RISE looks at the latest headlines involving Medicare Advantage.
MA health plans gear up for the potential of thousands of new members with ESRD
Modern Healthcare looks at the implications of new members with permanent kidney failure who will be able to enroll in Medicare Advantage plans for the first time in 2021. The Centers for Medicare & Medicaid Services expects 83,000 of these patients to switch to Medicare Advantage, with half of them enrolling in 2021, according to the publication.
Some insurers may do well financially, but others may be forced to raise premiums or slash benefits to compensate for the high cost of managing the population with end-stage renal disease (ESRD). Insurers have asked for higher payment rates for ESRD, but CMS did not change the ESRD rate methodology in its April rate announcement. “If you are a smaller health plan, a regional plan with less than 50,000 members, if you get more than your fair share (of ESRD patients), I think it would be very hard financially for these health plans to survive,” Jill Selby, a corporate vice president at California-based SCAN Health Plan, which has offered a Medicare Advantage special needs plan for ESRD patients since 2006, told the publication. (Modern Healthcare, subscription required)
HHS files appeal to reinstate MA overpayment rule
The Department of Health and Human Services last week filed an appeal in the federal Court of appeals for the District of Columbia Circuit to reinstate a rule that handles MA overpayments, according to FierceHealthcare.
Earlier this year a federal court denied a motion to reconsider its previous decision to vacate the 2014 CMS final rule that required MA payers to report and return overpayments. The case dates to 2016 when UnitedHealth challenged the rule, arguing that it was fundamentally unfair because the documentation that the government used to set rates to pay insurers was inconsistent with the documentation it used to determine if they overpaid them. (FierceHealthcare)
CMS calls on MA and Part D plans to waive prior authorization
CMS has updated guidance as of April 21 and will allow MA plans to waive or relax prior authorization requirements to facilitate access to services. The agency says plans must uniformly provide a relaxation or waiver to similar situated enrollees who are affected by COVID-19. The agency also said Part D sponsors can waive or relax requirements at any time for formulary drugs. The updated guidance was issued following a request from The American College of Cardiology, American College of Surgeons, and other health care societies that CMS ask MA plans waive prior authorization requirements during the COVID-19 pandemic. (CMS guidance)