Radar on Medicare Advantage

  • News Briefs: CMS’s Enhanced MTM Model Still Isn’t Showing Savings to the Medicare Parts A and B Programs

    After four years, the Enhanced Medication Therapy Management (MTM) Model still has not generated any net savings to the Medicare program. Through the five-year model that started in January 2017, model participants tested a variety of interventions to improve Part D beneficiaries’ medication use. Despite efforts by some sponsors to alter their interventions, there continued to be no statistically significant impacts on Medicare Parts A and B expenditures for the overall enrollee population in model-participating plans, observed the Fourth Evaluation Report released by the CMS Innovation Center last month. Findings from subgroup analyses suggested that enrollees eligible for the low-income subsidy and enrollees with medically complex profiles did not benefit more from the model compared to the overall enrollee population, while the program saw decreases in inpatient expenditures and admissions related to the Ambulatory Care Sensitive Conditions for both the medically complex subgroup and the all-enrollee cohort, according to the report prepared by Acumen.
  • Medicare Advantage Organizations Chase ‘Signature Trend’ of Offering Extra Benefits for 2023

    Judicious enhancements to supplemental benefits was the common theme as Medicare Advantage organizations prepared their bids for 2023, according to actuaries who recently helped sponsors submit bids that were due on June 6. The benefit changes come as plans considered potential bonus payment losses in 2024 and other possible drivers of increased costs next year.

    “The signature trend of this year was carrying forward a lot of the innovative benefits that we’ve seen take hold over the past few years,” remarks Tim Murray, principal with Wakely, an HMA company. These include “wallet” benefits such as over-the-counter card allowances and flexible “choose your own adventure” benefits often involving healthy food and/or groceries, he observes.

  • MedPAC Mulls Method of Reducing High-Cost Outlier Impact on Risk Scores

    After its last two reports suggested comprehensive reforms to Medicare Advantage plan reimbursement, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress shifted its MA focus to one area in particular: the potential for high-cost patient outlier data to skew the calculation of risk scores that determine MA plans’ risk-adjusted pay.

    Although the Hierarchical Condition Category (HCC) risk adjustment model is intended to produce scores that reflect the relative health status of a plan’s enrollees, fee-for-service (FFS) Medicare spending data that is used to calculate risk scores can include a small group of outliers whose annual costs are much higher than the average costs of patients with a given condition, explained MedPAC Executive Director Jim Mathews during a June 15 web briefing with members of the press.

  • Trustees Report Underscores Need for Wholesale Medicare Reform

    While the headline takeaway from the latest Medicare Trustees report was that the Hospital Insurance (HI) trust fund will be exhausted two years later than previously projected, industry experts suggest that the report should light a fire under Congress to take swift legislative action to sustain Medicare financing. During a recent webinar hosted by the Bipartisan Policy Center, a panel of seasoned policy experts agreed that the report underscored the need for comprehensive structural reform to the Medicare program, including potential changes to the way Medicare Advantage plans are paid.

    Published on June 2, the Medicare Board of Trustees’ annual report provides previous and projected costs for the Medicare program’s two separate trust funds: the Hospital Insurance trust fund (HI), which helps pay for inpatient hospital and other services covered by Medicare Part A; and the Supplemental Medicare Insurance trust fund (SMI), which helps pay for physician, outpatient hospital, home health and other services covered by Parts B and D.

  • Latest Audit Report Highlights Enforcement Activity Outside Program Audits

    In CMS’s latest audit report, the agency confirms what an earlier AIS Health analysis of compliance notices indicated: the agency imposed approximately $1 million in civil money penalties (CMPs) based on 2021 referrals, and nearly half of that stemmed from one-third financial audit findings. CMS, meanwhile, cautioned the industry not to read too much into the latest audit results as they relate to 2020, when CMS audited a relatively small number of plans due to the COVID-19 public health emergency (PHE).

    In the 2021 Part C and Part D Program Audit and Enforcement Report, published on June 7, CMS said it imposed 16 CMPs amounting to $1,043,953, or an average of $65,247 per CMP. Sponsors audited in 2021 covered 26% of enrollment.

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