October 31, 2018

A proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) would expand telemedicine services for Medicare Advantage (MA) plan enrollees while enhancing the methods used to scrutinize MA program integrity.

Among other things, the proposals would implement provisions of the Bipartisan Budget Act of 2018, which enables MA to expand telehealth benefits for beneficiaries beginning in 2020 and to treat these services as basic benefits for payment by CMS.

If approved, the proposal would allow MA plans to offer additional telehealth benefits as part of the basic benefits package and would allow plans to offer enrollees telehealth benefits whether they live in rural or urban areas. However, plan participants would have the option to receive the service through an in-person visit or as an additional telehealth benefit.

“We believe additional telehealth benefits would increase access to patient-centered care by giving enrollees more control to determine when, where and how they access benefits,” the proposed rule states. In a statement, CMS Administrator Seema Verma said the changes would facilitate innovations that are more responsive to patient needs.

Also in keeping with provisions of the Bipartisan Budget Act of 2018, the proposed rule calls for the development of a streamlined and unified grievance and appeals process for Dual Eligible Special Needs Plans (D-SNPs) serving Medicare and Medicaid beneficiaries, as well as the establishment of new standards for integrating these benefits.

Specifically, among other things, the proposal requests that the new procedures give weight to the existing grievance provisions that are most protective of enrollees, be easy for participants to navigate, incorporate a single written notification of all grievance and appeal rights, provide a single pathway for resolution, and incorporate existing law providing continuation of benefits pending appeal. The unified procedures would be required to be established by April 1, 2020 and put into use by state Medicaid agencies by 2021.

CMS proposes two enhancements to the Star Ratings system’s current methodology to determine cut points for non-CAHPS measure stars. The first, mean resampling, would reduce the sensitivity of the current clustering algorithm to outliers and reduce the random variation that contributes to fluctuations, improving the cut points’ stability with time. The second enhancement would be a “guardrail” for measures that have been included in the Part C and D Star Ratings system for more than three years.

Another key provision in the proposed rule would heighten review of the data MA plans submit that may be contributing to overpayments. The proposal suggests the use of extrapolation and sampling of sub-cohorts of enrollees as methods to identify improper payments.

Comments on the proposed rule must be received by December 31, 2018. A fact sheet on the proposed rule is available here.  The complete proposed rule is available here.