March

As Lawsuits Loom, Ohio Gets Medicaid Work Requirements

March 21, 2019

Amidst uncertainty around the fate of Medicaid work requirements as they are tested in two separate cases this month, Ohio on March 15 became the ninth state to gain section 1115 demonstration authority to tie work-related provisions to Medicaid coverage. Medicaid managed care organizations in Ohio have reportedly been preparing for the “Work Requirement and Community Engagement” demonstration project since the state legislature passed a bill requiring it in 2017, but one Medicaid expert warns that if the courts eventually strike down these programs, plans in Ohio and other states with similar demonstrations may never recoup the administrative costs associated with implementation.

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MA Switching Behavior May Inform 2020 Benefit Design

March 21, 2019

With switching rates during the 2019 Annual Election Period (AEP) on the rise after years of decline, experts say it’s hard to predict what will happen during the newly reinstated Medicare Open Enrollment Period (OEP) that ends on March 31. But as Medicare Advantage organizations prepare their bids for 2020, emerging market research on consumer behavior during these periods may provide valuable insight into the types of benefits and practices that attract — and keep — enrollees.

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MedPAC: MA Still Has Coding Intensity, Star Ratings Snags

March 21, 2019

Despite observing some positive developments in the Medicare Advantage program such as improved parity in MA and fee for service (FFS) payments, the Medicare Payment Advisory Commission (MedPAC) in its March report to Congress flagged some ongoing issues it feels Congress needs to address, including CMS’s methodology around coding intensity. And although concerns remain about the accuracy and completeness of encounter data used for MA risk adjustment, the commission discussed its possible use in determining star quality ratings.

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Part D Sponsors Prepare Two Sets of Bids Sans Rebate Clarity

March 21, 2019

Despite some noise early on about insurers not being prepared to deal with a yet-to-be-finalized HHS rebate rule that would take effect Jan. 1, 2020, publicly traded insurers during a recent health care conference indicated that they are preparing Part D bids with and without rebates that HHS would like to see passed along to consumers at the point of sale (POS). Meanwhile, because of minimal potential impact to beneficiaries, the inclusion of Medicaid managed care organizations in the rebate rule had some congressional Medicaid advisors scratching their heads during a recent meeting of the Medicaid and CHIP Payment and Access Commission (MACPAC).

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Select Medicare Advantage Startups and New Risk-Based Entities, With Year-Over-Year MA Enrollment

March 21, 2019

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News Briefs

March 21, 2019

✦ A new Avalere analysis suggests that data underlying CMS’s plan to use an extrapolation methodology in ongoing Risk Adjustment Data Validation (RADV) audits of Medicare Advantage plans may result in underpayments. CMS this month posted data underlying its November 2018 proposal to use an extrapolation methodology in RADV audits. The agency in a proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said its latest plans to recoup improper payments would not involve a “fee-for-service” adjuster as originally planned to account for differences between MA data and Medicare FFS data, and solicited comment on whether it should revise the contract-level audits for payment years 2011, 2012 and 2013 that were conducted using the adjusted methodology unveiled in 2012 but not finalized (RMA 11/1/18, p. 1). CMS at the time also released an internal study finding that errors in reporting diagnosis codes in FFS claims data do not meaningfully impact risk adjustment model estimates and therefore do not bias MA plan payment. But Avalere asserts that “certain key assumptions” in that study “do not appropriately capture the full variation in the data.” According to a March 6 notice from CMS, the agency has requested a 120-day extension for public comments for the RADV provision, pushing the comment period to April 30, 2019. Visit https://federalregister.gov/d/2019-04052 or www.avalere.com.

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✦ A new Avalere analysis suggests that data underlying CMS’s plan to use an extrapolation methodology in ongoing Risk Adjustment Data Validation (RADV) audits of Medicare Advantage plans may result in underpayments. CMS this month posted data underlying its November 2018 proposal to use an extrapolation methodology in RADV audits. The agency in a proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said its latest plans to recoup improper payments would not involve a “fee-for-service” adjuster as originally planned to account for differences between MA data and Medicare FFS data, and solicited comment on whether it should revise the contract-level audits for payment years 2011, 2012 and 2013 that were conducted using the adjusted methodology unveiled in 2012 but not finalized (RMA 11/1/18, p. 1). CMS at the time also released an internal study finding that errors in reporting diagnosis codes in FFS claims data do not meaningfully impact risk adjustment model estimates and therefore do not bias MA plan payment. But Avalere asserts that “certain key assumptions” in that study “do not appropriately capture the full variation in the data.” According to a March 6 notice from CMS, the agency has requested a 120-day extension for public comments for the RADV provision, pushing the comment period to April 30, 2019. Visit https://federalregister.gov/d/2019-04052 or www.avalere.com.