Medicare Advantage 2020 Proposed Rule

It’s been a long wait since the passage of the Bipartisan Budget Act in February, but the 2020 Medicare Advantage (MA) proposed rule is finally here. Perhaps the biggest opportunity for plans is the shift that makes telehealth a basic benefit, which means the digital revolution that brought us things like ATMs on every corner, iPhones, and Teslas is finally seeping into Medicare. Plans can decide which benefits to provide via telemedicine in any geography. What is really exciting is the service can be delivered to the patient in the home. This is a tremendous opportunity to bring continuity to episodes of care that will really impact outcomes. It will also be possible for plans to offer telehealth services as a supplemental benefit. Additionally, it’s an opportunity for MA to offer new advantages over Original Medicare where telemedicine is still restricted to rural areas and the patient must be in a health facility to partake in the services.

Star Ratings are in for some changes, too. Measures with proposed changes will include Medicare Plan Finder price accuracy, all-cause readmission, and controlling high blood pressure.  Additional enhancements will be made to CMS’ methodology to adjustments will be made to handle unusual situations beyond a plan’s control like the fires and hurricanes that seem to be less unusual as of late.

The Centers for Medicare & Medicaid Services (CMS) gives, but, unfortunately, it also takes. On the program integrity side, the agency proposes using extrapolation in the Risk Adjustment Data Validation audits. That is a definite cloud on the horizon for plans as the regulation predicts a return to the program of $4.5 billion for the government over 10 years. Since 2012, CMS has held extrapolation from a valid sample of records was coming, and now there is an opportunity to comment on the specific methodology that might be used. Comments on the proposed rule are due 12/31. Happy New Year.



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David Sayen
David Sayen

David Sayen is Senior Vice President of Client Relations at Gorman Health Group (GHG). In this role, David guides GHG clients in developing strategies to respond to rapidly changing federal program opportunities. David recently joined GHG after a distinguished career at the Centers for Medicare & Medicaid Services (CMS), most recently as the Administrator of the San Francisco Regional Office.

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