Category Archives: Medicare

An Overview of the Bundled Payments for Care Improvement Advanced Model

In January, the Centers for Medicare and Medicaid Services announced a new voluntary bundled payment model, Bundled Payments for Care Improvement Advanced (BPCI Advanced). This model starts on October 1, 2018, and creates a replacement for the current BPCI initiative. This paper by Milliman consultants Samuel Bennett and Pamela Pelizzari outlines the major provisions of the newly announced BPCI Advanced model.

State of the 2018 Medicare Advantage industry: Stable and growing

Each Medicare Advantage (MA) plan has an associated “value added,” defined as the value of benefits provided to a specific plan’s beneficiaries above traditional Medicare that are not funded through member premiums. This report by Milliman actuaries Julia Friedman and Brett Swanson highlights key changes in beneficiary premiums and benefits for the 2018 MA market. The report also examines the reasons for, and the magnitude of, the decrease in value added within the MA market between 2014 and 2016 as well as the increases in value added in 2017 and 2018. The report aims to assist Medicare Advantage organizations in making strategic decisions during 2019 bid preparations.

Medicare Advantage star ratings: Expectations for new organizations

Successful Medicare Advantage organizations maximize federal revenue to provide enhanced benefits and/or reduced premiums to their members, which ultimately improves marketability with the aim of increasing membership. Organizations entering the Medicare Advantage market should be aware of the current star rating climate as well as short- and long-term star rating and revenue considerations. This report by Milliman consultants provides perspective.

Medicare Advantage’s transition from RAPS to EDS risk scores

In 2017, there were many changes to Medicare Advantage (MA) risk adjustment as the transition continued from Risk Adjustment Processing System (RAPS) data to Encounter Data System (EDS) data. MA organizations will also experience complexity and challenges in payment year (PY) 2019.

This article by Milliman’s Deana Bell, David Koenig, and Charlie Mills compares EDS and RAPS risk scores and details some of the program highlights from the past 12 months:

• A 25% EDS weight for PY 2017
• EDS file layout updates
• PY 2016 EDS deadline extension and change to payment timing
• PY 2017 RAPS and EDS deadline extensions
• Including inpatient RAPS diagnoses in EDS risk scores for PY 2019

How will the budget bill affect Medicare Part D’s donut hole?

The Bipartisan Budget Act of 2018 enacted key changes to Medicare Part D that will affect the program’s coverage gap—the “donut hole”—starting in 2019. The changes to the coverage gap have several financial implications for Part D stakeholders. In this article, Milliman consultants Adam Barnhart, Gabriela Dieguez, and David Mike explain the financial impact the bill will have on beneficiaries, employers, pharmaceutical manufacturers, the federal government, and plan sponsors.

Medicare Part D DIR: Direct and indirect remuneration explained

Direct and indirect remuneration (DIR) has grown to be an important provision that Medicare Part D plan sponsors use to reduce their claim liabilities and thus member premiums. As DIR continues to increase, it is important for Part D sponsors to consider the effect of potential regulatory changes on plans’ bottom lines and operations. Milliman actuaries Deana Bell and Tracy Margiott provides some perspective in this article.