On May 22, 2020, the Centers for Medicare & Medicaid Services (CMS) released a final rule adopting policies for contract year 2021 for Medicare Advantage (MA) and Medicare Part D.
Acknowledging the upcoming MA and Part D bid deadlines for the 2021 plan year, CMS has decided only to address a portion of the proposed policies including in a rule released in February 2020. The outstanding policies will be addressed in a second final rule released later in the year that will likely address the proposal for a second specialty tier in Part D, use of real-time benefit tools (RTBT), and drug management programs. No specific timeline is given for when this second final rule will be released. Policies in the second rule will be effective in the 2022 plan year.
ESRD Beneficiaries May Begin Enrolling in Medicare Advantage Plans
Effective for the 2021 plan year, end-stage renal disease (ESRD) patients will be allowed to enroll in Medicare Advantage (MA) plans. This change was adopted into law in the 21st Century Cures Act, which was passed in 2016. Existing statutory language prohibiting ESRD patient enrollment in MA plans will be changed to reflect this new policy.
In response to a public comment, CMS notes that they agency plans to include dialysis cost sharing information in the Medicare Plan Finder (MPF) tool.
Acquisition Costs for Kidney Transplants for MA Enrollees will be Covered under Traditional Medicare
In addition to allowing ESRD beneficiaries to enroll in MA plans, the 21st Century Cures Act also excluded coverage of organ acquisitions for kidney transplants from the benefits an MA plan is required to cover. In this final rule, CMS is codifying this requirement so effective January 1, 2021, the costs for organ acquisition will be covered under Medicare fee-for-service (FFS). These costs will be excluded from MA benchmarks that determine payment to MA plans.
However, CMS clarifies that PACE organizations will still continue to cover acquisition costs for kidney transplants since the 21st Century Cures Act does not provide for Medicare FFS coverage for this occurrence and an existing statutory requirement outlines that PACE organizations provide for all Medicare-covered items and services. Kidney acquisition costs will then remain in PACE payment rates.
CMS Finalizes Increased Weight for Patient Experience/Complaints and Access Measures in Star Ratings
For the Star Ratings system for the MA and Part D programs, CMS is finalizing an increased weight of 4 for the patient experience/complaints and access measures; the previous weight was 2. Some of the measures in this category are collected through the CAHPS survey, including Members Choosing to Leave the Plan, Appeals, Call Center, and Complaints measures. Many commenters were opposed to this change, saying that CMS should not value patient experience over clinical outcomes, which is currently weighted at 3. CMS responded, saying that the agency believes the patient voice and putting patients first is important and that increasing the weight would provide plans without enough enrollees to report all the Star Ratings outcome measures an opportunity to focus on improving patient experience and differentiating themselves in the market.
Beginning with the 2022 measurement year, CMS will remove outliers prior to calculating cut points. This policy is designed to increase the predictability and stability of the Star Ratings system. The 2022 measurement year is tied to the 2024 Star Ratings that are produced in October 2023.
CMS is finalizing the following changes to specific measures for the 2021 measurement period/2023 Star Ratings:
- Removing the Rheumatoid Arthritis Management (Part C) measure since the measure steward is retiring the measure; and
- Changing the classification of the Part D Statin Use in Persons with Diabetes measure to a process measure from an intermediate outcome measure.
CMS notes that a recent interim final rule addressing the COVID-19 outbreak includes changes to the 2021 and 2022 Star Ratings, including eliminating collection and submission requirements for HEDIA and CAHPS data, using scores from 2020 for 2021 for measures with systemic data quality issues, and expanding the existing hold harmless provision for improvement measures to all contracts for the 2022 Star Ratings.
Additional Star Ratings policies will be addressed in the second final rule that will be released later this year. These policies include adding new Part C measures, clarifying rules related to consolidations, and implementing updates to Health Outcomes Survey measures among other technical changes.
Existing MA Network Adequacy, Special Enrollment Period (SEP) Rules Codified
CMS is codifying existing network adequacy rules for Medicare Advantage including:
- List of provider and facility types subject to network adequacy reviews;
- County type designations and ratios;
- Maximum time and distance standards;
- Minimum number requirements;
An MA organization will have to attest to network adequacy in the organization’s application or contract for a given year as well as when CMS performs other network adequacy reviews, such as when there is a significant change in a plan’s provider network. Outpatient dialysis facilities will not be a facility specialty type subject to network adequacy standards.
In addition, CMS is reducing the percentage of beneficiaries that must reside within maximum time and distance standards in non-urban counties. The percentage will decrease from 90 percent to 85 percent.
Current policies for special enrollment periods (SEP) are also being codified for a variety of circumstances including employer/union group health plan elections, disenrolling in connection with a CMS sanction; enrolling in a Program of All-inclusive Care for the Elderly (PACE); an ESRD beneficiary whose Medicare entitlement determination was made retroactively, and inadequately informed of loss of creditable prescription drug coverage among others.