Radar on Medicare Advantage

Carrying out another directive from President Trump’s Medicare-focused executive order issued last fall (RMA 10/17/19, p. 3), CMS on Aug. 31 released a proposed rule that aims to fast-track Medicare coverage of certain innovative FDA therapies once they are approved. Although the rule applies to Medicare fee for service, it has implications for Medicare Advantage organizations that are required to cover Medicare Parts A and B approved services.

According to a CMS fact sheet on the rule, CMS is proposing a new Medicare coverage pathway, Medicare Coverage of Innovative Technology (MCIT), for medical devices that are granted breakthrough designation by the FDA. The MCIT proposal would allow for national Medicare coverage on the same day as a breakthrough device receives FDA approval. CMS proposes a coverage duration of four years, which it suggests will “encourage manufacturers to voluntarily develop evidence to show these treatments improve the health of Medicare patients.”

In its latest review of the Encounter Data System (EDS) that is used largely to determine Medicare Advantage plan payments, the HHS Office of Inspector General (OIG) urged CMS for the second time to incorporate National Provider Identifiers (NPIs) into its collection of data from MA organizations. Despite their potential to improve program integrity in certain fraud-prone areas, NPIs for ordering providers are still not required in encounter data submissions and continue to be “largely missing” from records submitted by MAOs, observed the new OIG report.

CMS in 2012 began collecting encounter data from MAOs and, with the goal of eventually replacing the legacy Risk Adjustment Payment System, in 2016 began using it to determine risk-adjusted payments to MAOs. But the agency has always maintained that it could be used for program integrity and research purposes and in 2018 began making MA encounter data available to researchers. Last year, the Medicare Payment Advisory Commission suggested that encounter data also be used to determine star quality ratings at a local level (RMA 3/21/19, p. 3).

Before a pandemic forced the rapid adoption of telehealth in the U.S., the Trump administration had already implemented or was taking steps to support the use of telehealth in the Medicare Advantage program. But one remaining barrier for plan adoption of telehealth was the inability to collect diagnosis codes for risk adjustment purposes. CMS temporarily addressed this issue during the pandemic, but as providers anticipate telehealth to play a more permanent role in health care delivery, they are joining with plans to advocate for a permanent shift in MA telehealth policy.

CMS in an April 10 memo to plans stated that MA “organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter” (RMA 4/16/20, p. 3). The document said little else, other than specifying that such diagnoses would count only when the services are provided using an interactive audio and video telecommunications system that allows for “real-time interactive communication.”

In advance of the 2021 Medicare Annual Election Period (AEP) that starts on Oct. 15, venture-backed Medicare Advantage firms like Alignment Healthcare and Clover Health are unveiling their plans for expansion while new startup insurers are declaring their intentions. Although the collective membership of startups is a drop in the bucket compared to the five major insurers that dominate two-thirds of the MA market, one expert says their focus on technology positions them for enrollment success during the COVID-19 pandemic, as long as they can follow through on the clinical side.

Given the increasing share of Medicare beneficiaries who select MA over fee-for-service Medicare, the maturity of the program, and the aging baby boomer population, “organizations are comfortable with both the costs and the revenue streams associated with [MA] and are building infrastructures from the ground up to be able to be successful,” observes Jason Montrie, president of Pareto Intelligence, a Convey Health Solutions company. “And I think we’re seeing there’s a lot of available capital. [Startups] are looking in new markets…where they think they can be successful, they can acquire new investors, and they can grow in a market that has a lot of tailwinds.”