CMS on Friday finalized several changes to Medicare Advantage and Part D but said more updates are coming.
The final rule will make it easier for Medicare Advantage plans to meet network adequacy standards. Advantage plans can now contract with telehealth providers for such specialties as cardiology and receive a 10% boost to their percentage of beneficiaries that live within the time and distance requirements, according to a CMS fact sheet.
“This flexibility will encourage plans to enhance their benefits to give beneficiaries access to the latest telehealth technologies and increase plan choices for beneficiaries residing in rural areas,” CMS said in a statement.
The agency is also reducing the percentage of beneficiaries required to meet those standards from 90% to 85%, and easing network adequacy standards for outpatient dialysis. Advantage plans can also get a credit to offset the “adverse effects” of state certificate of need laws, according to CMS.
Beginning in 2021, Medicare beneficiaries with end-stage renal disease will be able to enroll in Medicare Advantage plans, as mandated by the 21st Century Cures Act. Until now, they couldn’t get dialysis treatment under Medicare Advantage unless they were diagnosed with the disease after enrollment.
“This will give beneficiaries with ESRD access to more affordable Medicare coverage options that may include extra benefits such as health and wellness programs, transportation, or home-delivered meals that are not available in Medicare Fee-For-Service,” according to CMS.
The final rule also boosts the impact of patient experience and access under the Medicare Advantage and Part D star ratings system. The agency said that it increases the predictability and stability of the ratings by lowering the impact of outliers. By removing outliers from the ratings calculations, CMS estimates the federal government will save $3.65 billion over 10 years.
CMS changed how Medicare Advantage plans calculate their medical-loss ratio, allowing them to include fees paid to non-providers for covered services in their incurred claims.
Dual-eligible special needs plan “look-alikes” are now on the chopping block. Except for so-called “Special Needs Plans,” CMS won’t contract with a new Advantage plan that expects 80% of their beneficiaries to be Medicaid eligible beginning in 2022. The agency will have similar requirements for renewing Advantage plans starting in 2023.
“Phasing out D-SNP look-alikes will strengthen the ability of states and CMS to meaningfully implement existing and new statutory requirements for D-SNPs that Congress created,” CMS said.
The agency said that the final rule “focuses on more immediate regulatory actions,” which includes implementing changes required by the Bipartisan Budget Act of 2018 and the 21st Century Cures Act. Both laws required the changes to be made by June 1, 2020.
“CMS plans to address the remaining proposals for plans later in 2020 for the 2022 plan year,” the agency said in a statement.
Changes to Medicare Part D, including a proposal for a new specialty tier with lower cost-sharing for beneficiaries, didn’t make it into the rule. Neither did CMS’ proposals to force Part D plans to give patients plan-specific, real-time formula and benefits information or disclose to CMS how they evaluate pharmacy performance.
Other changes that didn’t make it into the final rule include several opioid provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT Act. That includes expansions of drug management and medication therapy programs.
Proposed changes to the Programs of All-Inclusive Care for the Elderly, or PACE, didn’t make it in either.
The Trump administration had argued that allowing Advantage plans to use more telehealth services would improve seniors’ access to care in rural areas and lower premiums. But some experts were skeptical that the changes would significantly increase access since telehealth uptake had been slow among both providers and beneficiaries.
The COVID-19 pandemic has since forced hospitals, physician groups and patients to adopt telehealth at a breakneck pace so the rule changes could have more of an impact than the industry expected.