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Robert B. Vogel, MD, JD
Retinal Ophthalmologist at Piedmont Eye Center, Lynchburg VA;
Attorney, Overbey Hawkins & Wright, PLLS, Lynchburg, VA;
Adjunct Professor, Humanities and Bioethics, Liberty University School of Medicine, Lynchburg, VA.
The Centers for Medicare and Medicaid Services (CMS) plans to raise rates paid to Medicare Advantage (MA) and Part D plans by 3.4%, according to its recently released 2019 Rate Announcement and Call Letter.
There also is a proposed change to the Part C Risk Adjustment Model. The new model would account for such conditions as mental health disorders, substance abuse, and chronic kidney disease when calculating payments. However, to allow stakeholders more time to understand the changes’ implications, the new system will not be implemented until 2020, in accordance with the 21st Century Cures Act.
CMS also is offering several changes to the way opioids are handled in the United States. In one proposed change, Part D sponsors would be able to limit certain beneficiaries’ coverage of frequently abused medications to certain prescribers and pharmacies and beneficiary-specific point-of-sale claim edits. Opioid naïve patients would be limited to an initial prescription of seven days for acute pain and Part D sponsors through case management reviews would monitor high-risk opioid users.
Additionally, to make MA plans more attractive and useful to the consumer, CMS is planning to increase the number of allowable supplemental benefits options. Currently, those benefits are limited to specifically disallow coverage for services that are considered “daily maintenance.”
The new plan would allow such coverage if the services 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.”
America’s Health Insurance Plans (AHIP) publishes a response to CMS’s proposed rate schedule and Call Letter each year. In a statement commenting on the higher-than-expected 3.4% hike in rates, AHIP Chief Operating Officer Matt Eyles praised the policy, saying, “AHIP commends CMS on enacting policies that overall will strengthen and improve Medicare Advantage for America’s seniors. By finalizing many of its innovative proposals, CMS has acknowledged the value of the private sector solutions for Medicare enrollees.”