CMS Releases Draft Payment and Coverage Rules for Private Medicare Plans
Last Friday, the Centers for
Medicare & Medicaid Services
(CMS) released the 2012 Advance Notice and draft Call Letter for Medicare private health plans, also known as Medicare
Advantage (MA) plans, and Medicare prescription drug plans. The Call Letter sets forth changes to bid, payment and coverage policies for private plans offered through Medicare Part C and Part D.
In the 2012 draft Call Letter, CMS uses authority provided by the Affordable Care Act (ACA) to require review and potentially limit enrollment for MA plans that raise premiums by more than ten percent, as compared to 2011 rates. Other new proposals in the draft Call Letter address bonus payments and incentives for MA plans that achieve high ratings under the star rating system used to measure MA plan quality. CMS proposes providing bonus payments not only to plans with the highest star ratings—four and five stars—but also to plans with a rating of three stars. The dollar amount of bonus payments will be tied to the number of stars a plan receives. In addition, CMS proposes allowing five-star MA plans to enroll Medicare consumers year-round, rather than only within the traditional fall enrollment period.
The draft Call Letter also provides specific numbers for the 2012 plan year, such as out-of-pocket limits and deductibles for Medicare Advantage and the initial coverage limit and out-of-pocket threshold for Medicare Part D. CMS will accept comments through Friday, March 4, 2011.
Read the 2012 Advance Notice and draft Call Letter.
Report Examines History and Trends of Quality Ratings for Medicare Advantage Plans
The Centers for Medicare & Medicaid Services (CMS) has proposed providing quality bonuses to Medicare private health plans, also known as Medicare Advantage (MA) plans, that receive a rating of at least three out of five stars. According to a report released by the Kaiser Family Foundation, this proposal would make the majority of MA plans in the market eligible for extra payments. The report, Reaching for the Stars: Quality Ratings of Medicare Advantage Plans, 2011, explains the background of the star rating system, which is used to measure the quality of MA plans, and examines trends in star ratings. In addition, the paper describes the new meaning given to star ratings as the result of the Affordable Care Act (ACA), which provides “bonus payments” to plans with ratings of at least four stars.
This year, CMS proposed expanding these bonus payments to also include plans that receive three stars. While ratings of four and five stars indicate that plans exhibit above-average to excellent performance, three-star ratings indicate average performance. Kaiser estimates that 24 percent of people in Medicare Advantage plans in 2011 are enrolled in plans with four or more stars, and about 60 percent of Medicare Advantage consumers are in plans with a star rating of three or three and half stars.
Read the Kaiser Family Foundation’s report.
If your Medicare private health plan is refusing to pay for care you have already received, you have the right to appeal.There are several stages to the process, and there are deadlines you must meet.
Note: If your plan will not approve care that you need and have not yet received, you are entitled to a faster appeal.
Below are the steps you must take to file a “standard” appeal. Make sure to keep any notices you receive from your plan, and write down the names of any representatives you speak to and when you spoke to them.
- Get a Denial Notice
- Request a Reconsideration
- Get the Plan’s Decision
- Get an Independent Review
- Continue to Additional Levels of Appeals
Learn more about each step of the appeals process at www.MedicareInteractive.org.
A survey published this week by the Commonwealth Fund indicates that a majority of health care experts support the Affordable Care Act and the path it has set for the American health care system.
Read the survey results.