Overview of New Benefit Flexibilities in Medicare Advantage

Transcription

1 Overview of New Benefit Flexibilities in Medicare Advantage State Councils for Home and Hospice September 11, 2018 Jane Galvin Managing Director, Regulatory Affairs Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 2 Expanded flexibilities available starting in 2019 MA organizations will be able to target supplemental benefits to certain members in 2019, and tailor benefits to chronically ill members in Expanded Definition of Starting in 2019, MA plans can offer supplemental benefits that Diminish the impact of injuries or health conditions / reduce avoidable emergency and health care utilization Focus directly on member s health care needs Be medically appropriate and recommended by licensedprovider Offered for defined period of time and in certainsituations Example: Fall prevention devices Flexibility in Uniformity Requirements Starting in 2019, MA plans can Reduce or eliminate deductibles, copay, and/or cost-sharing Offer specific tailoredsupplemental benefits to certain members All members that meet specific criteria must be treated the same Criteria used must be objective and measurable There must be a connectionbetween the benefit and the member s health disease or status Example: More frequent foot exams for members withdiabetes Targeted to Chronically Ill Members Starting in 2020, MA plans can target supplemental benefits to individual member s specific medical condition and needs if Member has required health status or disease state Benefits are medically appropriate Benefit has reasonable expectation of improving or maintaining health or overall function of chronically ill enrollee Example: e.g., in-home meals or other nutritional services for members withdiabetes 1

2 3 Existing flexibilities have been further enhanced, expanded MA organizations can use other new and existing flexibilities to tailor benefit designs so as to help attract, engage, and retain members Removal of Meaningful Difference requirement expands possible range of offerings(new) MA organizations can tailor offerings in variety of ways to members health care needs and financialsituations Must ensure that offerings do not discourage enrollment, benefits clearly communicated Tiered cost-sharing for certain providers, provider-specific plans (Existing) MA organization no longer required to submit tiering proposals to CMS Tiered cost-sharing amounts, requirements must be disclosed to members Organizations can offer benefits through a subset of their network through provider-specificplans Rewards can be used to encourage completion of Health Risk Assessment (HRA) (New) Completion of an HRA can be a permitted healthrelated activity in a rewards and incentives program Rewards are valuable in engaging, retaining members and driving desired member behavior Value Based Insurance Design ModelAvailable (Existing) The VBID model will expand in 2019 to a total of 25 states in 2019, and nationwide in 2020 Supplemental benefits can now vary withinplan segments (New) MA organizations can now tailor supplemental benefits, premiums, and cost-sharing to members of individual plan segments 4 Uniform Benefit Requirement: Clarification and Waiver 2

3 5 Uniform Benefit Clarification/Waiver Regulatory Framework Benefits must be available and accessible to each individual within the plan service area and premium may not vary. Social Security Act, 1852(d) and 1854(c). MA plans must be offered with uniform benefits, premium, and cost-sharing throughout the plan's service area. 42 C.F.R (d)(2). Only applies to basic or supplemental benefits under the MA plan. MMCM, Ch. 4, The requirement to provide coverage for all Medicare covered services is not intended to dictate care delivery approaches for a particular service. 65 Fed. Reg , (June 29, 2000). 6 Uniform Benefit Clarification/Waiver Bipartisan Budget Act of 2018 Effective Date: CY 2020 Application: Chronically ill members, as defined by BBA Scope of Change: Permits CMS to waive uniform benefit requirement entirely CMS Clarification in Final Rule Effective Date: CY 2019 Application: Members with specified disease states or health status identified by MAO; do not necessarily need to be chronically ill Scope of Change: Uniform benefit requirement still applies, but CMS interprets it to permit variation in supplemental benefits and cost-sharing for members that meet specified health criteria 3

4 7 Uniform Benefit Clarification/Waiver BBA: Definition of Chronically Ill One or more comorbid and medically complex chronic conditions that is life threatening or significantly limits the overall health or function of the enrollee; High risk of hospitalization or other adverse health outcomes; and Requires intensive care coordination Final Rule: Health Criteria Must be objective and measurable Must be based on a diagnosed condition, rather than functional status or medical complexity Must be communicated to members and providers Plan provider must diagnose member or affirm diagnosis 8 Uniform Benefit Clarification/Waiver Interplay with Non-Discrimination Rules MAOs may not condition coverage on: (1) Medical condition, including mental as well as physical illness; (2) Claims experience; (3) Receipt of health care; (4) Medical history; (5) Genetic information; (6) Evidence of insurability, including conditions arising out of acts of domestic violence; [or] (7) Disability. 42 C.F.R (a). Focus on discrimination against high-acuity members CMS will be concerned about potential discrimination if an MA plan is targeting cost sharing reductions and additional supplemental benefits for a large number of disease conditions, while excluding other, potentially higher-cost conditions. Other relevant laws: Title VI of the Civil Rights Act, Section 504 of the Rehabilitation Act, Age DiscriminationAct, Section 1557 of the Affordable Care Act, conscience and religious freedom laws 4

5 9 Expansion of Permissible Supplemental Benefits 10 Regulatory Framework Statutory MAOs may provide supplemental health care benefits approved by CMS. Social Security Act, 1852(a)(3). Regulatory Minimal regulatory guidance. See, e.g., 42 C.F.R Subregulatory Supplemental benefits are primarily regulated through subregulatory guidance. See, e.g., Medicare Managed Care Manual, Ch. 4, 30. CMS Review CMS reviews and approves supplemental benefits through annual benefit package review. 5

