CMS Finalized Medicare Advantage and Part D Changes for 2019

Written by Jessica Adkins

April 6, 2018

CMS Finalized Medicare Advantage and Part D Changes for 2019

This week, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare Advantage and Part D Rate Announcement and Call Letter. This the finalized annual update to MA and Part D programs, which includes payment updates and policy changes for the 2019 plan year. CMS also released a preview and fact sheet of the Final Rule Implementing Policy and Technical Changes to Part C and Part D for 2019 and will be formally published later.

Changes to make note of for the 2019 plan year:

  • Eliminating the Star Rating Measure that separately captures the results of audits and enforcement actions.
  • Expanding the ability for plans to offer supplemental benefits that are health related but are not covered by Traditional Medicare, including benefits that address social determinants of health, like nutritional support.
  • Finalizing a new method for calculating payments to Medicare Advantage plans that employers can offer to Medicare enrollees.
  • Expanding the list of conditions included in the CMS-HCC Risk Adjustment Model.
  • The 21st Century Cures Act eliminates the existing MA disenrollment period that currently takes place from January 1st through February 14th of every year, and effective for 2019, replaces it with a new Medicare Advantage open enrollment period (OEP) that will take place from January 1st through March 31st annually.

The final changes will result in an estimated $295 million in savings a year for the Medicare program over 5 years (2019 – 2023) which ultimately will result in lower premiums or additional benefits.

Earlier this year, CMS launched the “Patients Over Paperwork” Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with the goal of reducing unnecessary burden, increasing efficiencies, and improving the beneficiary experience. The final rule furthers this initiative and would empower patients and doctors in making decisions about patient healthcare. Specifically, the final rule reduces regulatory burdens by:

  • Authorizing CMS to permit plans to use notice of electronic posting (and provision of copies upon request) to satisfy disclosure requirements for certain bulky documents to Medicare beneficiaries, thereby empowering patients with the information to make their own healthcare decisions
  • Eliminating requirements that plans submit, in addition to their bids, similar and overlapping accounting information
  • Making it easier for plans to communicate with beneficiaries by streamlining government review and approval of marketing materials used by plans
  • Eliminating enrollment requirements for healthcare providers and prescribers that bring value to Medicare Advantage and Part D beneficiaries

CMS is finalizing the proposal to significantly reduce the amount of MLR data that MA organizations and Part D sponsors submit to CMS on an annual basis. Under these new rules, MA organizations and Part D sponsors will only report the MLR percentage and amount of any remittance owed to CMS for each contract. CMS is also finalizing our proposal to revise the MLR calculation to include in the MLR numerator all expenditures related to fraud reduction activities (including fraud prevention, fraud detection, and fraud recovery) and Medication Therapy Management (MTM) programs.

Expect to see updates and more information regarding future changes:

There has also been an update to the definition of “Marketing.”
Currently, a variety of materials that are not intended to steer a beneficiary into a particular plan fall under the regulatory definition of marketing and its related requirements, including a statutory requirement that these materials be subject to CMS review. CMS is changing the definition to include only materials that are most likely to lead to a beneficiary to make an enrollment decision. This will allow CMS to focus its oversight efforts on these materials to help ensure that beneficiaries are making the right decisions for their health care needs. This change lessens the burden of marketing submission on plans and CMS reviewers. To account for those materials that will now fall outside of the new marketing definition, CMS is adopting more appropriate requirements and oversight for a new category of materials and activities called “communications.” Agent Pipeline’s Compliance Department will keep you updated on the changes to Medicare Marketing Guideline changes and requirements/oversight on “Communications.”

Maximum Out-of-Pocket and Cost Sharing Limits
CMS is revising the regulations controlling maximum out-of-pocket (MOOP) limits
, to enable future changes to CMS’s existing methodology of using the 85th and 95th percentiles of projected beneficiary out-of-pocket Medicare Fee-For-Service (FFS) spending beginning no earlier than in CY 2020. CMS will then have authority to change and implement additional levels of MOOP limits, as well as provide flexibility to encourage plan offerings with lower MOOP limits. In addition, CMS will be able to update discriminatory cost-sharing standards using a new standard beginning no earlier than in CY 2020.

Default Enrollment
CMS is codifying changes to a current enrollment mechanism that allows MA organizations to provide a seamless continuation of coverage for their beneficiaries once they become Medicare eligible.

Restoration of the Medicare Advantage Open Enrollment Period
The 21st Century Cures Act eliminates the existing MA disenrollment period that currently takes place from January 1st through February 14th of every year and, effective for 2019, replaces it with a new Medicare Advantage open enrollment period (OEP) that will take place from January 1st through March 31st annually. The new OEP allows individuals enrolled in an MA plan, including newly MA-eligible individuals, to make a one-time election to go to another MA plan or Original Medicare. Individuals using the OEP to make a change may make a coordinating change to add or drop Part D coverage.

Implementation of CARA (Comprehensive Addiction and Recovery Act of 2016)
CMS is implementing new CARA requirements to provide an important additional tool to combat the growing opioid epidemic that is devastating families and communities across the nation. CARA requires CMS to establish through regulation a framework that allows Part D sponsors to implement drug management programs. Under such programs, a sponsor can limit at-risk beneficiaries’ access to coverage for frequently abused drugs beginning with the 2019 plan year. CMS will designate opioids and benzodiazepines as frequently abused drugs. Drug management programs will be integrated with CMS’s existing Overutilization Monitoring System (OMS). The clinical guidelines used to determine if a beneficiary is potentially at-risk, which are based on using opioids from multiple prescribers and/or multiple pharmacies, will be expanded from those used in OMS currently. Sponsors will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to a selected prescriber(s) and/or pharmacy(ies) (“lock-in”), and through the use of beneficiary-specific point-of-sale (POS) claim edits, which are already permitted under the current policy. Part D sponsors may not implement such limitations unless they have engaged in case management with the prescribers of these drugs, and beneficiaries can submit prescriber and pharmacy preferences. CMS will also exempt beneficiaries who are being treated for active cancer-related pain, are receiving palliative or end-of-life care, or are in hospice or long-term care from drug management programs. CMS is limiting the availability of the special enrollment period (SEP) for dually or other low income subsidy (LIS) eligible beneficiaries who are identified as at-risk or potentially at-risk for prescription drug abuse under such drug management programs. At-risk determinations, which include prescriber and pharmacy lock-in, will be subject to the existing beneficiary appeals process.

As always, Agent Pipeline provides you with the most up to date information regarding changes on industry regulations and compliance. Stay tuned for more CMS policy changes and updates to prepare for this year’s AEP. If you have any questions, please contact complianceboard@agentpipeline.com or contact your Regional Market Manager at 800-962-4693 to learn more.

Sources: CMS fact sheet, 2019 Rate Announcement & Call Letter – CMS.gov, (Published: April 2nd, 2018)

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