The Centers for Medicare & Medicaid Services (CMS) has recently unveiled the Calendar Year (CY) 2025 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates, as well as for Part C and Part D Payment Policies.
Stakeholders and interested parties are invited to submit their comments on the proposed changes until 6 o’clock p.m. Eastern Time on Friday, March 1, 2024, before CMS finalizes the Rate Announcement by April 1, 2024.
Medicare Advantage, a cornerstone of the Medicare program, offers beneficiaries an alternative to the traditional Medicare fee-for-service (FFS) model available through private plans. These plans are reimbursed by CMS through a capitation model, which pays a fixed amount per enrollee, making the accurate and fair setting of these rates critical to the program’s health and sustainability. The CMS is tasked with yearly updates to these payment rates, incorporating technical adjustments aimed at maintaining the accuracy and relevance of the MA payments.
The CY 2025 Advance Notice proposes several methodological changes that, if finalized, are anticipated to yield a net increase in MA payments to plans. This development is significant, suggesting a positive outlook for plans and potentially for beneficiaries in terms of available services and coverage options. The proposed updates take into account several factors, including the effective growth rate, changes in star ratings, MA coding pattern adjustments, risk model revisions, and the MA risk score trend. Together, these factors contribute to an expected average revenue change of +3.70 percent for MA plans in CY 2025.
A closer look at the individual components reveals a nuanced picture of the proposed changes:
An increase of 2.44 percent signals optimism about the growth and stability of the Medicare Advantage market. This rate reflects broader economic trends and healthcare cost projections, indicating a healthy trajectory for the program.
Yet to be determined (TBD), this factor is crucial for aligning payment rates with current healthcare costs and economic conditions, ensuring that MA plans are adequately compensated for the services they provide to beneficiaries.
A slight decrease of -0.15 percent in this area suggests adjustments in how plan quality is measured and rewarded. Star ratings are a key component of how CMS evaluates plan performance, impacting payments through quality bonus payments.
Set at 0 percent, indicating no change in the adjustment factor that accounts for differences in diagnosis coding patterns between MA plans and traditional Medicare.
A significant negative adjustment of -2.45 percent reflects updates to the risk adjustment model and efforts to normalize payments between MA and traditional FFS Medicare, ensuring equity and accuracy in compensation for the care of beneficiaries.
An increase of 3.86% in this area suggests that MA plans are expected to manage a population with increasing health risks, necessitating higher payments to accommodate the greater needs of these beneficiaries.
Additionally, the Advance Notice proposes updates to reflect the Part D redesign mandated by the Inflation Reduction Act, signaling significant changes in how prescription drug benefits are structured and financed within the Medicare Advantage and Part D ecosystems. Stakeholders are encouraged to engage in the comment process, contributing to the refinement and finalization of these policies. As the healthcare landscape continues to evolve, such updates are essential for maintaining the balance between adequate plan compensation, beneficiary affordability, and program sustainability.
The Centers for Medicare & Medicaid Services (CMS) has published several new proposed rules regarding Medicare payments for 2025. In addition to updating payment rates,
The Centers for Medicare & Medicaid Services (CMS) has recently taken significant steps to enhance the Medicare Prescription Payment Plan by issuing final guidance and
Please log in to your account to comment on this article.
ICD10monitor has teamed up with renowned CDI expert Dr. Erica Remer to bring you an exclusive webcast on how to recognize sepsis, how to get providers to give documentation that will support sepsis, and how to educate to avert sepsis denials. Register now and become a crucial piece of the solution to standardizing sepsis clinical practice, documentation, and coding at your facility.
Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.
Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.
This webcast, presented by Tiffany Ferguson, LMSW, CMAC, ACM, addresses the critical gap in Social Determinants of Health (SDoH) reporting for pediatric populations. While SDoH efforts often focus on adults, this session emphasizes the unique needs of children. Attendees will gain insights into the current state of SDoH, new pediatric Z-codes, and the importance of interdisciplinary collaboration. By understanding and applying pediatric-specific SDoH factors, healthcare professionals can improve data capture, compliance, and care outcomes. This webcast is essential for those looking to enhance their approach to pediatric SDoH reporting and coding.
Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, VP of CDM, for a webcast addressing oncology service coding challenges. Learn to navigate coding for infusions and injections alongside Evaluation and Management (E/M) services, ensuring compliance and accurate reimbursement. Gain insights into documenting E/M services for oncology patients and determining medical necessity. This webcast is essential to optimize coding practices, maintain compliance, and maximize revenue in oncology care.
During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.
Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
