The Medicare Payment Advisory Commission (MedPAC) met on September 7 to review a draft of a chapter on Medicare Payment Policy and to review the work they will undertake for 2023-2024. MedPAC staff identified five reports it will issue in 2024 related to Medicare Advantage (MA), including looking at plan consolidation impacts, D-SNP quality,  and standardizing MA benefits.

One report that will be of particular interest to LeadingAge members is MedPAC’s examination of access and quality in MA. Specifically, they will compare MA plan performance on ambulatory care sensitive hospitalizations, plan networks, prior authorizations, and claims denials. Several MedPAC commissioners stressed the importance of their work examining how these plans work for frail, seriously ill and nursing home beneficiaries. Other commissioners noted the need to understand the impact of plan consolidation at a more local level, include plan outcomes for the beneficiaries they serve, and provider satisfaction with MA.

New commissioner Tamara Konetzka advocated for a better understanding of how MA plans could better serve nursing home residents. MedPAC chair, Michael Chernew, did note that the goal of these reports is not to issue new recommendations in this cycle but about data collection on these issues to understand the situation.

LeadingAge will continue to monitor the Commission’s work in the coming year.

LeadingAge members are familiar with Medicare Advantage (MA) plans using third-party tools, such as NaviHealth or MyNexxus, to make generalized coverage determinations. LeadingAge has asked the Centers for Medicare & Medicaid Services (CMS) to limit use of these artificial intelligence (AI) tools, as they don’t examine the needs of the individual but instead suggest a treatment timeline based upon the typical person with the same diagnosis.

Congress has been looking at establishing some regulation around AI and on September 6, 2023, Sen. Bill Cassidy (R-LA) suggested that AI should have its own regulations in health care. He noted “a sweeping, one-size-fits-all approach for regulating AI will not work and will stifle, not foster, innovation.” The Senate is ramping up its AI work, according to Congressional Quarterly, with another Senate Commerce, Science and Transportation subcommittee hearing on AI scheduled for September 12.

The Office of Inspector General (OIG) released a July report revealing high rates of prior authorization denials in Medicaid Managed Care programs allowed to perpetuate because of limited state oversight and external medical reviews. Ranking Member of the Energy and Commerce committee, Congressman Frank Pallone (D-NJ), announced that he will be contacting each of the health insurance companies whose claims were reviewed in the OIG report. The congressman noted the responsibility of health plans to their beneficiaries and beneficiary families.

A set of new analyses released on August 9 by KFF found that Medicare Advantage (MA) plans will see a 30% increase in federal bonus payments (a program established under the Affordable Care Act that increases payments to plans based on a five-star rating system). Plans are collecting nearly $13 billion in bonus payments this year.  The papers also show clearly how most MA enrollees are paying less for coverage and gaining coverage for vision, hearing, dental, and prescription drugs.

The analyses fail to point out that coverage of post-acute care, which is far more costly than most of these other additional benefits, does not usually meet the needs of MA plan participants, even though Medicare Advantage beneficiaries are supposed to receive comparable coverage to fee for service Medicare. LeadingAge’s March 16 white paper, Fulfilling the Promise of Medicare Advantage, offers recommendations for the Department of Health and Human Services to improve the program to ensure the best care for beneficiaries, emphasizing reimbursement, contracting, and transparency.

KFF released on a new brief, How Do Dual-Eligible Individuals Get Their Medicare Coverage? Medicare and Medicaid provide health coverage to 12.5 million individuals who are enrolled in both programs, known as “dual-eligible individuals.” The brief shows that 49% of duals are enrolled in Medicare Advantage and 51% are in Traditional Medicare, and 30% of duals are in dual-specific plans (DSNPs, Medicare-Medicaid Plans, PACE, and FIDE SNPs), while 19% are in regular Medicare Advantage Plans.

AHIP, the American Hospital Association, American Medical Association and the Blue Cross Blue Shield Association sent a letter on July 27 to CMS Administrator Chiquita Brooks-LaSure, requesting that Centers for Medicare & Medicaid Services (CMS) not implement its proposal in the Advancing Interoperability and Improving Prior Authorization (AIIPA) proposed rule. The groups noted that, if implemented, these rules would conflict with electronic transaction standards proposed for health care attachments. This may be why the proposed AIIPA rule has not yet made its way to the Office of Management and Budget as a final rule.

Congress continues to apply pressure to CMS to make changes to prior authorization practices. The House Ways & Means Committee passed the Health Care Transparency Act of 2023 (HR 4822) on July 26 that includes language from last year’s bipartisan bill, Improving Seniors’ Timely Access to Care Act, which seeks to improve prior authorization processes through electronic transmissions and track plan prior authorization data.

