Medicare Advantage and Part D actuarial compliance considerations

Operating Medicare Part C and Part D plans has become increasingly complicated. The Affordable Care Act and a growing number of rules and regulations added each year have heightened the complexity and associated compliance burden for the health insurance companies that sell and administer these plans.

Actuaries are instrumental in developing the bids that plan sponsors submit annually to the Centers for Medicare and Medicaid Services (CMS). Those bids include a plan benefit package and Part C and Part D bid pricing tools. The bid submission also includes a set of supporting documentation describing how the financial projections were developed and demonstrating compliance with the many bidding rules.

During desk review, CMS independently confirms that the bids pass compliance tests. It is critical that plan sponsors understand the tests and confirm compliance before bids are submitted.

In this paper, Chris Girod and Shyam Kolli discuss a relatively narrow area of rules that is sometimes loosely referred to as actuarial compliance. This information can be useful for actuaries and other professionals who are tasked with understanding and following the many rules and regulations as they relate to Parts C and D.

Utilizing LTC projection methods

Estimating future claims usually entails using historical data as a starting point to develop an assumption about the future. Developing financial projections of long-term care (LTC) insurance utilization is similar. In this article, Milliman’s Jeremy Hamilton and Tim Kempen focus on two methods for using current utilization levels to develop utilization assumptions for future durations: an “average utilization” method and a “distribution” method. They also outline the advantages and disadvantages of both methods.

Regulatory roundup

More healthcare-related regulatory news for plan sponsors, including links to detailed information.

IRS inflation adjusted amounts for HSAs in 2019
The Internal Revenue Service (IRS) released Revenue Procedure 2018-30, which provides the inflation-adjusted amounts for health savings accounts (HSAs) for calendar year 2019. The updated limits specify the maximum annual contributions to HSAs that may be tax deductible, as well as the minimum deductibles and the maximum out-of-pocket expenses allowed under qualifying high-deductible health plans (HDHPs).

For more information, click here.

Opioid prescription patterns affect risk scores

Opioid prescribing nationwide peaked in 2012 at over 80 prescriptions per 100 persons. Between 2012 and 2016, the prescribing rate decreased by almost 20%. Even after this decline, 19% of the U.S. population filled at least one opioid prescription during 2016.

As opioid prescribing declined, many doctors switched to other pain relief drugs. The change in prescribing patterns has potential implications for risk adjustment, because some of the drugs now being used for pain relief were previously flagged in pharmacy-based risk adjustment models as associated with high cost conditions such as multiple sclerosis.

This brief by Christine Mytelka, Melanie Kuester, Colin Gray, and Lucas Everheart provides data on the decline in opioid prescribing and the increased use of other non-opioid pain relief drugs. Additionally, it addresses the corresponding effect that changing prescribing patterns may have on evaluating population health and risk-adjusted payments in risk-based managed care programs.

Infographic: Paid family leave requirements by state

Lobbyists and lawmakers across four states—Hawaii, Massachusetts, Connecticut, and Colorado—are considering paid family leave bills, with Connecticut’s legislation awaiting only a floor vote. If passed, the state would join California, New Jersey, Rhode Island, and New York in offering paid family leave benefits to its workers; Washington state and the District of Columbia will begin offering benefits in 2020.

Of those that offer benefits, the details of each paid family leave program vary from state to state. This infographic summarizes paid family leave requirements that employers must consider when adding these benefits to their health and welfare programs. To learn more, read Marcella Giorgou’s article “Paid family leave gaining traction in the United States.”

Medicare ACO assignment methodology change may have unintended consequences

A number of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) experienced significant, unanticipated changes in their 2017 performance year historical benchmarks and performance expenditures. These changes were not consistent in direction or magnitude. The exclusion of some nursing facility visits from MSSP assignment, effective in 2017, is the likely cause of the unanticipated changes.

The Centers for Medicare and Medicaid Services (CMS) now excludes nursing facility provider evaluation and management visit codes with place of service (POS) 31 as a qualifying claim type for beneficiary assignment. This assignment methodology change is referred to as the POS 31 exclusion. It started with the 2017 performance year and is also applied to the corresponding baseline years for all MSSP tracks.

Some ACOs likely lost and some likely gained costly nursing facility beneficiaries due to the new exclusion in both the baseline and performance years. The POS 31 exclusion only works as intended if POS codes correctly differentiate between Part A skilled nursing facilities and other nursing facility patient services. Unfortunately, our analysis across the Medicare 5% sample indicates that POS codes for nursing facility-based claims may not always be reliable.

To read more about the possible impact of these changes, read this article by Tia Sawhney, Kate Fitch, and Cory Gusland.