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- Janet on What Sequestration Could Mean to Medicare Advantage Claims Payment
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Tag Archives: Medicare Advantage
On April 25, 2013 CMS issued a proposed update to the Benefits and Beneficiary Protections Chapter (Chapter 4) of the Medicare Managed Care Manual. The CMS cover letter provides a good summary of the changes that they are proposing to make. Most of the changes are clarifications to existing policy, for example, providing Medicare Advantage plans (MA) with the option of charging beneficiaries higher cost sharing for non-emergency out-of-network services and prohibiting MA plans from imposing policies that prevent enrollees from accessing a Part B drug administered in a physician’s office. CMS is removing the example of how total beneficiary cost-sharing (TBC) is calculated and instead stating that TBC requirements will be included in the Call Letter, as they did for 2014.
According to The Hill’s Elise Viebeck President Obama is receptive to combining Medicare Part A (in-patient hospital) and Part B (outpatient and doctor) deductibles, into a single deductible just like every other insurance scheme in the US. Predictably those to his left complained, maybe because Virginia’s Eric Cantor also likes the idea. The impact would raise the deductible for people who use only physician services, lower it for anyone who is hospitalized, and, net, save Medicare money by shifting more costs to beneficiaries. However, some of the savings would also be used to add an annual out-of-pocket cap on what beneficiaries would have to spend. This is good insurance logic: don’t cover relatively low cost, predictable expenses. Focus coverage on protecting beneficiaries from catastrophic loss.
The March 28 edition of Medicare Advantage News cites a possible trend for provider organizations to sponsor their own Medicare Advantage plans. In the waning days of the old Medicare+Choice program, many provider-sponsored plans came on hard times, so this may seem like an unusual reversal. However, Medicare Advantage lives up to its name, and offers advantages to sponsors as well as members. This includes risk adjusted capitation payments, the option to offer drug coverage that is subsidized by Medicare, and bonus payments for achieving quality targets. Even with the payment reforms imposed by the Affordable Care Act, Gorman Health Group is hearing from a number of provider organizations that the predictable capitation revenue under MA is looking preferable to the fee-for-service treadmill. Medicare fee-for-service reimbursement is becoming increasingly complex, and fee-for-service margins are eroding. The prospect of moving up the food chain is especially appealing to organizations whose costs are largely fixed. MA matches predictable fixed revenue to fixed costs, while FFS requires a constant scramble after variable revenues to achieve necessary margins.
Click here to review GHG’s comments in response to the Advance Rate Notice, submitted to CMS on March 1, 2013.
The Senate Finance Committee held a hearing on Medicare yesterday and received testimony by CMS Medicare chief Jon Blum. Almost a week after the shocking 45-day Notice for Medicare Advantage (MA) and Part D was released, Blum offered little in the way of good news on the 2014 rates.