Sen. Bernie Sanders (I-VT) also included language to improve prior authorization processes in a bipartisan HELP Committee bill entitled, Primary Care and Health Workforce Expansion Act. This proposal similarly seeks electronic prior authorizations, requires a prior authorization to cover an entire course of treatment, and for plans to track and report on certain data related to their prior authorization decisions.

LeadingAge seeks improvements in prior authorization and long-sought reductions to the administrative burden of prior authorizations remain a congressional priority. For more information, see our Fulfilling the Promise: Medicare Advantage paper, and statement to the Senate Homeland Security & Government Affairs Permanent Subcommittee on Investigations held a hearing on May 17, 2023.

Centers for Medicare & Medicaid Services (CMS) released data on skilled nursing facilities (SNF) utilization patterns for Medicare Advantage (MA) enrollees between 2016-2019 using MA encounter data. The data shows a few notable takeaways:

• A slight uptick in the percentage of MA enrollees aged 65+ utilizing SNF services between 2016-2019.
• MA enrollee admissions aged 65+ per 1,000 increased from 49.53 to 52.96 over this time period.
• The total days per admission decreased from 23.04 days to 20.40 days.

On behalf of the Better Medicare Alliance (BMA), Avalere Health issued a report updating a 2018 analysis that compares demographic and clinical characteristics of Medicare Advantage (MA) and FFS beneficiaries. The study uses 2019 claims and demographic data to reach its conclusions with a focus on  three key diagnoses—hypertension, hyperlipidemia and/or diabetes. Demographically, MA enrollees are more racially and ethnically diverse (28% in MA versus 12.5% in FFS) and have more social risk factors.

The report notes that MA enrollees had lower rates of inpatient utilization and emergency room visits and slightly higher rates of physician visits. MA enrollees who did incur an inpatient stay stayed there on average two days longer than their FFS counterparts. On this latter point, the report doesn’t address whether the long length of stay was the result of an inability of the MA plan to find a post-acute care provider to accept the individual.

Also of note, longer hospital stays don’t result in higher spending for the plan since hospitals are paid essentially a flat rate by diagnosis. The report also finds that MA enrollees with the three studied diagnoses had lower overall health care spending. In this case, we must question whether this lower aggregate spending is the result of plans paying providers less per unit of service and/or reducing the number of units of services delivered.  MA enrollee per member per month spend for MA enrollees in the subgroups ranged was roughly 70% of FFS spending. Skilled nursing facilities and home health agencies report MA plans paying them roughly 60-80% of FFS rates. Regardless of amount spent and changes in utilization patterns, the report finds that quality was similar between MA and FFS.

The current rate setting structure for Medicare Advantage (MA) plan payments results in plan overpayments of more than 20%, according to a new study from the University of Southern California Schaeffer Center. This finding is particularly galling when these same plans are often paying Skilled Nursing Facilities(SNFs) and Home Health(HH) agencies only 60-80% of what Medicare FFS pays and denying MA enrollees access to medically necessary Medicare A & B services.

Read the full LeadingAge article here.

The Centers for Medicare & Medicaid Services (CMS) looks at Medicare Advantage (MA) enrollees use of Skilled Nursing Facility (SNF), examining the data by type of entitlement and demographic characteristics, including whether they are dual eligible and area of residence.

• The data shows the percentage of MA enrollees with a SNF stay has remained fairly constant between 2016 and 2019, but the length of those stays are 11% shorter in 2019 than in 2016, with roughly 3.6 fewer days per person and almost three fewer days per admission.
• When examining demographics of the 2019 MA population, CMS notes nearly 41% of MA enrollees were dual eligible.
• While Non-Hispanic whites represent nearly 75% of all SNF admissions, they are only 67.5% of the MA population in 2019. Similarly, Black or African American MA enrollees represented 12.5% of the enrolled population but 14.5% of the SNF admissions.
• In contrast, Hispanic enrollees have disproportionately fewer SNF stays (7.7%), representing 13.7% of the enrolled population.
• It comes as no surprise that those age 85-94 have roughly 138.29 admissions per 1,000 Medicare Advantage Part A enrollees, compared to 26.96 admissions per 1000 for those age 65-74.
• Interestingly, the data shows that those under 65 years old have longer lengths of stay in SNF (average of 28.21 days per admission) than those over 65 (average of 21.19 days).
• Finally, the data shows considerable variation among states in not only their use of SNFs but also their total days per admission. Rhode Island has the highest number of SNF admissions per 1000 MA enrollees at 88.12 per 1000 but also the fewest days in SNF once admitted at 16.45 per admission.

