CMS Releases Proposed Rules for 2023 Medicare Advantage and Part D Plans Special Bulletin January 7, 2021 The agency proposes several policies intended to increase oversight of health plans and solicits information on the impact of prior authorization during a public health emergency Stakeholder panelists should prepare a 10-minute PowerPoint presentation to present on the day of the workshop. Medicare Payment Advisory Commission. For the 2022 Star Ratings, CMS adopted a number of changes to address the impact of the 2019 Novel Coronavirus (COVID-19) in the Medicare and Medicaid Programs and to encourage that members and patients faced minimal hurdles to receiving necessary care and treatment. There are many names that can be invented to achieve the goal of price controls. 2022, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs proposed rule1. Read how Medicare Advantage provides better services, better care, and better value. 216 Blvd of the Allies, Sixth Floor Pittsburgh, PA 15222 412.391.1100 [emailprotected], 2023 ProspHire, LLC. Toll Free Call Center: 1-877-696-6775. HCAHPS Measures Receiving HCAHPS Stars HCAHPS Star Ratings are applied to each of the 10 publicly reported HCAHPS measure. With respect to MA organizations, the denial rates and associated burden, including rates at which denials are upheld and overturned, for prior authorizations for patient transfer from hospitals to post-acute care facilities. 1. GR. DISCLAIMER: The contents of this database lack the force and effect of law, except as These include: MA plans are required to comply with certain special requirements during disasters and emergencies to ensure that enrollees can continue to access care, including by covering services provided by non-contracted providers and waiving gatekeeper referral requirements (note: these are not the same as prior authorization requirements). Toll Free Call Center: 1-877-696-6775. Quality Indicator Reference for Physicians - Humana CMS released the Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies on February 2, 2022, with feedback accepted until March 4, 2022. JAMA Health Forum. . Complaints in category 2.30 (Plan Lead Marketing Misrepresentation: Allegation of inappropriate marketing by plan, plan representative, or agent/broker) are currently included in the Complaints against Health/Drug Plan measure specifications. The responses to the survey items used in each HCAHPS measure (shown below) are scored linearly, adjusted, rescaled, averaged across quarters, and rounded to produce a 0-100 linear-scaled score ("Linear Score"). The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. U.S. Department of Health & Human Services This type of regulatory framework is in sharp contrast to current FFS Medicare payment regulations, which immerse CMS in the constant minutiae of setting rates for every service, entrenching a focus on services rather than outcomes. Washington, D.C. 20201 Fast forward to 2023, more than 60 million Americans depend on Medicare for financing their health benefits. Implemented changes for the 2022 Star Ratings includes the delayed implementation of guardrails until the 2023 Star Ratings so cut points for the 2022 Star Ratings (based on 2020 measurement year) could change by more than 5 percentage points if needed. For policymakers, MAs risk-adjusted capitated model offers a framework for population-based budgeting and revenue planning, with evidence showing that it likely drives more appropriate care utilization and increased quality of care, but does not improve mortality or the patient experience.5 In contrast, FFS Medicare relies on price regulation, with the total cost driven by price, volume, and the intensity of service, with centralized administrative pricing failing to adequately control expenditure growth. Comparing spending across Medicare programs. authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically To view the proposed rule, please visit: https://www.federalregister.gov. The main difference between complaints in categories 1.30 and 2.30 is that CMS may need to act for complaints in category 1.30, whereas cases where a beneficiary wants a prospective action are in 2.30. Corresponding Author: Brian J. Miller, MD, MBA, MPH, The Johns Hopkins Hospital, 600 N Wolfe St, Meyer 8-143, Baltimore, MD 21287 (brian@brianjmillermd.com). Stars is also graded against a curve. Medicare Advantage enrollees continue to have access to and receive high-quality, affordable care. , Chakravarthy CMS expanded the existing hold harmless provision for the Part C and D improvement measures providing protections against a plans summary or overall rating to decrease due to lower scores as a result of the COVID-19. Overall, 51% of the contracts rated for next year received 4 stars or better. 