Tag Archives: Medicare

Evolving landscape of preventive services

The introduction of the Patient Protection and Affordable Care Act (ACA) brought about many legislative changes intended to improve the health of people in the United States. One such change was the introduction of mandatory coverage with no cost sharing for services determined to be “preventive.” Some examples of the services included on the A and B Recommendations lists of the U.S. Preventive Services Task Force (USPSTF) are blood pressure screening for adults, depression screening for adolescents and adults, intimate partner violence screening for women of reproductive age, and skin cancer behavioral counseling.

The USPSTF regularly updates its recommendations and the ACA preventive services list has been modified many times since the introduction of the ACA in 2014. In this paper, Milliman’s Barbara Collier and Michelle Klein examine the evolution of preventive services. They also discuss how these services have been impacted by the COVID-19 pandemic.

Overview of Part D Senior Savings Model and impact on out-of-pocket costs

The Centers for Medicare and Medicaid Services (CMS) recently announced the Part D Senior Savings Model, a new Medicare Part D initiative created to reduce beneficiary cost sharing for insulin products. It is designed to make insulin product cost sharing more affordable and predictable for Medicare beneficiaries. Plans opting to participate in this voluntary Model are required to provide insulin at a maximum $35 copay per 30-day supply in the first three phases of coverage under Medicare Part D.

The new Model also modifies how supplemental benefits, such as a $35 copay, are applied in the coverage gap. Under the current Part D benefit design, if a plan sponsor provides supplemental benefits on applicable drugs in the coverage gap, the manufacturer coverage gap discount of 70% applies only to the beneficiary cost sharing. This increases the plan’s liability in the coverage gap and may discourage a plan from offering supplemental gap benefits for applicable drugs. Through the Model, however, the 70% discount paid by the manufacturer will apply prior to any supplemental benefits.

In this paper, Milliman professionals explore the impact of the Model on patient out-of-pocket costs. Using Milliman’s Part D Claims Database, they apply the Model benefits to observed experience of non-low-income beneficiaries on insulins.

2020 cost-of-living adjustments for Medicare

The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has announced cost-of-living adjustments (COLAs) for Medicare Parts A and B for 2020. In April this year, CMS announced the 2020 amounts for the Medicare Part D standard prescription drug benefit.

For more perspective, read this Milliman Client Action Bulletin.

What was the impact of the Next Generation ACO Model on Medicare spending in 2016?

In September 2016, the Center for Medicare and Medicaid Innovation (CMMI) selected NORC at the University of Chicago to conduct an independent evaluation of the Next Generation Accountable Care Organization (NGACO) Model program. On August 27, 2018, CMMI released NORC’s first report on the findings of its evaluation, which included NORC’s estimate of the impact of the NGACO program on Medicare Part A and Part B spending (gross impact) in 2016. NORC defined the net impact of the program by combining this gross impact with the results of the NGACO program’s shared savings and losses. These results were published by CMMI in October 2017 (i.e., shared savings and losses).

In this paper, Milliman consultants combine the aggregate gross impact of each of the NGACOs shown in the NORC report with the shared savings/(loss) results of each NGACO to calculate the net impact of each individual NGACO.




Modified HRRP benchmark may affect provider reimbursements

The 21st Century Cures Act was passed into law in 2016 with the express purpose of decreasing hospital readmissions. In connection with the legislation, the Centers for Medicare and Medicaid Services (CMS) announced changes to the Hospital Readmission Reduction Program (HRRP) in fiscal year (FY) 2018, finalizing those changes with the release of the FY 2019 Inpatient Prospective Payment System (IPPS) final rule. The program has been modified to incorporate measurements of the socioeconomic status of patients served by each hospital.

CMS has altered the HRRP benchmark that readmission rates are measured against. The new rule groups hospitals into “peer groups” that are defined in terms of the proportion of patients with dual eligibility for both Medicare and Medicaid. Rather than one benchmark applying across the board to all hospitals, different benchmarks will now apply for each peer group.

The changes to HRRP starting in FY 2019 could have significant monetary impacts to a provider’s reimbursement. Milliman’s James Lucas illustrates the effects in his article “Fiscal year 2019 HRRP impact to hospitals.”




Critical Point podcast: Alternative Payment Models 101

In the latest Critical Point podcast, healthcare consultant Pamela Pelizzari discusses alternative payment methods, bundled payment, accountable care organizations (ACOs), and more. She explains in more detail what is meant by the term alternative payment model and why people should be interested. Pamela also explains how ACOs fit in and how alternative payments fit with Medicare and Medicaid.

To listen to this episode of Critical Point, click here.