 to 2014. This is a one-year jump of around 9.8 percent.
These increases are evident in all parts of the country. In New York, for instance, enrollment grew 8 percent during the same period. Additionally, 50 percent of Medicare subscribers in 11 counties around the state are registered in Medicare Advantage. A lot of them are located in the western portion of New York.
Medicare Changes – What Are The Sharp Criticisms So Far?
Critics of this healthcare program note that the plans are simply closed networks that limit the number of hospitals and physicians that the enrollees may utilize. This is not the case with the traditional Medicare plan. It allows policy holders to use any health care facility or physician that accepts Medicare. In the state of New York, about 90 percent of doctors accept Medicare according to the data obtained by the nonpartisan Kaiser Family Foundation. The data also shows that the health practitioners who are least likely to accept Medicare are obstetricians, gynecologists, dermatologists and psychiatrists.
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Medicare Advantage – Political power Play – Huge Influence in Obtaining Votes
Democratic senators who supports the Affordable Care Act say that they continue to push for phased-in reductions in federal payments to Medicare Advantage providers. However, they opposed a round of cuts that was averted early in 2014. They said that these cuts could have hurt the Democrats’ election prospects if they had been enacted.
Aside from that, they urge the Center for Medicaid and Medicare Services to maintain payment levels that will help protect Medicare Advantage participants from disruptive changes. This bipartisan letter was signed by 19 Democratic and 21 Republican senators. They think that Medicare Advantage is very beneficial to senior citizens when done well as it provides them with extra help.