2. achieve improved health outcomes. Through data driven analyses and clearly defined strategies, our team of seasoned subject matter experts implement interventions to increase Stars ratings and maximize rebate potential. Miller These changes will force health plans to reevaluate their Stars intervention strategies and better communicate to both providers and members. Medicare must provide additional cost and access information to enhance decision making around trade offs between Medicare Advantage and Medigap. Triple check your Star Ratings dashboards to ensure they include both the Part C and Part D QI measures and that they are being calculated accurately with the right measures and the right weights. The CAM includes notices of non-compliance, warning letters (with or without business plan), ad-hoc corrective actions plans (CAPs) and the severity of CAPs. Many require reinvestment to drive continued improvement. ACTION: Final rule. On October 8th, CMS released the Medicare 2022 Part C & D Star Rating Technical Notes. PQS Summarizes the 2022 Medicare Part C & D Star Rating Technical Notes Today, the program faces questions of fiscal sustainability, with hospital insurance (Part A) trust fund insolvency projected for 2028. Elected officials returning to a broader focus will benefit population health while providing Americans a voice in important policy decisions. CMS proposes using a web survey for a sample number of enrollees. Medicare 2020 Part C & D Star Ratings Technical Notes Providers inability or unwillingness to contract with MA plans, including issues related to provider reimbursement. The Tax Equity and Fiscal Responsibility Act of 1982 introduced episode-based bundles for hospitalization and early Medicare managed care models in response to runaway health care cost growth in the 1970s. In the proposed rule, CMS reviews its current policies with respect to these special requirements and proposes several modifications. The audience is Part C and D plan sponsors and stakeholders. achieve improved health outcomes. Conflict of Interest Disclosures: Dr Miller reported receiving fees from the Federal Trade Commission, the Health Resources and Services Administration, the California Association of Neurosurgeons, the Maryland Neurosurgical Society, the Digestive Health Physicians Association, and the Heritage Foundation; receiving grants from Arnold Ventures, the Charles Koch Foundation, and the Mercatus Center all outside the submitted work; and serving as a member of the Centers for Medicare & Medicaid Services Medicare Evidence Development and Coverage Advisory Committee. *As per the 2023 CMS Stars Rating Technical Notes, Controlling Blood Pressure has a weight of 1 for the 2023 Star Ratings because it is considered a new measure. Read the 7 things you need to know about Medicare Advantage. AHIP and our member plans will continue to review the latest Star Ratings results and data closely to assess impacts. Previously, the BAPP was broader and included CMS sanctions and civil money penalties (CMP), as well as CAM data. But dont worry, you are not alone! Statin Use in Persons with Diabetes (Part D) measure updates have been implemented which will change this measure from a triple-weighted intermediate outcome measure to a process measure with a weight of 1. as well as the current CMS Medicare Part C & D Star Ratings Technical Notes available at www.cms.gov. Each Project Lead (or a delegate) should plan to present an in-person project talk during plenary. Hospitals - Inpatient Hospitals - Outpatient Hospitals - Rural Emergency incorporated into a contract. This measure will have a weight of 1 for the first year (2023 Star Ratings) and a weight of 3 thereafter. The value of insurance corporation and private equity stock? Accessed February 26, 2023. Guidance for the document that describes the methodology for creating the Part C & D Star Ratings displayed on the Medicare Plan Finder (MPF) at http://www.medicare.gov/ and posted on the CMS website at http://go.cms.gov/partcanddstarratings. JM, Afendulis Changes to the Star Rating Program . The Gradual Transition to Value-Based Care. PDF Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease If the COVID-19 outbreak prevents the agency from having validated data or results in systemic data integrity issues for any other measures, CMS will replace the 2019 data that has any quality issues due to COVID-19 with the measure-level Star rating and score from the 2020 Star ratings. The methodology outlined by CMS clarified that the enrollment figures used in the enrollment weighted QBP rating calculations are the Nov. enrollment in the year the Star Ratings are released. Uniting the need for transitioning to value-based care with fiscal sustainability and a comprehensive, integrated health benefits package, the future of Medicare favors MA. As a result, these patients less frequently hit the maximum out-of-pocket