Tag Archives: CMS

What should qualified health plans understand about the CMS Quality Rating System?

The Centers for Medicare and Medicaid Services (CMS) issued a Quality Rating Information Bulletin in August 2019, announcing that public display of 2019 quality rating information by all exchanges will begin during the individual market open enrollment period for the 2020 plan year. The initial guidance regarding this program was released in October 2018, and there have been several deadlines for health plans to meet throughout 2019. However, there may be some uncertainty for both plans and consumers regarding what the quality scores represent, how they are developed, and/or how they may be used now or in the future.

This paper by Milliman’s Dustin Grzeskowiak, Darin Muse, and Daniel Perlman provides some clarity on these topics, general background on the program, and a summary of the 2019 quality information published by CMS in the public use file.

What’s new about Medicare Plan Finder?

Medicare Plan Finder, provided by the Centers for Medicare and Medicaid Services (CMS), summarizes plan information to allow beneficiaries to quickly compare plan options on a computer or mobile device. CMS recently overhauled Medicare Plan Finder, retaining much of the tool’s valuable and highly accessible information while aiming to improve the transparency and the overall user experience.

In this paper, Milliman actuaries Michelle Klein and Matt Kranovich discuss in more detail several key changes to Medicare Plan Finder—and potential unintended consequences—and offer suggestions as to how those changes could potentially affect Medicare Advantage organizations.

Regulatory roundup

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

Executive Order protecting and improving Medicare issued

President Donald Trump signed an Executive Order stating it would improve private Medicare plans for seniors. The Executive Order is expected to bolster Medicare Advantage, offer more affordable plan options, encourage wider use of telehealth services, promote wellness benefits, and bring payments in Medicare fee-for-service programs in line with payments for Medicare Advantage.

To learn more, click here.

Opportunity for states to participate in a wellness program demonstration project

The Centers for Medicare and Medicaid Services (CMS), in consultation with the U.S. Departments of Labor (DOL) and the Treasury, announced an opportunity for states to apply to participate in a wellness program demonstration project. Participating states may implement nondiscriminatory health-contingent wellness programs in the individual market, as described in section 2705(l) of the Public Health Service Act (PHS Act).

For more information, click here.

Primary Care First payment model overview

The new voluntary payment model of the Center for Medicare and Medicaid Innovation (CMMI), Primary Care First (PCF), will debut in 2020. As its name indicates, the new model focuses on primary care. PCF aims to offer additional flexibility in how physicians care for patients while holding them accountable for patient outcomes. It also offers providers a payment model option for accepting accountability for the high-need seriously ill population. Milliman consultants Raheel Sohail, Cory Gusland, and Daniel Henry provide an overview of the payment model in their paper “Early thoughts on the Primary Care First model.”

Guidance for Medicaid managed care MLR calculations

In May 2019, the Centers for Medicare and Medicaid Services (CMS) released an Informational Bulletin clarifying how payments to subcontracted vendors should be accounted for in the medical loss ratio (MLR) calculation required by 42 CFR §438.8 as established by the Medicaid and Children’s Health Insurance Program (CHIP) managed care final rule published in May 2016. In the May 2019 bulletin, CMS focuses on the responsibilities of a subcontractor in providing data and the proper accounting of subcontractor payments for purposes of MLR reporting. The provisions outlined in the May 2019 bulletin apply to all subcontractor relationships, but CMS specifically highlights pharmacy benefit manager (PBM) arrangements that may include “spread pricing” and rebate retention.

The final rule requires states to complete MLR reporting for the first contract period beginning on or after July 1, 2017. It is anticipated that many state Medicaid programs will be providing MLR data for CMS for the first reporting period during calendar year 2019, so states should clearly articulate this guidance to contracted managed care plans and modify data collection processes and vehicles to collect the necessary detail to meet CMS requirements.

The final rule also stipulates that a managed care plan must ensure that its subcontractors fully comply with all terms and conditions of its contract with a state and must comply with all applicable Medicaid law and regulations. One area in which managed care plans commonly use subcontractors is in the delivery of pharmacy benefits. PBMs maintain and develop pharmacy networks, negotiate rebates with drug manufacturers, and perform other activities that support managed care plans’ obligations under contracts with states. In this paper, Milliman’s Paul Houchens, Ian McCulla, and Amber Kerstiens discuss reporting requirements for PBMs and other third-party vendors under this new CMS guidance.

How will changes to Medicare Part D risk score model affect health plans?

In April, the Centers for Medicare and Medicaid Services (CMS) released details for the 2020 Medicare Part D pharmacy hierarchical condition categories (RxHCC) risk score model. The model change will affect health plans differently based on demographics and other factors. Overall the model change increased low-income risk scores and decreased non-low-income risk scores.

In this paper, Milliman’s Adrian Clark and David Koenig summarize the changes in member risk scores resulting from the risk score model update. They also quantify the model change using three separate metrics: the change to the model coefficients, the overall change in risk score for a nationwide population by key enrollee characteristics, and the change to the normalization factor.