CMS has released a proposed rule concerning several administrative and technical changes to Medicare Advantage (MA) and Medicare Part D plans. Many of the changes were mandated by the Bipartisan Budget Act of 2018 (BBA), while others are intended to reduce administrative burden on providers, plans, and beneficiaries. The rule will appear in the November 1, 2018 edition of the Federal Register.

Comments on the rule are due Monday, December 31, 2018.

Beneficiaries Gain Access to Expanded Telehealth Benefits in 2020

• The BBA allows MA plans to offer expanded access to telehealth benefits, starting in the 2020 plan year.
• The benefits may be offered as part of the “basic benefit package” meaning MA plans may build costs into their bids, and the costs will be subsidized through the Medicare program.
• Benefits must be more generous than those currently allowed under the Medicare telehealth benefit, but must be among those designated by CMS as “appropriate” to furnish via telehealth.
• MA plans cannot restrict coverage of a specific service to telehealth; if a service is covered via telehealth, the same service must also be covered in-person.
• MA plans will continue to be able to offer coverage of other telehealth services beyond the current and expanded telehealth as supplemental benefits, meaning costs may not be incorporated into their bid submissions, and must be borne between the beneficiaries and the plan.

Unified Grievance and Appeals Process, Capitated Payments for Medicaid Benefits for D-SNPs Start in 2021

• The BBA also requires CMS to develop a unified grievance and appeals process for Dual Eligible Special Needs Plans (D-SNPs) and establish new standard of integration between Medicare and Medicaid benefits for beneficiaries enrolled in a D-SNP.
• The standards for integration require all D-DNPs to cover Medicaid benefits through a capitated payment from a state Medicaid agency or by meeting a minimum set of requirements established by CMS. CMS is soliciting input from stakeholders on what those requirements should be in this proposed rule.
• D-SNPs that fail to meet these requirements starting in the 2021 plan year may face enrollment sanctions
• The unified grievance and appeals process must be finalized by April 1, 2020 and the procedures must be used in plan year 2021 and beyond.

Updates for Some Star Ratings Measure Specifications Proposed for 2020

• The 2019 Call Letter updated regulations concerning the MA and Part D Quality Rating Program (Star Ratings), especially additional transparency surrounding the mechanisms for removal of measures from the program.
• In this proposed rule, CMS is proposing updates to the cut points for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, as well as the specifications for selected measures for the 2022 and 2023 Star Ratings.
• The proposed rule also includes changes to rule for calculating a plan’s Star Ratings in the case of extreme and incontrollable circumstances.
• If finalized, the proposed changes would impact the 2020 data collection (measurement) year.

Prescriber Preclusion List Changes Could Add Some Prescribers Faster, Clarifies Beneficiary Notice Requirements

• In April 2018, CMS formally eliminated requirements that MA and Part D plans only cover prescriptions written by prescribers meeting Medicare enrollment requirements, regardless of whether the provider accepted Medicare reimbursement.
• Instead, CMS established a “preclusion list” which would contain the names of prescribers meeting certain risk factors and for which payment for prescriptions written by these providers would be denied.
• While there is an existing appeal process for providers and entities placed on the preclusion list, this process means that it may take up to 9 months for a provider or entity to be placed on the list. CMS is proposing that if a provider or entity has their ability to bill Medicare revoked, they must also be placed on the preclusion list within 5 months.
• The agency is also clarifying that providers will not be placed on the preclusion list until their have exhausted their first level of appeal; CMS is proposing to add this provision to the regulatory text. However, if a provider is excluded from Medicare based on an order from the Office of the Inspector General (OIG), that provider would be immediately added to the list, regardless of their appeal status.
• MA and Part D plans will be required to notify beneficiaries that his or her prescriber has been added to the preclusion list within 30 days of the addition. Plans must then wait 60 days before denying claims for prescriptions written by that prescriber.
• CMS is proposing to continue to implement the preclusion list, as initially finalized in April 2018, on January 1, 2019, and to implement the proposed revisions in this rule, if finalized, on January 1, 2020.

MA Risk Adjustment Data Validation Procedure Changes Could Increase Payment Recovery by $1 Billion in 2020

• CMS has proposed to use extrapolation in Risk Adjustment Data Validation (RADV) contract-level audits, beginning with payment year 2011 contract-level audits and all subsequent audits.
• Additionally, CMS is proposing to not apply a fee-for-service (FFS) Adjustor to audit findings.
• If finalized, CMS estimates that an additional $1 billion in improper payments may be collected in 2020, though that amount is expected to drop to $380 million in subsequent years.