CMS Issues Proposed Payment and Policy Changes for 2016 Medicare Health and Drug Plans

The Centers for Medicare & Medicaid Services (CMS) released its annual guidance to Medicare drug plan sponsors, for proposed changes for 2016 payment and policy updates.

The agency said that the proposed changes for the coming year for the Medicare Advantage (MA) and Part D Prescription Drug Programs advances an initiative associating payments to providers with quality, rather than quantity of care they deliver to patients.

Health and Human Services (HHS) Secretary Sylvia M. Burwell previously announced an initiative of building a better, smarter health care system and moving the Medicare program and health care system toward paying providers based on the quality and value they provide as opposed to the current model of paying providers based on the quantity of patients they care for.

“Improving patient outcomes is a goal shared across the healthcare industry. To improve patient outcomes, patients must receive quality of care from their providers,” said Gary M. Cohen, BSPharm, RPh, CSP, Executive Director of the Specialty Pharmacy Certification Board (SPCB). “By switching to a model that incentivizes providers for the quality they provide to patients versus the quantity of patients they see, we are ultimately improving patient outcomes.”

According to Andy Slavitt, CMS Principal Deputy Administrator, the proposed rates will minimize disruption to seniors and care providers, while enhancing the stability of the Medicare Advantage program. The proposed policies will continue the movement toward value-based care for the Medicare Advantage and Part D Programs.

Since the Affordable Care Act (ACA), the Medicare Advantage and Part D Prescription Drug programs’ enrollments and quality continue to grow and improve. Since 2010, enrollment in Medicare Advantage has reached a record high each year. This has continued in 2015, with a total increase of more than 40 percent since passage of the ACA, and premiums have fallen by almost six percent from 2010 to 2015. Additionally, more than 90 percent of Medicare beneficiaries have access to a $0 premium Medicare Advantage plan.

CMS said that the proposal will provide fair payments to plans, rewarding high-quality care, and spending our health care dollars wisely. The proposed changes support the agency’s commitment to a Medicare program that provides consumers with better care, spends health care dollars wisely and results in healthier people. The agency estimates that in 2015, 60 percent of Medicare Advantage enrollees will be in 4 or 5 star plans, an increase of 43 percent since 2009. In order to encourage improved quality, CMS is proposing to continue to refine the star rating system, with changes including modifying the system to ensure plans are not unfairly penalized for enrolling dual eligible or low-income beneficiaries.

The Advance Rate Notice proposes changes in payments that will impact plans based on a variety of factors. On average, when combined with expected growth in plan risk scores due to coding, the expected revenue change would be a positive growth of 1.05 percent. Those that have shown an improvement in quality and a focus on customer satisfaction would see additional growth.

The policies also promise to provide enrollees with more information so that they can make informed decisions regarding their care and coverage. The Draft Call Letter proposes steps to ensure plans maintain accurate provider directories, which should be made widely available to help enrollees understand the providers available to them. Additionally, CMS proposes to work with Part D sponsors that provide limited access to preferred cost sharing pharmacies in their networks to make sure all beneficiaries have access to affordable coverage.

Source: Centers for Medicare & Medicaid Services


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