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On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) issued its draft 2019 Call Letter, an annual set of proposed rules, guidelines and clarifications for Part C Medicare Advantage (MA) and Part D plans that wish to participate in Medicare in the following calendar year.  In collaboration with several other advocacy organizations, the Center for Medicare Advocacy drafted and submitted comments regarding the draft Call Letter. The full comments are available at

The Center’s comments included the following points:

  • Part C and D Plan Star Ratings – we raised concern about the proposal to remove the Beneficiary Access and Performance Problems (BAPP) measure from the Star Rating system. We are troubled that the new measure would only take into account notices of non-compliance, warning letters and ad-hoc corrective action plans, without including sanctions and civil money penalties imposed by CMS. We believe that decoupling audits and enforcement actions from the Star Ratings undermines the integrity of the Star Ratings system. We urged CMS to ensure that the Star Rating system does not mask or otherwise minimize plan conduct that puts Medicare enrollees at risk.  Particularly when CMS finds that a plan’s conduct poses a serious threat to the health and safety of Medicare beneficiaries, that finding must have an impact on overall ratings.
  • Plan Finder Civil Money Penalty (CMP) Icon or Other Type of Notice – We offered support for CMS’ proposal to display an icon or other notice on the Plan Finder to alert beneficiaries when a sponsoring organization has received a Civil Monetary Penalty (CMP).
  • Meaningful Difference (Substantially Duplicative Plan Offerings) – In a recent proposed Part C and D rule, CMS proposed to eliminate the meaningful difference requirement that MA insurance company plan sponsors that wish to offer more than one plan in a given service area ensure that the plans are substantially different. While CMS noted in the Call Letter that it was still reviewing comments about the proposed rule, we reiterated our opposition to this proposal, as outlined in our comments to the proposed rule.  As noted in our comments, there exists a large body of research and analysis that explores the challenges consumers face in making choices about their health insurance coverage, including when there are a multitude of plan options, with little to no standardization. Much of the findings in this work weigh against CMS’ proposal to loosen both meaningful difference standards and uniformity requirements (discussed below).  Rather than loosening plan requirements, which will result in making informed choices far more difficult for beneficiaries, we urged CMS to instead focus on addressing current methods of beneficiary decision-making, including enhancing consumer-directed tools, also discussed in our comments to the proposed rule.
  • Health Related Supplemental Benefits – CMS intends to expand the scope of the primarily health related supplemental benefit standard by reinterpreting the statute “to permit MA plans to offer additional benefits as ‘supplemental benefits’ so long as they are healthcare benefits.” Following issuance of the draft Call Letter, the Bipartisan Budget Act (BBA) of 2018 was signed into law on February 9, 2018.  Section 50322 of the Act, entitled “Expanding Supplemental Benefits to Meet the Needs of Chronically Ill Medicare Advantage Enrollees”, states that starting in plan year 2020, MA plans can provide supplemental benefits to chronically ill enrollees. 

    On the one hand, we noted that this expansion of benefits has the potential to improve the lives of MA plan enrollees by providing coverage of services and items they otherwise might not be able to obtain.  On the other hand, we note that the rationale of “enhanc[ing] beneficiaries’ quality of life and improv[ing] health outcomes” is equally compelling for all Medicare beneficiaries, not just those who enroll in Medicare Advantage plans.  We urged CMS – and Congress – to promote policies that maintain a level playing field between traditional Medicare and MA to ensure that the full range of covered items and services are equally available to all beneficiaries without regard to how they choose to receive their benefit.

  • Medicare Advantage (MA) Uniformity Flexibility – CMS first articulated a reinterpretation of the MA plan uniformity standards in a recent proposed Part C & D rule (referenced above) to “permit MA organizations the ability to reduce cost sharing for certain covered benefits, offer specific tailored supplemental benefits, and offer lower deductibles for enrollees that meet specific medical criteria, provided that similarly situated enrollees (that is, all enrollees who meet the identified criteria) are treated the same and enjoy the same access to these targeted benefits.” 
  • Unlike the proposed change to MA meaningful difference requirements, however, CMS presents its new interpretation of MA uniformity requirements in the draft Call Letter as if it is final policy, without consideration of comments to the proposed C and D rule.  This policy change, which could dramatically increase the range of benefits and cost-sharing between plans, risks allowing some MA plans to devise discriminatory plan designs, intentionally or otherwise.  Such flexibility begs the question whether CMS will have the capacity to adequately review plan benefit packages for discriminatory designs.  Further, CMS began to test Value-Based Insurance Design (VBID) through the Centers for Medicare and Medicaid Innovation (CMMI) beginning in January 2017. The Demo is limited by condition, geography and plan and incorporates significant consumer protections.

    By loosening uniformity standards for all plans, CMS is putting the proverbial cart before the horse by scaling up an experiment before we have meaningful results, including whether such flexibility – even for a much smaller cohort with specific conditions – improves health outcomes.  The Bipartisan Budget Act of 2018, signed into law on February 9, 2018 following issuance of the draft Call Letter, expands testing of the VBID demonstration nationally by 2020. Through this provision of the Budget Act, Congress has expressed its intent to introduce flexibility in MA benefits through the parameters of the pre-existing VBID demonstration model, including the built-in consumer protections.  Loosening uniformity requirements in the manner CMS proposes could – by itself – create a chaotic environment for Medicare beneficiaries trying to make informed decisions about what options might be best for themselves.  To do so without issuing strong guard rails in the form of consumer protections and more firm restrictions on plans is a stark departure from the more thoughtful and cautious approach recently taken by CMS in rolling out the VBID Demo.  

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