For Medicare Advantage and Part D plans, CMS’ advance notice of proposed reimbursement and other changes and the draft call letter are eagerly anticipated. This year’s gives the usual glimpse into CMS’ thinking about these programs. (CMS Announcement) A headline issue is always what the reimbursement change will be for the next year, in this case 2015. It appears that the median change will be less of a decrease than was feared, perhaps 2% to 3%. The formula is complex, and is developed county by county, so the final impact for a specific MA or Part D plan is a very individual calculation. In 2015, the “demonstration” under which plans with 3 star ratings got bonuses will end and only plans with 4 or more stars will be eligible for a bonus. Despite cumulative reductions in MA reimbursements of almost 10% since 2010, enrollment has grown to 30% of all beneficiaries. CMS is trying to limit financial impacts on beneficiaries, as it is reducing cost-sharing in the donut hole for Part D and limiting both out-of-pocket maximums and monthly premium increases in MA. While the risk adjustment methodology itself will be unchanged in 2015, the downward adjustment for differential coding in MA versus fee-for-service Medicare will be increased and overall risk score baselines are being decreased as more people age into Medicare each year and these people are in better health than the overall pool of beneficiaries. Related to the risk score issue is the practice of many MA plans to conduct or contract for a home assessment which is designed to pick up all health problems of a beneficiary. CMS perceives that these visits are often largely for purposes of improving diagnoses for risk-scoring purposes and not necessarily to help with ongoing care or health management. It therefore is requiring that any diagnoses picked up in these home assessments must have an in-person follow-up visit with a provider in order to be used for risk-scoring purposes.
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About this Blog
The Healthy Skeptic is a website about the health care system, and is written by Kevin Roche, who has many years of experience working in the health industry. Mr. Roche is available to assist health care companies through consulting arrangements through Roche Consulting, LLC and may be reached at [email protected].
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