6 11 Two New Expansions in Permissible Benefits Chronically Ill Members Authority: Bipartisan Budget Act Effective Date: CY 2020 New Scope of Benefits: Benefits that have a reasonable expectation of improving or maintaining the health or overall function of the member. Do not need to be primarily health related. All Members Authority: CY 2019 Final Call Letter Effective Date: CY 2019 New Scope of Benefits: Benefits still need to be primarily health related. Interpretation of primarily health related has expanded. 12 Basic Requirements for Non-Chronically Ill (No Change) Pre-2019 Not already covered by Medicare Primarily health related; and Involve a non-zero direct medical cost Post-2019 Not already covered by Medicare Primarily health related; and Involve a non-zero direct medical cost 6

7 13 Definition of Primarily Health Related Pre-2019 Primary purpose is to prevent, cure or diminish an illness or injury. Primary purpose cannot be comfort, cosmetic or daily maintenance Post-2019 Primary purpose is to: Diagnose, prevent, or treat an illness or injury, Compensate for physical impairments, Act to ameliorate the functional/psychological impact of injuries or health conditions, or Reduce avoidable emergency and healthcare utilization. 14 for Non-Chronically Ill: Additional Clarification Items and services must: Focus directly on a member s healthcare needs Be medically appropriate Licensed provider must recommend supplemental items and services Physicians orders will not be required (no change from status quo) Lower standard of recommended Considerations for MAOs regarding documentation Cannot be an inducement to enroll 7

8 15 Potential New Benefits Fall prevention devices Air conditioners Expanded grocery and meal delivery Expanded transportation Standalone memory fitness benefits Broader access to preventative foot care and orthopedic shoes Non-skilled in-home care and services provided by assisted living centers Assistance with activities of daily living (dressing, eating, bathing, etc.) Food preparation Medication reminders Alzheimer s/dementia care 16 Standard Supplemental Benefits Targeted Supplemental Benefits Chronic Supplemental Benefits 8

9 17 Expansion of Telehealth Benefits 18 Telehealth Expansion Current Telehealth Benefits Under MA MAOs can offer telehealth as a basic benefit only if coverage is limited to the coverage criteria under Original Medicare (e.g., rural originating sites) MAOs can offer more expansive telehealth benefits as supplemental benefits, but must be paid for entirely by rebate dollars or by members through increased premiums and cost-sharing MAOs have other priorities for rebate dollars Competing interest in keeping premiums low 9

10 19 Telehealth Expansion Expanded Telehealth Benefits Under BBA Effective Date: CY 2020 Applicability: All members Scope of Change: MAOs may offer telehealth benefits beyond Original Medicare coverage as part of basic benefits Impact: Financial significance of coverage under basic benefits versus supplementalbenefits Marketability vis-à-vis Original Medicare Cost and access Significance for telehealth industry Next Steps: Public notice and comment by November 30, Expansion of Value Based Insurance Design 10

11 21 Value-Based Insurance Design Model Expansion CMS s Value-Based Insurance Design (VBID) model will expand to additional states in 2019 (for a total of 25 states), and become available nationwide in C-SNPs will be able to participate in the model starting in Current Offerings, Flexibilities Conditions Covered CMS Requirements Thirteen MA organizations from 10 parent organizations are participating Can reduce cost sharing for highvalue services Can provide clinically targeted additional supplemental benefits Can reduce cost-sharing for high value providers Can reduce cost-sharing for membersin disease management programs Defined through ICD-10 codes: 1. Diabetes 9. Dementia 6. COPD 2. Congestive Heart Failure Lower Mood backpain* 3. Coronary ArteryDisease 11. Chronic disorders kidney 4. Patient with past stroke 8. disease* Hypertension 5. Rheumatoid Arthritis Obesity/prediabetes* Dementia * Starting in 2019, participants can 13. propose Asthma* other conditions be included, e.g., lower back pain, chronic kidney disease, obesity/pre-diabetes, 14. Tobaccouse* asthma, tobacco use Plans must be in operation for minimum 3 years and rated at 3 stars or higher Limited to plans located in specific states Plan(s) must be offered in no more thantwo states, with 50% plan members in onestate At least one participating plan must have at least 2,000 members; other plans must have at least 500 members Applications submitted in January; bids process continues as with other products Possible offerings of reduced cost sharing in these categories include: elimination of co-pays for eye exams for members with diabetes; reduction of prescription drug co-pays for members with heart disease who regularly monitor and report their bloodpressure. 22 Key Takeaways Targeting members based on health status is permissible CMS particularly concerned with discrimination against high-acuity members Different levels of flexibility for: (a) all members; (b) members with specific health status; and (c) chronically ill Different layers of change in legal framework: statutory, regulatory, and subregulatory changes 11

12 23 Sources Bipartisan Budget Act of 2018, Public Law , enacted February 9,2018 Centers for Medicare & Medicaid Services (CMS), Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter (released April 2, 2018), available at: Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2019.pdf CMS, Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (preview of CMS 4182-F (released April 2, 2018, prior to publication in Federal Register), available at: CMS, Medicare Managed Care Manual, Chapter 4, Benefits and Beneficiary Protections, (updated April 22, 2016), available at: CMS, Medicare Advantage Value-Based Insurance Design Model (VBID) Fact Sheet (updated February 12, 2018); Value Based Insurance Design Model Frequently Asked Questions (updated February 12, 2018); Value Based Insurance Design Model, Webinar, CMS 2019 Application Cycle (December 13, 2017); and CMS updates Medicare Advantage Value-Based Insurance Design (VBID) Model for 2019 (November 22, 2017), available at: Code of Federal Regulations (CFR), Title 42 Part 422, Medicare AdvantageProgram 24 Questions? 12

13 2 5 Thank You 13