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Medicare Advantage plans get a rate increase in Centers for Medicare and Medicaid Services final rule released Monday

CMS is also increasing the percent of encounter data in risk scores, a move opposed by stakeholders.

Susan Morse, Senior Editor

Credit: <a href="https://en.wikipedia.org/wiki/United_States_Department_of_Health_and_Human_Services#/media/File:DHHS2_by_Matthew_Bisanz.JPG">Matthew Bisanz</a>.Credit: Matthew Bisanz.

Medicare Advantage plans get a 3.4 percent payment increase in 2019, which is above the 1.84 percent proposed, the Centers for Medicare and Medicaid Services announced late Monday afternoon.

Risk scores for 2019 are expected to increase on average by 3.1 percent, due to an underlying coding trend. CMS has added mental health, substance use disorder, and chronic kidney disease conditions to the risk adjustment model.

For 2019, CMS is calculating risk scores using 25 percent encounter data and 75 percent from risk-adjusted processing system and fee-for-service diagnoses.

[Also: CMS proposes increases in Medicare Advantage payments]

In 2018, CMS used 15 percent encounter data and 85 percent RAPS scores. Stakeholders have opposed an increase in the use of encounter data, saying it is not accurate and puts them at a disadvantage for risk scores.

CMS said the quality of the encounter data has improved so that it is appropriate to move forward with the proposed increase in the data blend.

America's Health Insurance Plans commended CMS on the policies it said would strenghten and improve the plans for America's seniors.

"By finalizing many of its innovative proposals, CMS has acknowledged the value of private sector solutions for Medicare enrollees," said AHIP COO Matt Eyles, who is the incoming CEO. Americans deserve access to quality, affordable and comprehensive healthcare that improves outcomes. That's what Medicare Advantage delivers."

Ninety percent of Medicare Advantage enrollees are satisfied with their plan and enrollment continues to grow, he said.

Other policies released by CMS will save beneficiaries and CMS money on prescription drug costs. CMS is expected to save $10 million in 2019 and low-income beneficiaries will see a reduction in the maximum amount they pay for biosimilars.

Certain low-cost generic drugs will be able to be substituted on plan formularies at any point during the year, so beneficiaries immediately benefit and have lower cost sharing, CMS said.

A rule implemented for 2018 will help beneficiaries save on coinsurance on Part B drugs administered at hospitals that participate in the 340B program, by reducing the amount Medicare pays for those drugs.

The 340B program allows hospitals to buy drugs at a lower cost. Due to CMS's policy change last year, Medicare beneficiaries are currently benefiting from the discounts that 340B hospitals receive, saving an estimated $320 million on out-of-pocket payments, CMS said.

"The Trump Administration is taking steps for seniors with Medicare to save money on prescription drugs," said CMS Administrator Seema Verma. "The steps we are taking will drive more competition among plans and pharmacies to meet the needs of seniors and lower costs."

To combat the opioid epidemic, CMS is setting expectations for safety edits at the pharmacy counter to limit prescriptions for acute pain to a seven-day supply.

Opioid policies includes permitting Part D sponsors to require beneficiaries at risk of addiction or overuse to use only selected prescribers or pharmacies for opioid prescriptions.

CMS is increasing competition among plans by removing the requirement that certain Part D plans have to "meaningfully differ" from each other, making more plan options available.

It is also increasing competition among pharmacies by clarifying the "any willing provider" requirement, to increase the number of pharmacy options for beneficiaries.

More supplemental benefits are covered in the Medicare Advantage program including additional services for non-skilled in-home support and other assistive devices.

"This is an historic and long-awaited move by CMS to recognize how important non-medical home care can be for maintaining the health of older adults," said Seth Sternberg, CEO and co-founder of Honor, a non-medical provider. "Home care workers are professional caregivers that can spot and prevent problems before they lead to complications or unnecessary hospitalizations, and should be a central part of Medicare Advantage providers' care team."

CMS is expanding the definition of "primarily health related."

Under the new definition, the agency will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.

Insurers get a break from mailing notices in a Patients Over Paperwork incentive. CMS will permit plans to use notice of electronic posting, with printed copies to be sent upon request.

CMS is encouraging insurers to have data release platforms for their enrollees to improve transparency and in the future is considering rulemaking to require adoption of such platforms under the My Healthy Data initiative.

"We're giving plans the flexibility they need to give patients more choice," Verma said. "For beneficiaires at high risk, we expect all sponsors to implement a real time coordination program."

[Also: AHIP asks CMS to change Medicare Advantage payment formula]

The final rule does not implement a request by America's Health Insurance Plans to exclude the cost data of beneficiaries who are only enrolled in Medicare Part A.

Twitter: @SusanJMorse

Email the writer: susan.morse@himssmedia.com

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