limit, resulting in substantial cost to state Medicaid programs and to providers through uncollected cost-sharing. While CMS estimates this will result in certain plans submitting high-bid amounts, the agency also estimates it will save state Medicaid agencies $2 billion over 10 years and increase payments to providers by $8 billion. Accessed January 5, 2023. Comparative cost varies with stakeholder perspectives: for the beneficiary who must construct a comprehensive health benefits package, MA is appealing as it often adds a prescription drug plan (Part D), an annual maximum out-of-pocket limit, and supplemental benefits at no or little cost to the beneficiary compared with the alternative of selecting and purchasing separately FFS Medicare, supplemental coverage (Medigap), and prescription drug coverage. Comments on the rule are due March 7. We have led the industry for decadesand we have the tools and resources to serve you. On Jan. 19, the Federal Registrar published the Final Rule detailing those regulatory and measure level updates for the Stars program beginning in Measurement Year (MY) 2022. Mr Hargan reports serving as the Deputy Secretary of the Department of Health & Human Services from 2017 to 2021; currently serves as a board director at University Hospitals, Alio, and Capital Pulse; serves as an advisor to Tomorrow Health and HealthTrackRx; and serves as a board member of the Department of Population Science & Policy, Southern Illinois University Medicine. These changes will force health plans to reevaluate their Stars intervention strategies and better communicate to both providers and members. CMS assessed the change using 2019 CTM data from the 2021 Star Ratings. Pharmacy Quality Solutions (PQS) is a healthcare technology company focused on enabling data-driven quality improvement opportunities for payers and providers so patients can Private market actors like the American Medical Associations Relative Value Update Committee could transition into new roles such as developing outcome measures for CMS or assisting health plans with constructing fee schedules. Terms of Use| American Enterprise Institute. January 5, 2023. This measure has a weight of 1 for 2023 and will increase to a triple weighted measure for 2024. Privacy Policy| Health Insurance Providers Actions Concerning Mental, What They Are Saying: Mental Health Services Enabled by Employer-Provided, Healthier People Through Healthier Markets, Medicare + Fraud, Waste, and Abuse Training, 2023 Consumer Experience & Digital Health Forum. S, Navathe Healthcare 2020: 8 healthcare questions you need to be prepared to answer, State finds hundreds of medication errors linked to healthcare technology, Compliance & Ethics Hotline-Powered by Convercent. 2023. MA-only contracts (without prescription drug coverage, or Part D) are rated on up to 28 measures. Calendar Year (CY) 2023 Measure Technical Specifications Last Revised: June 13, 2023. 2023 Announcement. DISCLAIMER: The contents of this database lack the force and effect of law, except as CMS Announces Changes to Staffing Measure in Five-Star Rating System AHIP Statement on 2023 Medicare Advantage Stars Ratings As of October 15, 2022, Medicare beneficiaries can view these 2023 Star Ratings when selecting their MAPD or PDP for the 2023 benefit year as part of the Open Enrollment period which will continue through December 7, 2022. Improved transparency of costs and benefits in the CMS plan finder9 and in policy analysis is also critical. What scientific advancement(s) could contribute to your work? The 2023 Star Ratings for Medicare Part C & D plans are displayed on the Medicare Plan Finder found at www.medicare.gov. Rule of Record: Calendar Year (CY) 2023 ESRD Prospective Payment System (PPS) . Controlling Blood Pressure (Part C) measure will be moved from the display page and to the 2023 Star Ratings as a new measure. HxOpsis the full package of our complete third-party administration services. CMS proposes a number of policy changes related to SNPs. CMS is removing the requirement for submission of 2020 Consumer Assessment of Healthcare Providers & Systems (CAPHS) survey data for Medicare health and drug plans. (That might change: private equity is now hoping to monetize primary care, so lets see how that works out). Medicare Program; Contract Year 2024 Policy and Technical Changes to This document describes the methodology for creating the Part C & D Star Ratings displayed on the Medicare Plan Finder (MPF) at http://www.medicare.gov/ and posted on the CMS website at http://go.cms.gov/partcanddstarratings. Programmatic reforms, including decoupling Medicare from administrative pricing, offers an opportunity to achieve fiscal responsibility and provides a framework for prospective, population-based program budgeting for the first time in the programs history, saving