Featured in Health Business Daily, May 16, 2017

2018 VBID Model MAOs May Tailor Benefits to Multiple Conditions

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care. Subscribe today!

September 1, 2016Volume 22Issue 17

In addition to expanding the Medicare Advantage Value-Based Insurance Design model to three new states and two more targeted clinical conditions for 2018, plans participating in the second year of CMS’s VBID test will have additional flexibility when it comes to targeting members with multiple comorbidities and/or those with mood disorders, CMS officials said during an Aug. 25 webinar to discuss planned changes for the model.

Starting Jan. 1, 2017, MA plans in seven states for the first time will be able to offer targeted extra benefits or reduced cost-sharing to enrollees with at least one of seven specified chronic conditions as a means of improving quality and lowering costs. And even before the program’s initial launch date, CMS on Aug. 10 informed all MA organizations (MAOs) that it would make several tweaks to the 2018 model based on feedback from applicants for the first test year. These include lowering the minimum enrollment size for MAOs with at least 2,000 members that have additional plan benefit packages, and adding rheumatoid arthritis (RA) and dementia to the list of targeted clinical conditions (MAN 8/18/16, p. 4).

CMS is defining the RA group to include all enrollees with diagnoses included in the RA Healthcare Effectiveness Data and Information Set, with the option to include enrollees otherwise excluded from that value set due to HIV and pregnancy if clinically appropriate. The dementia group refers to all enrollees with diagnoses included in the CMS Chronic Conditions Warehouse: Alzheimer’s Disease, Related Disorders, or Senile Dementia algorithm. When reviewing MAOs’ proposals for the dementia population, CMS will specifically look to ensure that the proposal does not expose these members to increased risk of unnecessary drugs, particularly the use of atypical antipsychotics, or other risk of harm that is exclusive to this population.

Effective in 2018, CMS will offer additional flexibility to MAOs selecting certain clinical conditions, noted Gregory Woods, director of CMS’s Division of Health Plan Innovation, during the webinar. These include:

  • The ability to offer multiple comorbidity packages. MAOs participating in 2018 can combine two or more of the CMS-specified conditions to create a “multiple comorbidity group” and restrict benefits in that group only to enrollees with all specific conditions. For example, Woods said model participants could create a special VBID package targeting enrollees with diabetes and mood disorders and limit benefits to that “narrower subset” of members.

  • The ability to offer VBID around select mood disorders. The mood disorder group as defined for 2017 features many different conditions, but for 2018, model participants may choose from among the originally proposed ICD-10 codes to create a smaller group suitable to the participant’s proposed intervention. MAOs, however, must select all ICD-10 codes from within a chosen category. For example, if an organization opts to focus on Depressive Episodes (F32), it may not select just a few conditions of that subset (e.g., major depressive disorder, single episode, mild) but must provide benefits to all F32 codes in the CMS MA-VBID Mood Disorder code set. Moreover, plans choosing F32 or F34 may also propose to include all codes from within those categories and not just those specified in the model code set.

Medicare Advantage News

CMS Is Not Weighing Additional Changes

CMS is still in the process of finalizing plan benefit packages with the plans that received provisional approval to participate in 2017, and will make a list of model participants and plan benefit package data extracts available for public download after contracts are finalized this month. CMS expects to release a request for applications for 2018 in October that will “look very similar” to the 2017 RFA, added Woods.

When asked by MAN during the webinar whether CMS would consider offering plans a payment incentive or other bonus for achieving certain outcomes through the model interventions, Woods said the agency has no plans at this time to make additional changes to the model. “That said, part of our mission here is to constantly be evaluating our models and to see if there are opportunities for improvement,” he remarked. He said plans are encouraged to submit specific proposals on changes to the model for CMS consideration.

View materials from the webinar at https://innovation.cms.gov/resources/vbid-overview.html or submit questions to MAVBID@cms.hhs.gov.

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