The detailed report and spreadsheet can be found here.

In its April 2023 final CY2024 Medicare Advantage (MA) policy and technical rule, LeadingAge was pleased to see Centers for Medicare & Medicaid Services (CMS) clarified how MA plans make coverage determinations, added some guardrails on prior authorizations, and prohibited certain marketing and communication practices used by some plans and their agents. However, it remains to be seen if these new regulatory changes will truly affect change, if current enforcement and oversight is sufficient to achieve the goals of the changes, or if plans will continue to flout requirements or find new loopholes to avoid compliance.

Read the full article for detailed information on the final rule and what to expect when it is applied.

The Senate Homeland Security & Government Affairs Permanent Subcommittee on Investigations held a hearing on May 17 on the practice of Medicare Advantage (MA) plans denying care and creating access to care issues. LeadingAge submitted a statement to the subcommittee providing further evidence of the issues the subcommittee is exploring, and the difficulties LeadingAge members experience routinely.

For more details, read the full bulletin.

On April 14, Medicaid and CHIP Payment Access Commission (MACPAC) Commissioners and attendees heard a presentation from MACPAC staff on interview findings of beneficiaries and managed care organizations (MCOs). MACPAC serves as a non-partisan advisory and analytic agency to Congress and members of the president’s administration. The questions were designed to help interviewers better understand how appeals processes help beneficiaries access services and understanding of denials oversight in managed care.

MCOs asserted that many denials were issued because of inadequate documentation to determine medical necessity. Beneficiaries noted concerns with conflicts of interest in MCOs handling of appeals citing misaligned incentives.

Following the presentation from staff, spirited conversation and comments from commissioners aligned with many of LeadingAge’s concerns around prior authorization and denials as outlined in this LeadingAge article about our recently issued white paper, Fulfilling the Promise: Medicare Advantage. MACPAC is considering recommendations and LeadingAge will continue to monitor and engage on developments.

Centers for Medicare & Medicaid Services (CMS) issued its final CY2024 rate notice for Medicare Advantage (MA) plans. In addition to changes about how MA plans are paid, the notice also includes changes that reduce out-of-pocket costs for Part D enrollees.

Click here for more details on what is in the rate notice.

A possible concern about the rate notice and the CMS final rule on recouping plan overpayments, is that we might see plans more aggressively reduce provider rates in the coming year to offset any losses they experience. We are expecting the CY2024 MA policy and technical change final any day now. It contains provisions that could limit prior authorizations by the plans among other changes.

Medicare Advantage (MA) organizations benefitted from temporary enforcement discretion related to certain MA policies during the COVID Public Health Emergency (PHE). Some plans used this accommodation to make mid-year benefice enhancements to their plans. For example, some plans added an opportunity for some of their enrollees to receive in-home food delivery benefit.

Centers for Medicare & Medicaid Services notified that this enforcement discretion would end with the PHE on May 11 and this will prohibit plans from providing any expanded or additional benefits, including cost-sharing reductions if they are not already in the plans benefit package that was approved for Contract Year 2023 that started January 1, 2023.

CMS announced March 31 that Medicare Advantage (MA) plans will receive a 3.32% rate increase for CY2024, as part of CMS’s CY2024 Final Rate Announcement. This is a higher amount than the originally proposed 1.03% increase. A three-year phase in of the risk adjustment policy changes resulted in the additional rate increase.

The announcement also includes changes to Part D policies required by the passage of the Inflation Reduction Act (IRA) of 2022. Beginning in 2024, Part D plan enrollees will spend less money out of pocket for Part D, including no longer paying cost sharing in the Part D coverage gap or catastrophic phase. An expansion of the Low Income Subsidy program provides individuals with incomes between 135-150% of the Federal Poverty Level with $0 Part D premiums and low-cost, fixed copayments for covered prescription drugs. Insulin products will not be subject to the Part D deductible and plans are prohibited from charging more than $35 for a one-month supply of covered insulin products. Part D enrollees can access adult vaccines, recommended by the Advisory Committee on Immunization Practices (ACIP) at no cost and outside their Part D deductible. The final notice also caps Part D base beneficiary premiums at the lessor of 6 % or the amount that would have applied without the IRA.

The CMS Fact Sheet provides further details on the changes CMS is implementing related to risk adjustment and Part D policies.

LeadingAge expects the CY2024 MA policy and technical changes final rule to be issued later this week. The proposed rule contained key changes to MA prior authorization practices.

