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CMS 2016 Proposed Draft Call Letter – Stars are Changing

On February 20, 2015, the Centers for Medicare and Medicaid Services (CMS) released proposed changes for the coming year for Part D and Medicare Advantage plans. The 2016 Advance Notice and Draft Call Letter for the Medicare Advantage (MA) and Part D Prescription Drug Programs continues CMS’ focus on rigorous compliance and further enhancing the Star quality bonus program. CMS states at the beginning of the draft that the purpose is to build a better, smarter health care system and move the Medicare program toward paying providers based on the quality, rather than the quantity, of care they give patients.

In recent years, both the Medicare Advantage and Part D programs have continued to grow and premiums have remained stable. In the MA program:

  • MA enrollment has increased by 42 percent since passage of the Affordable Care Act to an all-time high of more than 16 million beneficiaries, with nearly 30 percent of Medicare beneficiaries enrolled in an MA plan.
  • In 2015, CMS estimates that 60 percent of MA enrollees will be enrolled in a 4 or 5 star plan, compared to an estimated 17 percent back in 2009.
  • Premiums remain affordable; the average premiums today are lower than before the Affordable Care Act went into effect, dropping 6 percent between 2010 and 2015.

CMS also provides a calendar listing of side-by-side key dates and timelines for operational activities that pertain to Medicare Advantage (MA), Medicare Advantage-Prescription Drug) (MA-PD), Prescription Drug Plan (PDP), Medicare-Medicaid Plan (MMP), and cost-based plans. The calendar provides important operational dates for all organizations such as the date bids are due to CMS, the date that organizations must inform CMS of their contract non-renewal, and dates for beneficiary mailings.

Specifically on the Star program, the following changes are occurring:

  • Addition of one new measure
  • Retirement of three measures
  • Return of three measures
  • Temporary removal of one
  • Reducing by 50 percent the weight of seven targeted measures
  • Changes to the methodology for several other measures.

A very important proposal in the Call Letter would begin to change the gross inequities faced in the Star program faced by Special Needs Plans (SNPs). While MA enterprises with a combination of regular MA and MA SNPs are less disadvantaged, those that operate SNP-only plans have a disproportionate amount of individuals with high acuity as well as socio-economic barriers to health care e.g., literacy, homelessness, financial status, and Medicaid status). While these plans are rewarded via the risk adjustment process for adversity, the Star program tends to discriminate against SNPs by treating all plans the same when it comes to quality achievement. It is simply not a level playing field in terms of the demographics of the membership and the ability to move the Star bonus ball.

CMS understandably could not make changes as they were reworking the entirety of the quality paradigm in MA. Having achieved great success overall, CMS is now trying to address the inequity. CMS also held back due to major concerns about plans’ true commitment to the SNP program. In the draft letter, CMS is proposing changes to the Star program to ensure that plans are not unfairly penalized for enrolling dual eligible or low-income beneficiaries. Although most changes proposed affect all plans, the proposals that tend to help SNPs include:

  • The reduction of the weights of certain measures as noted above. CMS studied 19 of the 46 Parts C and D Star measures. CMS determined that LIS/dual status had an impact on nine of those measures. CMS is proposing to reduce the weight in half for 7 of the measures looked at: breast cancer screening, colorectal cancer screening, diabetes care – blood sugar controlled, osteoporosis management in women who had a fracture, rheumatoid arthritis management, reducing the risk of falling, and medication adherence for hypertension (Part D standalone plans only).
  • The proposal for a potential integrated Star program for Medicare-Medicaid Plans (MMPs). More details will be announced later. While this initiative is focused on the so-called dual demonstration program itself, it will likely inform deeper changes to how SNPs are affected in MA Star program in the future.
  • Inviting comments on administrative flexibility for SNPs. On the drawing board are additional supplemental benefits, network and enrollment reforms.
  • After eliminating diagnoses from a home visit as qualification for risk adjustment purposes (if the only reported event), CMS is now endorsing home visits and HRAs as a good vehicle for care management and appropriate risk adjustment.

The 2016 Caller Letter also moves further down the compliance road. MA plans are expected to establish policies to evaluate the accurate availability of its contracted providers. Plans will also be expected to keep online directories updated in real-time and include information on which providers are accepting new beneficiaries. These provisions will help enrollees better understand the providers that are available to them and make informed decision about their coverage. CMS will undertake direct monitoring of this and will develop new audit protocols to ensure plans are compliant. For 2017, CMS is also considering a national provider database to provide better transparency on the availability of providers.

Proposed Changes
Star Measures
Additional Star Measure
* Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (Part D)
Retirement of Star Measures
* Cardiovascular Care: Cholesterol Screening

* Diabetes Care: Cholesterol Screening
* Diabetes Care: Cholesterol Controlled 

Return of Star Measures * Breast Cancer Screening (Part C)
* Call Center – Foreign Language Interpreter and TTY Availability measures (Part C & D)
* Beneficiary Access and Performance Problems (Part C & D)
 
Temporary Removal of Measures from Star Ratings  * Improving Bladder Control (Part C)
Reducing by 50 percent the weight targeted measures * Breast Cancer Screening,
* Colorectal Cancer Screening,
* Diabetes Care – Blood Sugar Controlled,
*  Osteoporosis Management in Women who had a Fracture,
* Rheumatoid Arthritis Management,
* Reducing the Risk of Falling
* Medication Adherence for Hypertension (RAS antagonists)
 
Changes to the Star measure methodology * Controlling Blood Pressure (Part C)
* Plan Makes Timely Decisions about Appeals (Part C)
* Plan All-Cause Readmissions (Part C)
* Osteoporosis Management in Women who had a Fracture (Part C)
* Complaints about the Health/Drug Plan (CTM) (Part C & D)
* Improvement measures (Part C & D)
* CAHPS (Part C & D)
* Appeals Auto-forward and Upheld measures (Part D).
* Medication Adherence (for Diabetes Medications and Hypertension (RAS antagonists)) and Diabetes Treatment (Part D)
* Medication Adherence (Diabetes Medications, Hypertension (RAS antagonists), and for Cholesterol (Statins)) (Part D)
* Obsolete NDCs (Part D)
 

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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