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CY 2016 Medicare Advantage and Part D Final Call Letter

On April 6, 2015, CMS released the Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter.

CMS continues to place a lot of focus on Value-Based contracting to reduce costs and improve health outcomes. Before making changes, CMS must first test and evaluate new payment models effectively. They will begin working with plans participating in Medicare Advantage to better understand, through a voluntary effort, the extent to which they use value-based payment models to compensate providers offering services to their enrollees.

Specifically on the Star Program, CMS finalized a new timeline for conducting terminations of plans that have received star ratings of less than three stars in three consecutive years. Plans will be subject to termination for the first time with the release of the CY 2016 star ratings and will receive a non-renewal notice in February 2016. CMS will add Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Reviews (Part D) to the 2016 Star Ratings. This measures Completion Rate for Comprehensive Medication Review (CMR), which is used to calculate the percentage of beneficiaries who met eligibility criteria for the MTM program and who received a CMR with a written summary in CMS standardized format. Star program updates were also discussed in our previous blog posted on March 20, 2015.

CMS will continue to work with stakeholders to identify a range of options for improving existing notices, including providing examples that satisfy notice requirements. CMS will continue enforcing the regulations using existing guidance and interpretations that require plans to include clear and detailed information related to the specific reason coverage is being denied.

CMS will be revising Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Medicare Prescription Drug Benefit Manual to include guidance on what constitutes “reasonable attempts” on the part of a plan to obtain clinical documentation.

CMS reiterated SNPs are required to perform a comprehensive initial HRA that includes assessment of each enrollee’s physical, psychosocial, and functional needs within the first 90 days of enrollment and conduct reassessments annually thereafter. CMS believes the CDC Model HRA and the other components of the AWV are sufficiently comprehensive to identify the medical, functional, cognitive, psychosocial and mental health care needs of enrollees, including those in SNPs. CMS strongly encourages MAOs to adopt the components in the CDC Model HRA beginning in CY 2016.

In the draft Call Letter, CMS proposed changes to the Star program to ensure that plans are not unfairly penalized for enrolling dual eligible or low-income beneficiaries. After serious consideration of all comments received in response to the draft Call Letter, CMS has decided not to move forward with the proposed interim step to reduce the weights on a subset of measures for the 2016 Star Ratings Program. While CMS acknowledges the unique challenges in attending to the needs of traditionally underserved subsets of the population, they do recognize the solution must focus on the beneficiaries.

The final letter continues CMS’ focus on compliance and quality outcomes. CMS is emboldened by the fact that the Star demonstration project paid huge dividends and has essentially silenced the doomsdayers. In just a few short years, 4 + Star plans have gone from 20% to 40%, with members in such plans rising from 20% to 60%. With this record of success, CMS will continue to refine both compliance and quality mandates to drive poor performers out.

2016 MA-PD Star Bonus Changes

CY2016 Changes Star Measures
Additional Star Measure (1)
-Medication Therapy Management Program Completion Rate for Comprehensive Medication Reviews (Part D)
Retirement of Star Measures (4)
-Cardiovascular Care: Cholesterol Screening
*Diabetes Care: Cholesterol Screening
*Diabetes Care: Cholesterol Controlled
*Appropriate Treatment of Hypertension in Diabetes
Return of Star Measures (3)
-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 (1)
-Improving Bladder Control (Part C)
Changes to the Star measure methodology (11)
-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 Minor modifications (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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