New MA Codes, Supplemental Benefits Could Improve Dementia Care
September 13, 2019
An estimated 5.5 million older Americans are living with Alzheimer’s disease, and this figure is expected to jump to 14 million by 2060 — but it is believed that Alzheimer’s and other forms of dementia in the U.S. are still largely underdiagnosed. With the addition of two new codes to the Medicare Advantage risk adjustment payment system and expanding flexibility in MA benefit design, Alzheimer’s advocates are hopeful that such changes will lead to increased diagnoses, improved treatment and greater awareness of clinical trials for disease-modifying therapies.
Starting Jan. 1, 2020, CMS will incorporate into its risk score calculation for MA plans an alternative payment condition count (APCC) model that includes additional Hierarchical Condition Category (HCC) codes for dementia: HCC51 — Dementia With Complications and HCC52 — Dementia Without Complications. Plans will therefore have a financial incentive to capture the appropriate diagnosis codes, and by assigning equal weights to the two codes, CMS has minimized the chance of upcoding, observes Catherine Murphy-Barron, a principal and consulting actuary with Milliman.