Tag Archives: CMS

Regulatory roundup

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

Agencies release final rule on short-rerm, limited duration health insurance
The Department of Labor’s (DOL) Employee Benefits Security Administration (EBSA), the Department of Treasury, and the Department of Health and Human Services (HHS) issued a final rule amending the definition of short-term, limited-duration health insurance that individuals may purchase. The final rule permits insurers to sell policies that cover periods longer than the three-month maximum permitted under the Patient Protection and Affordable Care Act (ACA), allowing for an initial period of 364 days and for renewals of up to 36 months.

To read the entire final rule, click here.

Medicare Part D premiums continue to decline in 2019
The Centers for Medicare & Medicaid Services (CMS) announced that the average basic premium for a 2019 Medicare Part D prescription drug plan is projected to decline for the second year in a row. Earlier this year, CMS announced several changes in the Part D program aimed at further empowering Part D plans to drive a hard bargain with drug manufacturers and lower the cost of prescription drugs. CMS has been working to ensure that Medicare Part D plans can leverage all of the tools that are available to commercial plans in negotiations.

To learn more, click here.

CBO publishes report on the cost related to employer mandate repeal and Cadillac tax delay
The Congressional Budget Office (CBO) released estimates related to the cost of the “Employer Relief Act” (H.R.4616), which would suspend the collection of penalties on large employers that decline to offer qualifying health insurance coverage for plan years 2015-2018 and delay implementation of the excise (“Cadillac”) tax on high-premium insurance plans by one year. The report assessed the costs based on the legislative text approved by the House Ways and Means Committee on July 11.

To learn more, click here.

CMS guidance presents Medicare Advantage plans with new LTC benefits considerations

In April, the Centers for Medicare and Medicaid Services (CMS) provided guidance for Medicare Advantage (MA) plans regarding the scope of the “primarily health related” supplemental benefit definition. The guidance clarified the types of long-term care (LTC) benefits that MA plans can provide as a supplemental benefit for individuals needing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

These plans face various challenges as they contemplate offering LTC coverage under the new CMS definition for primarily health related supplemental benefits. In this paper, Milliman’s Chris Giese and Al Schmitz examine some of these challenges and explain what MA plans must consider to make choices that benefit both plans and consumers.

Don’t TrOOP off the cliff

With the passage of the Patient Protection and Affordable Care Act (ACA) came a modification to how the true out-of-pocket (TrOOP) amount was calculated through 2019. With significant changes to Medicare Part D from the Bipartisan Budget Act of 2018 and the Centers for Medicare and Medicaid Services (CMS) Final Rule, one provision from the ACA that has gone largely unnoticed is the forthcoming TrOOP cliff in 2020, for which plan sponsors should prepare. Milliman actuaries Van Phan and Todd Wanta provide some perspective in this paper.

Regulatory roundup

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

2018 Social Security and Medicare Trustees Reports released
The Social Security and Medicare Boards of Trustees issued their annual financial review of the programs. The projections indicate that income is sufficient to pay full scheduled benefits until 2026 for Medicare’s Hospital Insurance program, until 2032 for Social Security’s Disability Insurance program, and until 2034 for Social Security’s Old Age and Survivors Insurance program. The Supplementary Medical Insurance (SMI) Trust Fund remains adequately financed throughout the projection period, but only because SMI has unlimited access to general revenues.

For more information, click here.

The CMS RDS Center changes its location for retiree and cost report files
The Retiree Drug Subsidy (RDS) Center of the Centers for Medicare and Medicaid Services (CMS) is changing the location where retiree and cost report files are sent via Connect:Direct. By the end of 2018, all files that are currently sent to the RDS Center via Connect:Direct must be sent to the new location. This change only impacts vendors that submit data to the RDS Center via Connect:Direct and does not affect vendors that submit data using the RDS secure website.

For more information, click here.

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.

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.