Fact Sheets

Contract Year (CY) 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P)

Contract Year (CY) 2020 Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P)

On October 26, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates Medicare Advantage (MA or Part C) and the Medicare prescription drug benefit program (Part D) by promoting flexibility and innovation so that MA and Part D sponsors are empowered with the tools to improve quality of care and provide more plan choices for MA and Part D enrollees.

CMS took significant action to increase MA plan choices for plan year 2019 and aims to continue to expand opportunities to enrollees so they have access to MA plans that meet their unique health needs. In continuing the efforts to increase plan flexibility and plan choices for beneficiaries, CMS is proposing to provide additional flexibilities in the MA program that will allow more options and new benefits for beneficiaries.

In addition to creating opportunities for increasing plan flexibility and plan choices, CMS is making critical updates with respect to program integrity and taking steps to help the agency recover improper payments made to Medicare Advantage organizations. If finalized, the proposed changes would result in an estimated $4.5 billion savings to the Medicare Trust Funds over ten years, largely arising from recovery of overpayments to MA plans.

This fact sheet discusses the major provisions of the proposed rule (CMS-4185-P) that would improve MA and Part D quality and accessibility; clarify program integrity policies, and implement certain provisions of the Bipartisan Budget Act of 2018. The proposed rule can be downloaded from the Federal Register at:

Implementing the Bipartisan Budget Act of 2018 Provisions

CMS is proposing to implement several sections of the Bipartisan Budget Act of 2018 (Public Law 115-123):

  • Section 50323 allows MA plans to offer “additional telehealth benefits”;
  • Section 50311 requires increased integration of Medicare and Medicaid benefits and appeals and grievance processes for MA Dual Eligible Special Needs Plans (D-SNPs); and
  • Section 50354 requires the Secretary to establish a process to allow Part D plan sponsors to request extracts of Medicare Parts A and B claims data for their enrollees. 

Medicare Advantage Plans Offering Additional Telehealth Benefits
The Bipartisan Budget Act of 2018 allows MA plans to offer “additional telehealth benefits” not otherwise available in Original Medicare to enrollees starting in plan year 2020. Under this proposal, MA plans will have broader flexibility than is currently available in how they pay for coverage of telehealth benefits to meet the needs of their enrollees. In addition, we solicit comment on how to implement the statutory provision that if an MA plan covers a Part B service as an additional telehealth benefit, then the MA plan must also provide the enrollee access to such service through an in-person visit.

The Original Medicare telehealth benefit is narrowly defined and includes restrictions on where beneficiaries receiving care via telehealth can be located. CMS believes that the additional telehealth benefits in MA will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits. The proposed rule would give MA plans more flexibility to offer telehealth benefits to all their enrollees, whether they live in rural or urban areas. It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places including their homes, rather than requiring them to go to a health care facility to receive telehealth services. Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries. 

Integration Requirements for Dual Eligible Special Needs Plans (D-SNPs)
CMS is proposing to establish new minimum criteria for Medicare and Medicaid integration in D-SNPs for Contract Year 2021 and subsequent years. Pursuant to the requirements in the Bipartisan Budget Act, we propose to require that D-SNPs meet the integration criteria either by (1) covering Medicaid long-term services and supports and/or behavioral health services through a capitated payment from a state Medicaid agency; or (2) notifying the state Medicaid agency (or its designee) of hospital and skilled nursing facility admissions for at least one group of high-risk full-benefit dual eligible individuals, as determined by the state Medicaid agency.

Unified Grievance and Appeals Procedures for D-SNPs
CMS is proposing rules to unify Medicare and Medicaid grievance and appeals processes for certain D-SNPs and affiliated Medicaid managed care plans. The processes would apply to D-SNPs with fully aligned enrollment and the affiliated Medicaid managed care organization, where one organization is responsible for managing Medicare and Medicaid benefits for all enrollees. In such D-SNPs, enrollees will have simpler, more straightforward grievance and appeals processes. The Bipartisan Budget Act of 2018 requires compliance with unified grievance and appeal procedures beginning in Contract Year 2021.

Improving Program Quality and Accessibility

Medicare Advantage and Part D Prescription Drug Plan Quality Rating System
As part of our efforts to continually improve the Star Ratings methodology, we are proposing several measure updates, an enhanced methodology for determining cut points, and a policy to adjust the methodology for Star Ratings for affected Medicare Advantage and Part D plans in the event of extreme and uncontrollable circumstances, such as hurricanes. The proposed policy for extreme and uncontrollable circumstances is similar to the one implemented for the 2019 Star Ratings.

Based on stakeholder feedback to a proposed rule from earlier this year and analyses of the data, we are proposing an enhanced cut point methodology for data collected during the 2020 measurement year and associated 2022 Star Ratings that would improve stability and predictability and reduce the influence of outliers by implementing a guardrail so that cut points do not increase or decrease more than the cap from one year to the next.

We are proposing to modify the following existing measures:

  • Controlling High Blood Pressure (Part C) to align with new clinical guidelines related to hypertension.
  • Medicare Plan Finder Price Accuracy (Part D) to better measure the reliability of a contract’s advertised prices. 
  • Plan All-Cause Readmissions (Part C) to include observation stays and remove individuals with high frequency hospitalizations. 
  • Improvement measures (Part C and D) to exclude from the improvement calculation any measure that receives a measure-level Star Rating reduction for data integrity concerns for either the current or prior year. 

Program Integrity Proposed Policies
Preclusion List Requirements for Prescribers in Part D and Individuals and Entities in MA, Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE)

CMS announced in April 2018 that the agency would prohibit payment for Part D drugs and MA items or services that are prescribed or furnished by prescribers and providers on a “preclusion list”. CMS is now proposing to improve the preclusion list process to clarify the expectations for stakeholders. CMS is proposing to revise the following requirements: 

  • Length of time on the preclusion list for providers or prescribers with a felony conviction
  • Consolidation of the appeals process
  • Effective date for the consolidation of appeals
  • Timeframe for the addition to the preclusion list
  • Beneficiary appeals
  • Beneficiary held harmless
  • Beneficiary notification

Medicare Advantage Risk Adjustment Data Validation Provisions
CMS conducts contract-level Risk Adjustment Data Validation (RADV) audits to verify the accuracy of payments made to MA organizations and recover improper payments. In 2012, CMS released a white paper informing MA and Part D sponsors of its intention to extrapolate audit recovery findings starting with payment year 2011 contract-level audits. This proposed provision updates stakeholders on our plans to use various sampling and extrapolation methodologies in these and subsequent RADV audits.

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