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AHIP advocacy group questions Medicare Advantage payment changes

Also, seven new insurers join America's Health Insurance Plans including Bright Health; CareFirst BlueCross BlueShield.

Susan Morse, Managing Editor

The Coalition for Medicare Choices, an advocacy organization connected with America's Health Insurance Plans, is calling on the government to keep Medicare Advantage plans affordable as the Centers for Medicare and Medicaid Services proposes changes the coalition says could limit health coverage, reduce benefits and raise premiums.

This spring, CMS is expected to announce the Medicare Advantage capitation rates and final payment policies for 2020, including the final risk adjustment model.

The original comment deadline has been delayed until April 30, AHIP said.

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CMS uses risk adjustment to make payments based on the health of beneficiaries. CMS's proposed changes reflect a requirement from the 21st Century Cures Act to take into account the number of conditions an individual beneficiary may have.

AHIP,  citing analysis from Oliver Wyman, said changing risk scores to reflect the total number of conditions a patient has could lower risk scores for dual-eligible patients, which would reduce payment to MA plans.


AHIP also questions Medicare Advantage risk adjustment data validation audits, in which CMS plans to modify the RADV audits without a fee-for-service adjuster. The FFS adjuster is based on coding errors in the traditional Medicare population.

A recent study by the Wakely Consulting Group said this could cause highly random and arbitrary results. As one example, based on a simulation of the RADV process, a single unsupported cancer diagnosis could increase the payment penalty by 16.7 percent, the study said.

AHIP has also raised concerns and has long advocated for CMS to fix what it calls the incorrect funding formula used to calculate county benchmark rates. The funding formula leads to inaccurate MA payment rates and lower program funding in certain counties, AHIP said.

"We strongly believe CMS should update its county benchmark calculation in the 2020 call letter," AHIP said.


Seven new members have joined AHIP: Bright Health; CareFirst BlueCross  BlueShield; Central States Health and Life Company of Omaha; Fidelity; First Medical Health Plan; Inland Empire Health Plan; and National Guardian Life.

Within the past few years, AHIP has lost as members large insurers UnitedHealth, Aetna and Humana.


"These new members represent the breadth, depth and variety of healthcare choices that Americans need to protect their health and financial security," said Matt Eyles, president and CEO of AHIP.