the program for future generations and improving outcomes for patients, orientating Medicare toward health rather than sickness. CMS employs all survey responses in the construction of the HCAHPS Star Ratings. The National Institute of Sciences concludes that primary care is the only medical specialty of which more clinicians improve longevity, equity, and the health of a population, and every health administration in the world has incentivized its availability, except CMS. Provide states with greater options for alignment with D-SNPs, as well as improve coordination between states and CMS of oversight of such plans. Specifically, these measures are Monitoring Physical Activity, Reducing the Risk of Falling, and Improving Bladder Control. 5 Star MAPD Health Plans for 2022 will increase to 74 individual plans up from 21 contracts in 2021. [5] F, Jacobson G, Haynes LA, Collins SR. 3 "CY 2023 Medicare Advantage and Part D final rule (CMS-4192-F)," CMS, April 29, 2022. For newer contracts where the 2021 Star Ratings would be the first year that they would receive a Star Rating, CMS will treat them as new for an additional year since CMS would not have enough data to assign a rating. CMS Star Ratings Calendar. This new methodology will take effect during in the 2023 Quality Bonus Payment period. We see the results in the continued growth of the program, numerous studies that demonstrate the high-quality care that enrollees receive, and sky-high satisfaction rates. Specifically, the agency proposes to establish an additional condition for triggering the special requirements: In order for these special requirements to be in effect, there must be a disruption in access to health care at the same time as the disaster or emergency. Medicare 2021 Part C & D Star Rating Technical Notes This document describes the methodology for creating the Part C & D Star Ratings displayed on the Medicare Plan Finder (MPF) at http://www.medicare.gov/ and posted on the CMS website at http://go.cms.gov/partcanddstarratings. The Centers for Medicare & Medicaid Services (CMS) yesterday released proposed regulations for the 2023 Medicare Advantage (MA) and Part D plan year. Open Access: This is an open access article distributed under the terms of the CC-BY License. All rights reserved. PDF Written in the Stars - Wakely PDF Technical Notes for HCAHPS Star Ratings PDF Center for Data Insights and Innovation (CDII) California Health Care June 13, 2023 Fiscal Year (FY) 2026 Inpatient Hospitals Selected Randomly for Validation June 12, 2023 CMS Releases Fiscal Year 2024 Hospital Value-Based Purchasing Program Medicare Spending per Beneficiary Measure HSRs I am looking for quality information associated with. Dynamic List Data. Links to upload your talk under My Account will be made available in September. Before sharing sensitive information, make sure youre on a federal government site. Other measures have proposed changes and CMS is seeking comments. CMS also proposes to clarify the period of time during which MA plans must comply with the special requirements, particularly to address situations where the end date of the disaster or emergency is unclear. Value-based care is simply the flavor of the day. PDF FACT SHEET - Centers for Medicare & Medicaid Services expand all HEDIS Measurement Year 2023 HEDIS Measurement Year 2022 HEDIS Measurement Year 2021 HEDIS Archives Rules for Allowable Adjustments of HEDIS Miller BJ, Grabert LM, Hargan ED. CMS will also be taking the following actions with respect to 2021 Star Rating calculations: For 2022 Star Ratings, CMS expects Medicare Advantage contracts to submit HEDIS data in June of 2021, and Medicare Advantage and Prescription Drug Plan (Part D) contracts to administer the CAHPS survey in 2021. The latest Updates and Resources on Novel Coronavirus (COVID-19). HEDIS MY 2023: See What's New, What's Changed and What's Retired Finally, policymakers can support the transition from volume to value by addressing default enrollment into FFS Medicare. NCQA Communications Every year, NCQA updates and releases measures in the Healthcare Effectiveness Data and Information Set (HEDIS ). Part C and D plans may use any CAHPS survey data collected for their internal quality improvement efforts. CMS proposes to change how cost-sharing is calculated for purposes of determining whether a beneficiary enrolled in an MA plan has met their maximum out-of-pocket cost limit. PDF CENTER FOR MEDICARE - HHS.gov A managed care program based on risk-adjusted capitation, Medicare Advantage (MA) today is close to commanding a majority share of Medicare program enrollees nationally, and in some markets dominates FFS Medicare. These include proposals to: CMS proposes to modify the methodology for calculating three quality measures for 2023 as a result of the COVID-19 public health emergency: Monitoring Physical