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CMS proposes increases in Medicare Advantage payments

Encounter data will make up 25 percent of risk score calculations.

Susan Morse, Senior Editor

The Centers for Medicare and Medicaid Services has proposed a 1.84 percent increase, on average, in Medicare Advantage payments for 2019.

Last February, CMS proposed average payment increases of just .45 percent.

[Also: CMS gives bigger increase to Medicare Advantage payment rates for 2018]

Risk scores, which affect payment, are expected to increase by 3.1 percent. The risk scores for 2019 will be 75 percent based on fee-for-service data under the risk-adjusted payment system, or RAPS, and 25 percent based on encounter data submitted by MA organizations.

In 2018, the blend was 85 and 15 percent, respectively.

CMS in the past has received numerous comments based on concerns over the use of encounter data, which is generated by healthcare providers and documents both diagnosed clinical conditions as well as the services and items used to treat these conditions.

America's Health Insurance Plans said this past year that two studies showed that risk scores based on encounter data were 4 to 16 percent lower than those using the traditional system.

The 2019 MA payment increase promotes stability and gives insurers the resources to support beneficiaries enrolled in private Medicare plans, according to CMS. 

"Our priority is to ensure that our seniors have more choices and lower premiums in their Medicare health and drug plans," said CMS Administrator Seema Verma. 

In addition, CMS announced new steps to ensure new patient-doctor-plan communication in combating the opioid crisis. The agency is designing the framework of several new policies that would give health plans additional tools to better manage chronic overuse among beneficiaries. 

CMS has also redefined health-related supplemental benefits to increase coverage of non-skilled in-home supports, portable wheelchair ramps and other assistive devices and modifications when patients need them. 

CMS has previously not allowed an item or service to be eligible as a supplemental benefit if the primary purpose included daily maintenance. Under the new policy, CMS would allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions and/or reduce avoidable emergency room utilization. 

Enrollment in Medicare Advantage is at an all-time high, as approximately one-third of all Medicare beneficiaries are enrolled in a plan.

Medicare Advantage remains a popular choice among beneficiaries and has high satisfaction ratings. In 2018, Medicare Advantage and Part D premiums decreased and the number of Medicare Advantage plans available to choose from across the country increased from about 2,700 to more than 3,100, CMS said.

Comments must be submitted by March 5. The 2019 final rate will be published on April 2.

Twitter: @SusanJMorse
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