LeadingAge, the association of nonprofit providers of aging services, unveiled a series of solutions to the critical and growing failures of Medicare Advantage (MA) to provide equitable access to needed post-acute services. The new report, Fulfilling the Promise: Medicare Advantage, explains the issues and offers policy recommendations.

“Whether it’s delayed claims processing and opaque explanations for prior authorizations or slow care approvals, MA plan practices and policies impact the entire health care system,” said Katie Smith Sloan, president and CEO, LeadingAge. “Failure to address these and a host of other issues now will jeopardize the health and well-being of millions of older adults as the MA juggernaut expands. The time is right to take action.”

Read the full LeadingAge press release.

LeadingAge published a white paper, “Fulfilling the Promise: Medicare Advantage,” which articulates the breadth of challenges faced by Medicare Advantage (MA) enrollees when attempting to access their Medicare benefits through MA and by PAC providers in caring for these individuals. It also offers solutions to resolve these issues to support providers and ensure beneficiaries’ equitable access to needed PAC. The paper lays out the issues and corresponding solutions in the following areas:

• Making payment rates adequate and predictable
• Understanding and addressing challenges with prior authorizations.
• Bringing the vision of high-quality care closer to routine practice by making value-based arrangements workable.
• Giving beneficiaries a true choice of high-quality providers by addressing network adequacy.
• Addressing transparency concerns by improving data collection and sharing.
• Actively supporting beneficiary needs and rights.

LeadingAge sent a letter to CMS Adminstrator Chiquita Brooks-LaSure on March 13 to offer support for the “Advancing Interoperability and Improving Prior Authorization Processes” proposed rule and its goals to make prior authorizations and data sharing more efficient. The letter expresses particular support for extending payer provisions to include Medicare Advantage plans. Read the full comments.

LeadingAge submitted comments Feb. 13 on CMS’s proposed rule governing how Medicare Advantage, Special Needs Plans, Part D and PACE programs will operate in CY2024 offering support for many of CMS’s proposed rules and suggestions for further refinement. While the comments cover a wide swath of topics, as did the proposed rule, the majority of the LeadingAge comments honed in on members’ pain points – how MA plans make coverage determinations for traditional Medicare Part A & B services and prior authorizations.

Read the full LeadingAge article.

A group of US Senators who sit on the Senate Finance Committee issued a Request for Information in Dec. 2022 seeking input on how to reform health care to achieve integrated care for dual eligibles. LeadingAge submitted comments on January 13 sharing its vision of integrated care from its 2017 white paper including highlighting member integration models  with better outcomes for senators to consider.

LeadingAge met with Senate staff recently to discuss these ideas further and learn how we can assist the Senate in their efforts to improve care for the dual eligible population.  This group of senators – Sens. Bill Cassidy, M.D., Thomas Carper, Tim Scott, Mark Warner, John Cornyn and Robert Menendez – continue to meet weekly on this topic and synthesize the responses they received from the RFI.  They’re working toward identifying some concrete solutions for discussion in the coming months.

Centers for Medicare & Medicaid Services (CMS) issued its annual proposed rule (CMS-4201-P) on December 7 to update the Medicare Advantage (MA) policies and technical changes that will apply to MA, Special Needs Plans (SNPs), Part D plans, and PACE programs and benefits beginning with Calendar Year 2024. The 957-page proposed rule also seeks to address: placing additional limits on permissible marketing to beneficiaries, revising the MA and SNP Star Rating System including a health equity index reward, improving access to behavioral health; affordability, and access in the Part D drug program, and expanding Part D low-income subsidies and timely access to more beneficiaries.

Read the LeadingAge article for detailed analysis.

LeadingAge took the opportunity to comment on Centers for Medicare & Medicaid Services (CMS) request for information on various aspects of Medicare Advantage (MA) Program and submitted comments to CMS Administrator Chiquita Brooks-LaSure on August 31. The comments reflect the perspective of providers of post-acute care, long-term services and supports, and home and community-based services who contract with Medicare Advantage and Special Needs Plans to provide services.

LeadingAge President and CEO, Katie Smith Sloan, sent a letter to CMS Administrator Chiquita Brooks-LaSure and CMS Director of Medicare Meena Seshamani on Monday, July 18 outlining concerns we have related to the future of Medicare and Medicare Advantage and asking to meet. The goal of the meeting would be to discuss the challenges providers face in delivering Medicare benefits in both programs and how we might work with CMS to ensure beneficiary access to services through the two programs as well as financial sustainability for providers. Dr. Seshamani quickly responded to the request and a meeting is being scheduled.