CMS Finalizes Plan Regulations and Guidance for 2013
This week, the Centers for
Medicare & Medicaid Services
(CMS) announced its final
payment and coverage rules
for Medicare private health
plans, also known as Medicare
Advantage (MA) plans, and prescription drug plans for the plan year beginning January 1, 2013. The guidance specifies basic benefit parameters for 2013, including the amount of the Part D deductible ($325), initial coverage limit ($2,970), and out-of-pocket threshold ($4,750).
The final rules and guidance institute policies that would allow CMS to terminate contracts with MA plans that receive less than a three-star quality rating for three consecutive years. Advocates, including the Medicare Rights Center, were supportive of this policy, believing that consistently low ratings demonstrate that a plan is performing poorly and may be unsuitable for beneficiaries. CMS also continues to implement improvements to the Medicare program made possible through the Affordable Care Act, including the continued closure of the Medicare prescription drug coverage gap.
CMS’ final rules and guidance back away from policies proposed in October 2011 that would have reduced conflicts of interest for consultant pharmacists working in long-term care settings. The policies were proposed because reports had demonstrated that associations with drug companies and other entities may cause pharmacists in nursing home settings to improperly prescribe medications, such as anti-psychotics. Unlike the proposed rule, the final rule and guidance do not require nursing homes and other long-term care facilities to work with independent pharmacists. However, in response to comments on the rule, CMS stated that the agency believes these conflicts of interest remain a programmatic problem, and it will continue to explore issues of conflict of interest for future rulemaking.
Final regulations and guidance for 2013 also allow certain special needs plans (SNPs) for dual eligibles, or people with both Medicare and Medicaid, greater flexibility in the extra benefits they may offer to their members. These benefits include non-traditional services that assist individuals with activities of daily living. CMS clarified that such additional benefits must be offered at zero cost-sharing and cannot be reflected by charging higher premiums. Additionally, in response to concerns voiced by Medicare Rights and other advocates, CMS will require SNPs to demonstrate specifically that there is no significant overlap between the extra benefits offered by the plans and those that might already exist through Medicare, Medicaid or other local benefit programs. However, CMS needs to further clarify its oversight and review of plan submissions to ensure that the information provided is accurate.
Read CMS’ fact sheet on the final rule and Call Letter for 2013.
Read the final rule.
Read the final 2013 Call Letter.
Reports Describe the Roles of Medicare and Medicaid for Dual Eligibles and New CMS Guidance Released for Plans on Medicare and Medicaid Integrated Products
Two updated briefs released by the Kaiser Family Foundation (KFF) discuss the roles of Medicare and Medicaid for dual eligible beneficiaries, or individuals who have both Medicare and Medicaid. According to the reports, in 2008, 9.1 million older adults and people with disabilities were dual eligibles. Compared to other Medicare beneficiaries, a larger number of dual eligibles were in fair or poor health.
Specifically, KFF found that almost half of all dual eligibles were in fair or poor health, compared to about 22 percent of their non-dual eligible counterparts. In addition, dual eligibles had higher rates of cognitive and mental impairments, chronic conditions and hospitalizations, and more lived in an institutional setting compared to other Medicare beneficiaries.
Though this population represents a small percentage of the total number of people with Medicare or Medicaid, dual eligibles account for proportionally higher amounts of spending in both programs, partially as a result of their greater health needs. In 2008, dual eligibles represented 15 percent of Medicaid enrollment, but accounted for 29 percent of all Medicaid expenditures. According to the KFF report, however, these proportions vary significantly across states. Furthermore, spending on duals was higher for those with greater health and long-term care needs. While only 14 percent of dual eligibles were in institutional care settings, such as nursing homes, these individuals accounted for 69 percent of all Medicaid spending on the dual eligible population.
In Medicare, on average, spending was 1.8 times higher for dual eligibles compared to other Medicare beneficiaries. As in Medicaid, a small number of those dual eligibles accounted for a substantial portion of Medicare spending within the greater dual eligible population. For example, though dual eligibles as a whole had higher rates of hospitalization than other Medicare beneficiaries, 74 percent of all dual eligibles themselves were not admitted to the hospital in 2008. The differences in utilization patterns and spending within the dual eligible population demonstrate the diversity of this group and indicate that different approaches and interventions may be required for such a population, with its varied needs.
In other news, the Centers for Medicare & Medicaid Services (CMS) and the Medicare and Medicaid Coordination Office (MMCO) released additional guidance to private plans interested in offering capitated financial alignment demonstration plans in states. These demonstration projects allow Medicare, Medicaid and private plans to enter into three-way contracts, under which a private plan would provide both Medicare and Medicaid benefits to its members. CMS’ additional guidance provides more information on plan selection requirements, as well as the deadlines by which plans must submit information on integrated models of care, formularies, and plan benefit packages. The memo also discusses the criteria that CMS will use to assess and approve models of care submitted by plans.
Read the KFF report, “Medicare’s Role for Dual Eligible Beneficiaries.”.
Read the KFF report, “Medicaid’s Role for Dual Eligible Beneficiaries.”
Read CMS and MMCO’s guidance to private plans.
How you appeal a denial for a service you have received depends on whether you have been denied by Original Medicare or your Medicare private health plan, also known as a Medicare Advantage plan.
If Original Medicare will not pay for care you received, you will find out when you receive your Medicare Summary Notice (MSN). An MSN is a summary of the claims that have been submitted to Medicare. It is not a bill. Find out first whether there was a mistake. Sometimes providers accidentally use the wrong billing or diagnostic codes when submitting claims. This can result in a denial that is easily resolved by your doctor resubmitting the claim with the correct codes. If your doctor believes the claim was correctly coded, you should appeal.
If you are enrolled in Original Medicare, follow the instructions on your MSN for how to appeal. If possible, get a letter from your health care provider stating why the service you received was medically necessary, and send the letter with your appeal.
If you are enrolled in a Medicare Advantage plan, you should get a written denial notice from your plan if you have not already received it. The notice will tell you what information you need to send to the plan to start an appeal. Ideally, you should include a supporting statement from your doctor explaining why the service you received was medically necessary.
Even if the denial is upheld after your first appeal, you have the right to continue to further levels of the appeals process.
Learn more about appealing denials, including pre-service denials and denials issued by your Part D plan, at www.medicareinteractive.org