5 things to know about proposed MA rates, Part D changes for 2019

CMS has released its proposed rule covering rates in Medicare Advantage (MA) and changes to Medicare Part D for 2019, expanding the definition of health-related supplemental benefits and putting limits on opioid prescriptions for beneficiaries.

Here are five major pieces of the proposed regulation:

1. Prescription opioid limits

Under the proposed rule, an initial prescription of an opioid would be limited to seven days for patients with acute pain, similar to what some states have been implementing to combat opioid abuse. Part D plans would also have additional federal oversight by implementing “hard formulary levels” that would warn pharmacists when a prescription exceeds recommended guidelines for opioid use. CMS said this warning could only be overridden after a consultation with the prescriber.

“The plan, prescriber and patient can all engage in a dialogue through a process designed to ensure the appropriate amount of opioids is getting prescribed,” Demetrios Kouzoukas, CMS deputy administrator and director of the Center for Medicare, told reporters.

Additional changes include using the existing CMS Overutilization Monitoring System (OMS) to identify beneficiaries using other drugs which, when taken in combination with an opioid, increase the risk of an adverse event.

2. MA rates up by 1.84 percent

The increase in baseline MA payments for 2019 is higher than the 0.45 percent plans were given in last year’s rule. After accounting for coding by health plans, the average increase will be 3.1 percent, above the 2018 rate of 2.95 percent.

3. Risk score changes

Other parts of the proposed MA policies could be more controversial. The proposed rule would move forward with increased use of encounter data in determining a plan’s risk score, despite a January 2017 report from the Government Accountability Office (GAO) which said CMS hadn’t made progress in its ability to “validate the completeness and accuracy” of MA encounter data.

The agency said in the regulation the quality of encounter data has improved. Its proposing for 2019 that 25 percent of the risk score be based on encounter data, with the remaining 75 percent based on fee-for-service data.

4. Supplemental benefits expanded

In a reinterpretation of existing Medicare law, CMS will expand what other health-related benefits MA plans can offer to patients. Those services could include “non-skilled in-home supports, portable wheelchair ramps and other assistive devices and modifications when patients need them.”

“Our priority is to ensure that our seniors have more choices and lower premiums in their Medicare health and drug plans,” CMS Administrator Seema Verma, MPH, said in a statement. “We are focused on addressing the specific needs of beneficiaries and providing new flexibilities for Medicare Advantage plans to offer new health-related benefits. This is a big win for patients.”

The standard for the expanded supplemental benefits is whether they “compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

5. Star rating changes

Medicare Advantage star ratings would include two new measures in 2019 under the rule, dealing with statin use for patients with diabetes or cardiovascular disease.

America’s Health Insurance Plans (AHIP), the largest lobbying group for health insurers, offered little insight in its stance on the proposed rule in its initial statement.

“AHIP will review the advance rate notice carefully to ensure the Medicare Advantage program is protected from policies that could impact the long-term stability of the program and seniors’ access to quality, affordable health care that meets their individual needs,” AHIP president and CEO Marilyn Tavenner said.

Comments on the rule will be accepted through March 5. CMS anticipates releasing the final rule on April 2.