CMS Requests Input on Health Plan Innovation Initiatives

Health Care and Life Sciences Client Alert

Epstein Becker Green Health Care and Life Sciences Client Alert

Medicare Advantage (“MA”) plans, prescription drug plans (“PDPs”), and other stakeholders have until November 3, 2014, to provide input into the Centers for Medicare & Medicaid Services’ (“CMS’s”) consideration of potential models to test a range of innovations in the Medicare and/or Medicaid managed care programs, including value-based insurance design (“VBID”), beneficiary incentives, and remote access technologies. CMS released a request for information (“RFI”) on Health Plan Innovation Model Concepts [1] on October 10, 2014. Through the RFI, CMS is specifically seeking information on stakeholder experiences with and perspectives on the following Medicare and/or Medicaid product types:

  • Stand-Alone Medicare PDPs
  • Medigap and Retiree Supplemental health plans
  • MA and MA Prescription Drug (MA-PD) plans
  • Medicaid managed care plans

The information gathered will help CMS assess whether mechanisms used in the non-Medicare/Medicaid markets to reduce costs, improve quality, and enhance beneficiary satisfaction should be tested in the referenced product types. While leaving open consideration of additional approaches, the RFI identifies particular mechanisms that CMS is considering in connection with PDPs, MA, and MA-PDs, including the following:

  • PDPs—CMS is interested in testing a “robust medication therapy management (MTM) program” and use of cost-sharing differentials to improve care coordination, care cost management, and outcomes.
  • MA and MA-PDs—CMS references testing of VBID, remote access technologies, and the integration of hospice care as among the approaches for improving the MA and MA-PD programs.

With respect to PDPs, CMS suggests that tested programs could employ MTM services of variable intensity and delivery depending upon beneficiary risk level, in conjunction with financial incentives to reinforce the MTM goals.

For MA and MA-PD plans, CMS is considering using VBID to encourage enrollees with specific chronic conditions to seek high-quality, low-cost care through the use of cost-sharing incentives. While the RFI does not specifically reference Special Needs Plans (“SNPs”), SNPs are a type of MA plan, some of which specifically target beneficiaries with chronic health conditions. Accordingly, chronic care SNPs could have particularly relevant experience to provide to CMS on the potential use of VBID or other mechanisms and could also benefit from any initiatives that result from the proposed innovations.

Availability of remote access technologies, beyond that covered under conventional Medicare, is being considered to allow health care providers in MA and MA-PDs to provide care to patients in remote locations in order to improve the accessibility and timeliness of needed care as well as care coordination. Among other things, CMS is seeking information regarding the type of acceptable modalities, services to be covered, and quality metrics. With respect to hospice care, such services are currently carved out of the MA and MA-PD programs, with Medicare hospice services covered under original Medicare, even for MA and MA-PD enrollees. Further, beneficiaries electing hospice under Medicare must generally forgo curative treatment in order to access hospice’s palliative care services. CMS is seeking input on the factors that it should consider in developing a model to integrate hospice services into the MA/MA-PD benefit package, while maintaining access to curative care.

Respondents are asked to draw their input from “objective, empirical, and actionable evidence” and cite this evidence in their responses. As this is solely a request for information, it is unclear whether CMS would provide additional funding for entities to participate in testing the chosen innovations.

* * *

This Client Alert was authored by Helaine I. Fingold, Lynn Shapiro Snyder, and René Y. Quashie. For additional information about the issues discussed in this Client Alert, please contact one of the authors or the Epstein Becker Green attorney who regularly handles your legal matters.

IRS Circular 230 Disclosure
To ensure compliance with requirements imposed by the IRS, we inform you that any tax advice contained in this communication (including any attachments) is not intended or written to be used, and cannot be used, for the purpose of: (i) avoiding any tax penalty, or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein.