Dive Brief:
- The CMS has agreed health plans serving large populations of enrollees dually-eligible for Medicare and Medicaid have been underpaid, though it did not say by how much. In addition, the agency announced plans to address the issue by modifying its risk-adjustment model.
- The position is a turnaround for the agency, which has previously disagreed with arguments its quality ratings and risk adjustments have posed disadvantages to plans serving those with low incomes and more complex healthcare needs.
- CMS changed course after looking back at its 2014 plan data in a retrospective analysis.
Dive Insight:
CMS' plans to modify its risk-adjustment model comes on the heels of a related revelation that the agency is looking into adjusting its Medicare Advantage quality ratings to factor in the socio-economic characteristics of a plan's enrollees, as Modern Healthcare notes--indicating the agency is embracing input from the industry.
“What I want you to take away from this is that the industry brought an issue to us, and we took it seriously—there is some substance to it,” Sean Cavanaugh, director of the Center for Medicare, stated at a recent America's Health Insurance Plans (AHIP) Medicare conference.
To address underpayment for dual-eligibles, CMS has released a notice proposing changes to its CMS-HCC Risk Adjustment Model for payment year 2017 it expects to result in more accurate payments. Comments are being taken until Nov. 25.