(December 4, 2018)—On October 26, 2018, CMS issued Contract Year (CY) 2020 Medicare Advantage and Part D Flexibility Proposed Rule CMS-4185-P. The rule updates Medicare Advantage (MA) and Medicare Part D by promoting flexibility and innovation so that MA and Part D sponsors are empowered with the tools to improve quality of care and provide more choices.

“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,” said CMS Administrator Seema Verma, in a press release. “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.”

The proposed rule will allow MA plans to offer additional telehealth benefits to enrollees starting in year 2020. This will allow broader flexibility in how plans pay for telehealth benefits to meet the needs of enrollees. CMS is soliciting comments on implementing a statutory benefit that if an MA plan covers a Part B service as a telehealth benefit, then the plan must also provide that service as an in-person visit.

Lee Horner, CEO of telehealth company Synzi, said of the proposed rule, “Expanded access and coverage for virtual care will help drive interest in the telehealth industry and, more importantly, it will benefit health care stakeholders. Instead of being seen as a business expense, telehealth and virtual care platforms will be viewed as necessary investments to ensure that home health agencies are improving their value proposition, their ability to manage and engage patients, and their ability to maintain and strengthen their referral and revenue sources amidst greater competition.”

“Innovation will continue to improve the user experience for administrators, nurses, patients and remote family members,” Horner added. “Ease of use—and an intuitive experience—is key to driving initial implementation and ongoing usage. As non-health care apps are already frequently used by staff and patients on a daily basis, more health care organizations will focus on being able to leverage health care-related apps versus continuing with the use of traditional patient portals.”

In addition to expanding access to telehealth services, CMS proposes to implement several sections of the Bipartisan Budget Act of 2018 including:

  • Section 50311 requires increased integration of Medicare and Medicaid benefits and appeals and grievance processes for MA Dual Eligible Special Needs Plans (D-SNPs); and
  • Section 50354 requires the Secretary to establish a process to allow Part D plan sponsors to request extracts of Medicare Parts A and B claims data for their enrollees.

The rule also updates the methodology for the Star Ratings under Medicare Advantage and Medicare Part D plans, measured in 2020 for associated 2022 ratings. Modifications would be made to the following measures:

  • Controlling High Blood Pressure (Part C) to align with new clinical guidelines related to hypertension
  • Medicare Plan Finder Price Accuracy (Part D) to better measure the reliability of a contract’s advertised prices
  • Plan All-Cause Readmissions (Part C) to include observation stays and remove individuals with high frequency hospitalizations
  • Improvement measures (Part C and D) to exclude from the improvement calculation any measure that receives a measure-level Star Rating reduction for data integrity concerns for either the current or prior year

Additional program integrity updates are included in the proposed rule to allow CMS to recover improper payments from MA organizations based on Risk Adjustment Data Validation Audits. The proposed changes would result in an estimated $4.5 billion in savings to the Medicare Trust Fund over a 10-year period.

Comments on the proposed rule are due by Dec. 31, 2018.

Find a fact sheet here [2], or download the full rule at the Federal Register [3].