Deep Dive Medicare Advantage Advance Notices Part I and II
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1 Deep Dive Medicare Advantage Advance Notices Part I and II
2 Noah Champagne, FSA, MAAA Noah Champagne is a consulting actuary in Milliman s New York office. Noah has a breadth of Medicare experience working with a variety of MA plans as well as a number of ACOs. Additionally, Noah has a large amount of experience working directly with providers to facilitate risk arrangements, contracting discussions, and benchmarking. Margaret Peterson Margaret Peterson is the Director of Federal Affairs at APG. Previously, Margaret served on the health policy team for Senator Joni Ernst (R-IA), focusing on ACA reform and MACRA implementation. Valinda Rutledge, MBA Valinda Rutledge is currently the Vice President of Federal Affairs at America s Physician Groups. She previously worked as a member of the leadership team (Senior Advisor and Group Director) at CMMI
3 America s Physician Groups (APG) Purpose of our Organization Resources Advocacy Representation on Capitol Hill Healthcare and the Hill Federal comment letters Education Standards of Excellence Risk Evolution Task Force Regional meetings Mission Statement The mission of America s Physician Groups is to assist accountable physician groups to improve the quality and value of healthcare provided to patients. America s Physician Groups represents and supports physician groups that assume responsibility for clinically integrated, comprehensive, and coordinated healthcare on behalf of our patients. Simply, we are taking responsibility for America s health. Strategic Vision America s Physician Groups and its member groups will continue to drive the evolution and transformation of healthcare delivery throughout the nation.
4 Membership 44 states, D.C. and Puerto Rico
5 Agenda MA 2020 BID TIMELINE HIGHLIGHTS FROM MA ADVANCED NOTICE AND CALL LETTER PART I AND PART II PART C TAKEAWAYS FOR PRACTICES, SSBCI, STAR AND QUALITY MEASURES ADVOCACY & SIGN ON LETTER QUESTIONS
6 MA 2020 Bid Timeline MA Advance Notice Part I released December 20, 2018 MA Advance Notice Part II released January 30, 2019 Deadline for comments on MA Advance Notice Parts I and II March 1, 2019 Final rate announcement released by April 1, 2019 Deadline for 2020 Bid Submission June 3, 2019
7 The proposed updates will continue to modernize and maximize competition among Medicare Advantage and Part D plans, as well as include important actions to address the nation s opioid crisis.
8 CMS s Estimated Net Payment Impact Impact on Payments Relative to 2019 Effective Growth Rate +4.59% Change in Star Ratings -0.14% MA Coding Intensity Adjustment % Risk Model Revision +0.28% Encounter Data Transition -0.06% EGWP Payment Policy +0.00% Normalization -3.08% Expected Average Change in Revenue % 1 Note that this reflects the 5.9% difference in coding patterns between MA plans and FFS (same as 2019) 2 Excluding the impact of the rebasing of benchmarks (available in Rate Announcement)
9 County-Specific MA Benchmark Payments 2020 MA Benchmark Payments will be released in Rate Announcement on April 1, 2019 No change in Quality Bonus Payments for 2020 Preliminary 2020 FFS rate increase of 4.52% from the 2019 Rate
10 County-Specific MA Benchmark Payments - Calculation Calculated as the lesser of: Pre-ACA Amount (Applicable Amount) ACA Amount (Specified Amount) Pre-ACA Amount (Applicable Amount) Calculated as the greater of: The 2019 Pre-ACA amount increased by the 2020 MA growth percentage (4.84% for non-esrd) The 2020 FFS amount (unknown) ACA Amount (Specified Amount) Calculated as: (2020 FFS Rate) x (applicable percentage + applicable percentage quality increase) Most notable this amount includes the Quality Bonus Payment (QBP) A majority of MAOs received some form of QBP bonus in 2018 (new contract or based on star rating)
11 Part C Risk Score Changes 50%/50% blend of 2020 and 2017 risk score models Sizable increase in FFS Normalization Factor (lowers risk scores) Risk Scores will be calculated as a 50%/50% Blend of EDS and RAPS 5.9% Coding Pattern Adjustment (Same as 2019)
12 Part C Risk Model Changes 2020 Risk Scores 50% 2020 CMS-HCC model with Payment Condition Count (1.069 FFS Normalization Factor) 50% 2017 CMS-HCC Model (1.075 FFS Normalization Factor) 2019 Risk Scores 50% 2019 CMS-HCC model without Payment Condition Count (1.038 FFS Normalization Factor) 50% 2017 CMS-HCC Model (1.041 FFS Normalization Factor)
13 Payment Condition Count (PCC) Model Proposed Payment Condition Count (PCC) model Coefficient added variable that counts the number of condition(s) a beneficiary has (among those included in the payment model) Materially improved predictive power of risk model Same model proposed in Part I of the 2019 Advance Notice, released December 27, 2017 Little impact on overall average risk scores but variation by beneficiary: 0-3 HCCs: No impact 4-5 HCCs: Slightly lower 6+ HCCs: Slightly higher 10+ HCCs: Largest impact (only 3% of population) Minimal impact by gender, age group, race/ethnicity, census region, plan type (HMO, PPO, POS), EGWPs CMS estimated 1.1% increase in MA individual plans average risk score 2 but Avalere estimated a 0.6% increase 1 Source: 2 Source:
14 Part C Normalization Factor Increase Accelerated increase in underlying risk scores driven by: Changes in demographics Changes in the reported health status in the FFS Population Implementation of ICD-10
