2019 Medicare Advantage Advance Notice Part 1. Dennis J. Hulet, FSA, MAAA
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1 2019 Medicare Advantage Advance Notice Part 1 Dennis J. Hulet, FSA, MAAA
2 How will the Proposed CMS Changes Impact Your Planʼs Financial Performance? Traditionally, Medicare Advantage (MA) Plans scramble resources in early February to understand CMS Advance Notice of Methodological Changes for the upcoming plan year and translate the changes into financial and operational impacts. CMS changed things up a bit this year by releasing Part I of the 2019 MA Advance Notice in late December. The focus of Part I is a proposed change to the MA CMS-HCC Risk Adjustment Model (Risk Model) (affects Part C payment only). This brief provides an overview of the changes proposed. Background Early release of the proposed changes to the Risk Model was required to provide sufficient comment time on the proposed changes while continuing to meet the other MA Plan notice requirements the balance of the 2019 Advance Notice on or before January 31, 2018 and the MA capitation rates and final payment policies no later than April 2, MA Plans have until March 2, 2018 to submit comments on the proposed Risk Model changes. The proposed Risk Model changes are what CMS believes is appropriate to comply with risk adjustment requirements of the 21st Century Cure Act. Proposed Changes in Brief CMS intends to integrate an updated HCC model, i.e., the 2019 CMS-HCC Risk Adjustment Model, which reflects: More recent cost experience (moving from 2013/2014 data to 2014/2015 data) Expand the use of HCCs for mental health and substance abuse and Add new factors to community and long term institutional factors that reflect the beneficiary s number of conditions. The 2019 Risk Model risk score will be phased-in over three years:» Plan year % weight on 2019 Risk Model risk score/ 75% weight on 2017 Risk Model risk score» Plan year % weight on 2019 Risk Model risk score/ 50% weight on 2017 Risk Model risk score» Plan year % weight on 2019 Risk Model risk score/ 25% weight on 2017 Risk Model risk score» Plan year % weight on 2019 Risk Model risk score MA payment will continue to reflect a blend of Risk Adjustment Processing System (RAPS) and encounter data increasing the weight on encounter-based risk scores from 15% in 2018 payment to 25% for 2019 payment. (Note: encounter diagnosis data will be amended with RAPS inpatient diagnoses.) 2
3 The Impact on MA Plan Revenue The proposal seems simple enough but, as with most things, the devil is in the details. More refined reflection of behavioral diagnoses and more direct consideration of or the number of a beneficiary s conditions (comorbidities) seems like good ideas. The range of cost to properly treat behavior problems (including alcohol and substance abuse) is wide so reflection of most diagnosisspecific payment should be good for MA plans with a material concentration of beneficiaries with these conditions. Multiple conditions complicate patient care management so including additional payment for more complex patients is sound. However, the CMS Part C payment mechanics force payment changes to be budget neutral. So, if your MA plan has a beneficiary population that is biased towards behavioral health diagnoses and multiple conditions, you should see a small increase in revenue; if your beneficiary population is biased towards a single or few multiple conditions without a material behavioral health burden, your revenue will likely be reduced by the new Risk Model. Number of Conditions Model(s) The CMS proposal includes three alternatives: 1. An HCC model that includes a number of conditions adjustment based on only HCCs that are used in Part C payment (Payment HCCs Count), 2. An HCC model that includes a number of conditions adjustment based on all HCCs (All HCC Count), 3. An HCC model that excludes the consideration of the number of conditions (without Count). The Payment HCC Count model includes consideration of 1 9 payment HCCs plus 10 or more payment HCCs with the adjustment ranges as follows: Community Beneficiaries Non-Duals No adjustment for 1-3 Payment HCCs/ for 4 Payment HCCs to for 10+ Payment HCCs (that is up to $397 per month on a $700 base rate) No adjustment for 1-4 Payment HCCs/ for 5 Payment HCCs to for 10+ Payment HCCs (that is up to $659 per month on a $700 base rate) Full Benefit Duals No adjustment for 1-5 Payment HCCs/ for 6 Payment HCCs to for 10+ Payment HCCs (that is up to $331 per month on a $700 base rate) No adjustment for 1-3 Payment HCCs/ for 4 Payment HCCs to for 10+ Payment HCCs (that is up to $805 per month on a $700 base rate) Partial Benefit Duals No adjustment for 1-4 Payment HCCs/ for 5 Payment HCCs to for 10+ Payment HCCs (that is up to $419 per month on a $700 base rate) No adjustment for 1-4 Payment HCCs/ for 5 Payment HCCs to for 10+ Payment HCCs (that is up to $645 per month on a $700 base rate) Institutionalized No adjustment for 1-5 Payment HCCs/ for 6 Payment HCCs to for 10+ Payment HCCs (that is up to $172 per month on a $700 base rate) 3
4 The All HCC Count model includes consideration of 1 14 HCCs plus 15 or more HCCs with adjustment ranges as follows: Community Beneficiaries Non-Duals for 1 HCCs to for 15+ HCCs (that is up to $503 per month on a $700 base rate) No adjustment for 1 HCC/ for 2 HCCs to for 15+ HCCs (that is up to $575 per month on a $700 base rate) Full Benefit Duals No adjustment for 1-7 HCCs/ for 8 HCCs to for 15+ HCCs (that is up to $337 per month on a $700 base rate) No adjustment for 1-3 HCCs/ for 4 HCCs to for 15+ HCCs (that is up to $519 per month on a $700 base rate) Partial Benefit Duals No adjustment for 1-2 HCCs/ for 3 HCCs to for 15+ HCCs (that is up to $439 per month on a $700 base rate) No adjustment for 1-2 HCCs/ for 3 HCCs to for 15+ HCCs (that is up to $547 per month on a $700 base rate) Institutionalized No adjustment for 1-9 HCCs/ for 10 HCCs to for 15+ HCCs (that is up to $378 per month on a $700 base rate) Adoption of either number of conditions models will likely result in material shifts in revenue by MA plan. Next Steps Comments and concerns regarding the CMS proposed risk model changes must be received by CMS no later than 6 PM Eastern Time on March 2, A general opinion can be formed based on the theoretical considerations presented by CMS in creating the three proposed risk models. However, financial analysis will be required to determine which of the two number of conditions models is most financially beneficial for your plan and to determine whether you should reluctantly go along or enthusiastically endorse the proposed change. We recommend MA plans estimate the impact on future MA revenue using each of the three alternative CMS-HCC models and a recent extract of your plan s beneficiary disease distribution. Presumably, MA plans will win financially if revenue shows an increase when the estimate for the number of conditions model is compared to the estimate for the without count model. This should be true even with the budget neutrality adjustment. However, if revenue estimates show your MA plan will lose financially should CMS proceed with the proposed change, then the discussion of strategic alternatives can begin now rather than in April or May. Please contact Dennis J. Hulet, FSA, MAAA, Consulting Actuary with Axene Health Partners, LLC at (206) or by at dennis.hulet@axenehp.com for more information about the proposed HCC model changes or for assistance with our recommended financial analysis. 4
5 About the Author: Dennis J. Hulet, FSA, MAAA is a Consulting Actuary with Axene Health Partners, LLC and is based in AHP s Seattle, WA office. Dennis can be reached at (206) or dennis.hulet@axenehp.com. Any views or opinions presented in this article are solely those of the author and do not necessarily represent those of the company. AHP accepts no liability for the content of this article, or for the consequences of any actions taken on the basis of the information provided, unless that information is subsequently confirmed in writing. Axene Health Partners, LLC 2018
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