The Center for Medicare and Medicaid Services (CMS) has released the plan year 2020 Draft Call Letter outlining proposed changes to policies impacting Medicare Advantage (MA) and Part D prescription drug plans (PDPs). The agency is continuing to focus on changes that will modernize the MA and PDP benefits to make the plans operate closer to plans available to non-Medicare members. Opioids are also a continued focus of the policies for 2020. CMS is predicting that the average MA plan will see a 1.6% increase in revenue due to the policies included in the proposal.
Comments on the proposals are due to CMS by Friday, March 1, 2019. The final Call Letter is expected to be released no later than Monday, April 1, 2019.
New Risk Adjustment Model Implementation Continues, CMS Seeks Comments on Risk Adjustment for Pressure Ulcers and Dementia
- The 21st Century Cures Act requires CMS to overhaul the current MA risk-adjustment process to better account for beneficiaries with multiple comorbid conditions.
- CMS is proposing two alternate risk adjustment models for 2020 and seeks comments from stakeholders on which model would be most appropriate:
- The 2019 model that was proposed, but not finalized, and which counts the number of conditions that a beneficiary has that are also in the risk adjustment model (“payment conditions”); or
- A model that includes the payment condition count formula from the 2019 proposal and adds conditions for pressure ulcers and dementia.
- For 2020, the risk adjustment will include a 50%/50% blend of the 2017 risk adjustment model and the new risk adjustment model.
Plans May Offer Non-Health Related Supplemental Benefits in 2020 to Chronically Ill Beneficiaries
- The Bipartisan Budget Act of 2018 allows MA and PDP plans to offer non-primarily health-related supplemental benefits to beneficiaries with chronic illnesses, starting in 2020.
- These supplemental benefits may include transportation for non-medical needs, home-delivered meals, food and produce.
- Benefits may be based on an individual beneficiary’s specific medical condition and needs.
- Plans are expected to develop objective criteria and maintain detailed documentation for determining when a beneficiary is “chronically ill” and eligible for the benefits.
- Plans must include supplemental benefit details in bid submissions and the benefits must be ultimately approved by CMS.
Agency Warns Plans on Generic Tiering Practices, Solicits Comments on More-Restrictive Tiers
- As in previous years, the agency is using the Call Letter to warn plans that they are expected to include no more than 25% generic drugs on a plan’s non-preferred brand tier, and that tiers labeled as “brand” or “generic” will contain a majority of those products.
- Additionally, CMS is soliciting comments from stakeholders on the possibility of “discouraging or prohibiting” plan sponsors from placing generic drugs on a tier labeled “brand” and requiring plans to place generic drug formulations on a generic tier once they become available.
- This policy change would be in keeping with general administration pressure to maximize generic utilization across Medicare.
- CMS is seeking comments and feedback from stakeholders on how such a policy could:
- Impact a plan’s ability to meet actuarial equivalence tests in the bid pricing tool;
- Influence beneficiary premiums or cost-sharing;
- Change formulary drug coverage and benefit designs; and
- Whether such a policy could be implemented for 2020.
- CMS is also seeking comments on whether biosimilars should be treated as generics under such a policy.
CMS Continues Efforts to Combat Opioid Abuse in MA and Part D
- CMS is encouraging Part D plan sponsors to put naloxone products on generic tiers and states that benefit designs that inappropriately restrict access to these products for clinically appropriate beneficiaries will not be approved
- CMS is also encouraging co-prescribing naloxone with opioid prescriptions for beneficiaries who have an increased risk of overdose
- The call letter also includes a reminder to MA organizations that supplemental benefits can include medically-approved non-opioid pain management treatments such as peer support services, non-Medicare covered chiropractic services, and acupuncture.
- CMS is proposing to implement the revised Pharmacy Quality Alliance (PQA) opioid overuse measures, which the agency believes will help better track of trends in opioid overuse in Part D
- Finally, CMS is seeking feedback from sponsors and stakeholders on ways to improve and expand the Overutilization Monitoring System (OMS) Criteria to help identify potential at-risk beneficiaries for contract years 2021 and beyond.
Measure Updates for 2020 Star Ratings
- Medication Adherence for Cholesterol (Statins) (Part D): as finalized in the CY 2019 call letter, the measure will exclude beneficiaries with ESRD for 2020.
- Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Reviews (CMR) Measure (Part D): as finalized in the CY 2019 call letter, this measure will include beneficiaries enrolled in the program for less than 60 days in the denominator and numerator if the beneficiary received a CMR within this timeframe.
- Medication Adherence for Hypertension (RAS Antagonists), Medication Adherence for Diabetes Medications, and Medication Adherence for Cholesterol (Statins) (Part D): CMS is proposing to exclude beneficiaries who elect to receive hospice care from this measure.
- Statin Use in Persons with Diabetes (SUPD) (Part D): CMS is proposing a weight of standard weight of 3 for this measure in contract year 2020. The measure was added to the 2019 ratings with a weight of 1.
- Controlling High Blood Pressure (Part C): CMS is proposing to temporarily move this measure to the display page for the 2020 and 2021 Star Ratings with a move back to the 2022 Star Ratings.