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As noted in a previous Alert, the Center for Medicare & Medicaid Services (CMS) recently finalized their 2018 Call Letter.  In the same document, CMS issued a Request for Information regarding ideas for “regulatory, sub-regulatory, policy, practice and procedural changes to better accomplish” the goals of “using transparency, flexibility, program simplification and innovation to transform the [Medicare Advantage] and Part D programs for Medicare enrollees to have options that fit their individual health needs.”

In response to this request, the Center submitted comments, in collaboration with several other consumer advocacy groups.

The Center’s comments began with an overarching statement: “while we recognize CMS’ stated intention to maintain benefit flexibility and efficiency throughout the MA and Part D programs, we stress that CMS’ focus should not be on rolling back regulations, reducing oversight or minimizing plan sponsor burdens. We anticipate that many plan sponsors will vigorously push for reduction in regulations and oversight – we think granting such requests would be a dangerous path.  Rather, we urge CMS to focus squarely on ensuring Part C and D enrollees (and the broader Medicare population) have access to and receive timely, quality health care.  CMS needs to ensure that MA and Part D plans provide what taxpayers are paying for; ultimately, both beneficiaries and taxpayer dollars must be safeguarded.”

The Center’s comments touched on a range of issues including the following:

  1. Beneficiary Support and Education
  • Support State Health Insurance Assistance Programs (SHIPs) – do not cut funding for this vital program
  • Improve notices that MA and Part D plans provide to individuals
  • Promote active and informed plan choices
  1. Medicare Advantage
  • Based on our experience assisting MA enrollees, coupled with research showing that MA plans might not serve sicker enrollees as well as they serve healthier ones, essential consumer protections must be preserved (with additional suggestions for improving existing protections)
  • Oversight of plan sponsors must increase
  • CMS must ensure that Medicare Advantage payment is accurate and that public funds are adequately protected, including greater  oversight of “upcoding” – when an MA plan inappropriately reports an enrollee as being more sick than they actually are in order to obtain a higher risk-adjusted payment (see note below)
  1. Part D
  • Streamline the Part D appeals process
  • Remove restrictions on Part D Tiering Exceptions
  • Protect Nursing Home Residents from the Inappropriate Prescribing of Antipsychotic Drugs

Note re: Inappropriate MA Payment

The Center is encouraged that Senator Chuck Grassley (R-IA), Chairman of the Senate Judiciary Committee, recently sent a letter to CMS about Medicare Advantage upcoding.  As Senator Grassley noted in his letter, “[b]y all accounts, risk score gaming is not going to go away.  Therefore, CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies.  The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake.”  We applaud the Senator for seeking answers to several questions, including the following raised in his letter:

1.  What steps will CMS take, or is currently taking, to ensure that insurance companies are not fraudulently altering risk scores?  Please explain…
4.  In the past two years, how many Medicare Advantage audits have been performed?  How many audits are currently ongoing?”

As the Center has noted elsewhere, we are deeply concerned by ongoing improper payments to MA plans and CMS’ lack of progress in recouping previous payments and deterring future misconduct.  In order to ensure that the traditional Medicare program is not further disadvantaged by inappropriate overpayments to MA plans, CMS must employ more rigorous oversight of MA payment.

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