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The Centers for Medicare & Medicaid Services (CMS) wants to modernize the Medicare Advantage and Part D programs, as well as launch an ambitious expansion of telehealth benefits, according to a proposed rule the agency issued last week.

Medicare Advantage (MA) and Part D provide seniors with health and prescription drug coverage through private plans, and the proposals announced Friday would allow those plans to cover several key additional benefits, CMS explained via a press release published online.

“President Trump is committed to strengthening Medicare, and an increasing number of seniors are voting with their feet and choosing to receive their Medicare benefits through private plans in Medicare Advantage. Today’s proposed changes would give Medicare Advantage plans more flexibility to innovate in response to patients’ needs,” CMS Administrator Seema Verma said in a statement. “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote access to care in a more convenient and cost-effective manner for patients.”

Additional benefits CMS said it plans to make available include adult day care services, in-home support services, and benefits tailored for patients with chronic diseases such as diabetes. The average Medicare Advantage premium is projected to decline by 6.1 percent, officials said, and enrollment is projected to grow by 11.5 percent – meaning, in turn, there will be approximately 600 more plans available across the country next year.

Medicare open enrollment for 2019 is currently ongoing and will remain so until Dec. 7, but the changes proposed last week would take effect in 2020, leveraging new authorities provided to CMS in the Bipartisan Budget Act of 2018, passed by Congress and signed into law earlier this year, CMS noted.

“With respect to telehealth, the proposed changes would remove barriers and allow Medicare Advantage plans to offer ‘additional telehealth benefits’ not otherwise available in Medicare to enrollees … as part of the government-funded ‘basic benefits,’” CMS said in its press release. “This proposal will (also) allow Medicare Advantage plans broader flexibility in how coverage of telehealth benefits is paid to meet the needs of their enrollees.”

The Medicare telehealth benefit is currently “narrowly defined,” CMS argued, and it includes restrictions on where beneficiaries receiving care via telehealth can be located. The proposed rule would give MA plans the ability to offer telehealth benefits to all their enrollees, whether they live in rural or urban areas, as the average beneficiary becomes more “tech-savvy,” the agency added.

“It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places like their homes, rather than requiring them to go to a healthcare facility to receive (such) services,” CMS said. “(The) proposed changes are a major step towards expanding access to telehealth services because the rule would eliminate barriers for private Medicare Advantage plans to cover such additional telehealth benefits under the MA plan. While MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that MA plans will offer them and that more enrollees will be able to use the benefits.”

CMS argued that its new proposal would also improve quality of care for dually enrolled beneficiaries in Medicare and Medicaid who participate in “Dual-Eligible Special Needs Plans,” or D-SNPs. The agency said the changes would also “improve accountability and bolster program integrity within the Medicare Advantage and Part D programs” by updating the methodology for calculating Star Ratings, which provide information to consumers on plan quality, with an emphasis on stability and predictability for plans.

Another two-pronged component of the new proposal centers on providers breaking or bending the rules.

“First, CMS is making revisions to an earlier regulation that made available to Part D sponsors and Medicare Advantage plans a list of precluded providers and prescribers that have engaged in behavior that bars their enrollment in Medicare,” CMS said. “Second, the proposed rule would take steps to help CMS recover improper payments made to Medicare Advantage organizations.”

The agency is continuing to conduct Risk Adjustment Data Validation audits to “confirm that diagnoses submitted by Medicare Advantage organizations for risk-adjusted payments are supported by medical record documentation,” the press release read. The proposed rule reportedly would strengthen CMS’s ability to return cash to the Medicare Trust Funds as a result of these audits.

If finalized, the proposed changes would result in an estimated $4.5 billion in savings to the Medicare Trust Funds over a 10-year period, largely from the recovery of improper payments, CMS said.

To access a fact sheet on the CY 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P), go online to https://www.cms.gov/newsroom/fact-sheets/contract-year-cy-2020- medicare-advantage-and-part-d-flexibility-proposed-rule-cms-4185-p. Alternatively, the proposed rule can be downloaded from the Federal Register at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-23599.pdf.

CMS is encouraging providers to submit written feedback on the proposal anytime through the end of the current calendar year. Comments can be submitted electronically through the CMS e-Regulation website at the following:



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Mark Spivey

Mark Spivey is a national correspondent for RACmonitor.com, ICD10monitor.com, and Auditor Monitor who has been writing and editing material about the federal oversight of American healthcare for more than a decade.

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