15 Part C Risk Scores EDS/RAPS Transition Year EDS Weighting RAPS Weighting % 90% % 75% % 85% % 75% 2020 (Proposed) 50% 50% EDS Encounter Data System RAPS Risk Adjustment Processing System
16 Part C Risk Scores EDS/RAPS Transition Based on payment year 2017 risk scores, EDS risk scores are on average 2.5% lower than RAPS risk scores 1 General enrollment plans: 2.2% lower Special Needs Plans (SNPs): 5.2% lower Risk score comparison: 89% had same Part C, 9% RAPS higher, 2% EDS higher Revenue impact will grow in future as EDS becomes larger portion of risk score and for SNPs where EDS risk scores are much lower than RAPS risk scores Member-level comparison of EDS and RAPS Part C risk scores by plan type 1 Source:
17 Part C Risk Scores Coding Pattern Adjustment Adjustment to plan payments to reflect differences in diagnosis coding between MA organizations and FFS providers Year Coding Pattern Adjustment % %
18 Health Insurer Provider Fee (HIPF) HR 195 Passed into law January 22, 2018 One year moratorium on the Health Insurance Providers Fee (HIPF) Set to expire for 2020 service year Service Year At least 3 bills that were introduced in January of 2019 that could repeal or further delay the HIPF
19 Employer Group Waiver Plans (EGWPs) 2019 Bids Administratively set rates for Retiree Plans CMS waive the bidding requirement for all MA EGWPs 2020 Bids CMS will continue to waive the bidding requirements for all MA EGWPs
20 Proposals to Address the Opioid Epidemic Encourage lower cost-sharing for naloxone as well as promoting co-prescribing of naloxone when clinically appropriate Encourage plans to offer medicallyapproved non-opioid pain management as supplemental benefit Implement Pharmacy Quality Alliance (PQA) opioid overuse measures for 2020 STAR Rating
21 Puerto Rico Specific Changes Adjust FFS rates in Puerto Rico to be based on beneficiaries who are enrolled in both Part A and Part B Adjust FFS rates in Puerto Rico to account for differences in the % of beneficiaries with zero claims versus nationwide (this was done in 2019) CMS is not anticipating adjusting Puerto Rico s FFS Rates to account for the 2017 hurricane
22 Additional Part C Items Included in Advance Notice No change to rebate percentages by star rating from 2019 Total beneficiary cost measure (TBC) will be maintained at $36 PMPM Minor updates to the measures included in 2020 Star Ratings Minor Increases to 2020 in-network cost sharing limits
23 Part C Takeaways for Practices Increase in Normalization Factors will decrease risk scores approximately 3% FFS Population Risk Score Growth has Accelerated
24 2019 Expansion of Supplemental Benefits IN 2019 CALL LETTER CMS EXPANDED DEFINITION OF HEALTH CARE SUPPLEMENTAL BENEFIT TO INCLUDE : DIAGNOSE, COMPENSATE FOR PHYSICAL IMPAIRMENTS OR ACT TO AMELIORATE THE FUNCTIONAL/PSYCHOLOGICA L IMPACT OF INJURIES THESE ITEMS INCLUDED FALL PREVENTION OR OTHER DEVICES, THEY DID NOT INCLUDE ITEMS ADDRESSING SDOH OR CAN T BE USED TO INDUCE ENROLLMENT MUST BE ORDERED BY LICENSED PROVIDER
25 2020 Special Supplemental Benefits for the Chronically Ill (SSBCI) BBA 2018 allowed supplemental benefits not primarily health expanded in 2020 to chronically ill Definition of Chronically ill: one of more co-morbid and medically complex chronic condition, high risk of hospitalization, requires intensive care coordination MA plans must document mechanism to identify enrollees and maintain records. Can use CBO to provide benefits Types of Supplemental Benefits: Home Delivered Meals Transport for non Medical Needs Must be detailed in EOC (Evidence of Coverage) Must be able to show reasonable expectation of improving or maintaining the health
26 CMS is soliciting SSBCI Guidance Should Plans have flexibility to determine what is chronic disease (will convene a Technical Advisory Panel to update list) Should these supplemental benefits have limits Should financial need be considered
27 Proposed Star Rating Changes ADULT BMI PROPOSED FOR REMOVAL MEDICATION ADHERENCE TO BE ADJUSTED FOR SDS ALL CAUSE READMISSION- ADDED OBSERVATION STAYS MEDICATION RECONCILIATION- RETIRE MEASURE AS STANDALONE BUT REPORTED THROUGH TRANSITIONS OF CARE MEASURE CONTROLLING BP- TEMPORARY REMOVAL DUE TO NEW AHA GUIDELINES
28 Request for Comments on New Measures Pain Management ( use of non opioid therapies and PRO for patients for chronic pain) Antibiotic Utilization Measures in the Ambulatory Setting PROM (Patient Reported Outcome Measures) 2 global measures: physical and mental health Physician /Plan Interactions-survey Interoperability- Measures plans progress to exchange info with providers
29 Summary Of Part I and II Changes Part I Rate Notice Changes Implement Payment Condition Count Encounter Data Transition from 75/25 to 50/50 Part II Rate Notice Changes 1.59% net average rate increase Normalization Chronically Ill definition of Supplemental benefits Minimal changes in Star Rating measures
30 MA 2020 Bid Timeline - Repeated MA Advance Notice Part I released December 20, 2018 MA Advance Notice Part II released January 30, 2019 Deadline for comments on MA Advance Notice Parts I and II March 1, 2019 Final rate announcement released by April 1, 2019 Deadline for 2020 Bid Submission June 3, 2019
31 Sign on Letter PHYSICIAN-LEAD COALITION EXPRESSING SUPPORT FOR MA ANNUAL TRADITION LAST YEAR S LETTER HAD 340 SIGNEES APG WILL BE BEGIN CIRCULATING LETTER FOR SIGNATURES WEEK OF FEB. 25
32 Questions? NOAH CHAMPAGNE MARGARET PETERSON VALINDA RUTLEDGE
33
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