CMS has finalized its rule for 2019 rates for Medicare Advantage and Medicare Part D, giving insurers a bigger-than-expected rate increase while finalizing proposals on expanded supplemental benefits and efforts aimed at fighting opioid addiction.
Here are five major pieces of the finalized regulation:
1. Drug pricing, opioid provisions finalized
CMS touted the rule as “saving Medicare beneficiaries on prescription drugs” with many of its provisions. Among them is allowing generic drugs to be added to formularies during any point of the year, rather than Part D plans having to wait until the next plan year to take advantage of lower-cost pharmaceutical options.
“The steps we are taking will drive more competition among plans and pharmacies to meet the needs of seniors and lower costs,” CMS Administrator Seema Verma, MPH, told reporters on an April 2 conference call.
Opioid restrictions are also a major feature of the final rule. CMS finalized several policies targeted at preventing and combating the abuse or overuse of prescription opioids, including “expecting” all Part D sponsors to limit initial opioid prescriptions for treatment of acute pain to seven days or less. For so-called “high risk” opioid users, the rule says the existing CMS Overutilization Monitoring System (OMS) will be integrated into drug management programs so prescribers and pharmacies can limit these beneficiaries’ access to frequently abused drugs.
Certain patients will be exempt from these requirements, such as those being treated for cancer-related pain, receiving end-of-life care or are in hospice or long-term care facilities.
2. MA rates and risk scores
The rule includes a 3.4 percent increase on average payments to Medicare Advantage insurers in 2019. The rate increase is above the 1.84 percent hike in the proposed rule, which CMS pinned on projections of higher medical cost growth.
CMS also finalized an increase in the use of encounter data in determining plans’ risk scores. A January 2017 report from the Government Accountability Office had said the agency hadn’t made progress on validating the “completeness and accuracy” of such data, but CMS said the quality of encounter data has improved. For 2019, risk scores will be calculated with a blend of 25 percent encounter data and 75 percent historical risk adjustment data.
3. Supplemental benefits expanded
CMS is finalizing the proposed expansion of supplemental health-related benefits in MA plans, which it said is a “reinterpretation” of existing Medicare law.
“Under this reinterpretation, CMS would allow supplemental benefits if they are used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization,” the agency said. “This expansion will effectively increase the number of allowable supplemental benefit options and provide patients with benefits and services that may improve their quality of life and health outcomes.”
In the proposed rule, CMS said some examples of supplemental benefits could include “non-skilled in-home supports, portable wheelchair ramps and other assistive devices and modifications when patients need them.”
4. ‘Patients Over Paperwork’ provisions
Industry groups have expected CMS to follow through on its many new initiatives through annual rules released this year. For the MA and Part D rule, several provisions are related to the “Patients Over Paperwork” deregulation push, such as allowing MA plans to satisfy disclosure requirements with “notice of electronic posting” and providing copies of documents like the Evidence of Coverage upon request.
MA and Part D plans will also have to report less information on their medical loss ratio—which will include expenses for fraud reduction activities and medication therapy management—with CMS only asking for the MLR percentage and “amount of any remittance owed to CMS for each contract.”
5. Blue Button 2.0
A more recent initiative from CMS—the MyHealthEData data sharing initiative announced at HIMSS18—didn’t result in new requirements for MA plans for 2019, but Verma strongly suggested new standards would be coming in next year’s rule. The final rule is “encouraging” plans to release data to patients which would meet or exceed the Blue Button 2.0 program announced as part of MyHealthEData, which would expand Medicare’s current Blue Button program of making claims data available in PDF form to allowing beneficiaries to “connect their Medicare claims data to the applications, services and research programs they trust.”
MA plans would have a head start on meeting Blue Button 2.0 standards if they listen to CMS’s advice, as the agency said the 2020 rule could make adoption of those standards mandatory.
“We’re seriously considering adding to this, per the MyHealthEData Initiative, empowering (patients) with information they need to make choices,” Verma said.
John joined TriMed in 2016, focusing on healthcare policy and regulation. After graduating from Columbia College Chicago, he worked at FM News Chicago and Rivet News Radio, and worked on the state government and politics beat for the Illinois Radio Network. Outside of work, you may find him adding to his never-ending graphic novel collection.