Activity, Reducing the Risk of Falling, and Improving Bladder Control. Previous Version Description of Change Revision Date OMB Approved Data Sources . That value is based on the successful maximal diversion of publicly funded healthcare dollars from healthcare to private profit. Star Ratings: What's Ahead | FTI Consulting Comparing Medicare Advantage And traditional Medicare: a systematic review. incorporated into a contract. The Centers for Medicare & Medicaid Services (CMS) announced it will put patients over paperwork to provide temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage, and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.. HEDIS Measures and Technical Resources - NCQA Our practitioners have years of experience helping large MCOs enhance quality improvement programs. CodySoft and Membership Suite, our proprietary suites of software, are designed specifically for health plans. Plans use these additional funds to meet beneficiaries needs for a comprehensive benefits package, with MA comprised of traditional Part A and Part B benefits, Medigap, Part D benefits, and supplemental benefits. CMS proposes to change this policy to count these amounts toward an individuals maximum out-of-pocket limit. December 12, 2016. Payment levels should be addressed through the gradual transition to a competitive bidding model inclusive of FFS Medicare, which would remain an option for beneficiaries. Launched in 1965 based on the design prevalent in employer-sponsored insurance markets, Medicare began as a fee-for-service (FFS) benefit for the very elderly, with eligibility at age 65 years when the average life expectancy in the US was approximately 70 years. LM. Medicare 2020 Part C & D Star Ratings Technical Notes. For your convenience, PQS has summarized the 2023 Medicare Part C & D Star Ratings Technical Notes, which includes general points and highlights, focused updates for medication-related Part D measures, performance trend graphs, and measure threshold charts. The display measure only reflects the Compliance Activity Module (CAM) measures, which plans can monitor in the CAM within Health Plan Management Services (HPMS). 2023 Announcement; Get email updates. 5 Star PDP Health Plans for 2022 will increase to 10 individual plans up from 5 contracts in 2021. While programmatic spending differs and necessitates further study,4 the costs of constructing a holistic health benefits packages are incurred costs to society: eg, catastrophic protections are funded through MA, Medicaid, or employer-sponsored retiree coverage. 2023 Star Rating ChangesCMS Advanced Notice for Review & Comment (CMS) announced it will put patients over paperwork to provide temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage, and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.. Please check back again as this page is updated on a regular basis. CMS found a decrease in stars for almost one-quarter of plans. PDF CENTER FOR MEDICARE - HHS.gov Changes in physician consolidation with the spread of accountable care organizations. R, Connolly CMS Issues Emergency Regulation Changes for 2022 Star Ratings | Icario The public reporting of the HCAHPS Star Ratings in January 2023 will be based on patients discharged between April 1, 2021 and March 31, 2022. HEDIS Technical Resources HEDIS Technical Specifications include a complete list of new and updated HEDIS measures with instructions on data collection and guidelines for calculations and sampling. TG, Landon In 2022, MA plan bids averaged 85% of FFS Medicare spending,3 demonstrating the ability of managed care to more efficiently deliver Part A and B benefits through implementation of a provider network and utilization controls. All Rights Reserved. Grabert CMS Meeting 2023 An additional downside of FFS Medicare over MA is its perpetuation of inefficiencies, such as the lack of site-neutral payment and the promotion of consolidation through the growth of accountable care organizations.6, Policy Preparations to Support the Transition From Volume to Value. GP, Polsky 2022-04-04. , Kanter Additional highlights of the proposed rule and accompanying RFIs follow. Individual Clinical Care Measure Scoring . Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease Quality Incentive Program (ESRD QIP) 1 . |, Quality Corner Show Podcasts Currently Available for Continuing Education Credit, Quality Corner Show Discusses Pharmacist Board Certification with Brian Lawson, PharmD. GR, Miller 52 plans (85% of eligible clients) achieved a 4-star rating or higher. 2023 American Medical Association. 200 Independence Avenue, S.W. 2. 2023;4(6):e231571. A federal government website managed by the Disclaimer: The views expressed are the authors own and do not represent those of any affiliated organizations or employers.
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