U.S. to increase Medicare Advantage payments to health insurers

by NCN Health And Science Team Posted on April 2nd, 2019

The Centers for Medicare & Medicaid Services (CMS) announced Monday that the US government will increase by 2.53 percent on average 2020 payments to health insurers that manage Medicare Advantage insurance plans for seniors and chronically ill beneficiaries.

The changes reflect an increase cost in medical care and align with the Trump administration’s efforts to increase competition among Medicare Advantage and Part D plans to provide higher quality care at lower costs. Under the new scheme, seniors will have the opportunity to choose a plan with greater supplementary benefits, which are benefits for daily maintenance of health. Medicare Advantage insurers can offer supplementary benefits “that are not covered under Medicare Parts A or B, if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

Additionally, chronically ill patients will be afforded the opportunity to access “a broader range of supplemental benefits that are not necessarily health-related but have a reasonable expectation of improving or maintaining the health or overall function of the enrollees.” Examples of those benefits include, “meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services in order to improve their health or overall function as it relates to their chronic illness.”

CMS also said the new plan seeks to combat the opioid crisis through encouraging “cost sharing reductions for patients with chronic pain or undergoing addiction treatment” and “Part D plans to provide at least one opioid-reversal agent on a lower cost-sharing tier.”

CMS finalizes Medicare Advantage and Part D payment and policy updates to maximize competition and coverage

Today, the Centers for Medicare & Medicaid Services (CMS) finalized updates that will take significant steps in continuing the Trump administration’s efforts to increase competition among Medicare Advantage and Part D plans so patients get higher quality care at lower costs. These changes will increase plan choices and benefits, and include important actions to address the opioid crisis.

“Today’s changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease,” said CMS Administrator Seema Verma. “With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy.”

The final policies will further expand opportunities for seniors to choose Medicare Advantage plans that are providing new supplemental benefits tailored to their specific needs. Last year, CMS empowered patients through expanding the definition of health related supplemental benefits that Medicare Advantage plans could offer to enrollees, where the primary purpose of the benefits are daily maintenance of health. Beginning in 2019, Medicare Advantage plans can now offer supplemental benefits that are not covered under Medicare Parts A or B, if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization. For example, plans may offer adult day health services, and/or in-home support services under the expanded definition of supplemental benefits when they meet these standards.

For 2020, today’s announcement gives chronically ill patients with Medicare Advantage the possibility of accessing a broader range of supplemental benefits that are not necessarily health-related but have a reasonable expectation of improving or maintaining the health or overall function of the enrollees. These benefits can address social determinants of health for beneficiaries with chronic disease. For example, beneficiaries enrolled in a Medicare Advantage plan could now receive meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services in order to improve their health or overall function as it relates to their chronic illness. For a patient with asthma, for example, a Medicare Advantage plan could cover home air cleaners and carpet shampooing to reduce irritants that may trigger asthma attacks. For someone with heart disease, a plan could provide heart healthy food or produce. And for someone with diabetes, a plan could provide transportation to a doctor’s appointment, diabetes education program or to see a nutritionist.

In addition to expanding opportunities for choice and providing flexibility in offering supplemental benefits, these payment and policy updates include actions that help combat the nation’s opioid crisis. In today’s announcement, CMS encourages Medicare Advantage plans to take advantage of new flexibilities to offer targeted supplemental benefits, cost sharing reductions for patients with chronic pain or undergoing addiction treatment, and encouraging Part D plans to provide at least one opioid-reversal agent on a lower cost-sharing tier. CMS’ overutilization policies have resulted in a 14 percent decrease in the share of Part D beneficiaries using opioids between 2010 and 2017 (36.3 percent to 31.3 percent), with the largest decrease from 2016 to 2017 (5 percent).

Medicare Advantage remains a popular choice among beneficiaries and has high satisfaction ratings. Average Medicare Advantage premiums are at their lowest in six years, Part D premiums are at their lowest in three years, and plan choices have increased. Today’s announcement builds in additional flexibilities that will continue to increase choice and competition among Medicare health and drug plans.

How do Medicare Advantage Plans work?

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. These “bundled” plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare prescription drug (Part D).

Covered services in Medicare Advantage Plans

Medicare Advantage Plans cover all Medicare services. Some Medicare Advantage Plans also offer extra coverage, like vision, hearing and dental coverage.

Medicare Advantage Plans must cover all of the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans, you’re always covered for emergency and urgently needed care.

The plan can choose not to cover the costs of services that aren’t medically necessary under Medicare. If you’re not sure whether a service is covered, check with your provider before you get the service.

Most Medicare Advantage Plans offer extra coverage, like vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan. In 2019, the standard Part B premium amount is $135.50 (or higher depending on your income).

If you need a service that the plan says isn’t medically necessary, you may have to pay all the costs of the service. But, you have the right to appeal the decision.

You (or a provider acting on your behalf) can request to see if an item or service will be covered by the plan in advance. Sometimes you must do this for the service to be covered. This is called an “organization determination.” If your plan denies coverage, the plan must tell you in writing.

You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:

The provider gave you or referred you for services or supplies that you reasonably thought would be covered.
The provider referred you to an out-of-network provider for plan-covered services.

Rules for Medicare Advantage Plans

Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.

Each Medicare Advantage Plan can charge different out-of-pocket costs. They can also have different rules for how you get services, like:

Whether you need a referral to see a specialist

If you have to go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
These rules can change each year.

Costs for Medicare Advantage Plans

What you pay in a Medicare Advantage Plan depends on several factors. Learn about these factors and how to get cost details.

Drug coverage in Medicare Advantage Plans

Most Medicare Advantage Plans include prescription drug coverage (Part D). You can join a separate Medicare Prescription Drug Plan with certain types of plans that:

  • Can’t offer drug coverage (like Medicare Medical Savings Account plans)
  • Choose not to offer drug coverage (like some Private Fee-for-Service plans)

You’ll be disenrolled from your Medicare Advantage Plan and returned to Original Medicare if both of these apply:

  • You’re in a Medicare Advantage HMO or PPO.
  • You join a separate Medicare Prescription Drug Plan.

How Medicare Supplement Insurance (Medigap) policies work with Medicare Advantage Plans

Medigap policies can’t work with Medicare Advantage Plans

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