CMS Gives Medicare Advantage Plans A Raise

April 3, 2018

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Source: Modern Healthcare

The CMS finalized a rule Monday giving Medicare Advantage plans a 3.4% pay hike in 2019. That’s well above the 1.84% bump the agency initially proposed and higher that [sic] the 2.95% increase for 2018.

The CMS is also moving forward with plans to increase the use of encounter data to determine risk scores for plans. As a result of the finalized rule, 75% of Medicare Advantage risk scores will be based on traditional fee-for-service data, and 25% based on encounter data. That differs from 2018, when the agency used a risk score blend of 85% fee-for-service data and 15% encounter data.

Stakeholders such as the American Hospital Association have pushed back at using encounter data after a January 2017 Government Accountability Office report found such information often isn’t accurate.

“Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased percentage of encounter data in the blend,” the agency said in a release Monday.

The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Instead, they’ll be locked into one pharmacy or prescriber for Medicare Part D benefits.

This lock-in will limit an at-risk beneficiary’s access to coverage for frequently abused drugs to those that are prescribed by a specified pharmacy or provider.

Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.

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