- CMS will boost payment to Medicare Advantage and Part D plans by 1.66% for the 2021 plan year, the agency said Monday in its finalized rate release. Earlier this year, it originally proposed a bump in payment of just 0.93%.
- CMS will rely more on detailed encounter data to calculate risk scores for payment rather than members' diagnoses. For 2021, MA will use 75% of encounter data and 25% of the former Risk Adjusted Processing Systems-based score. That is unchanged from the proposal.
- Those with end-stage renal disease will now be able to enroll in MA plans starting Jan. 1, 2021. However, plans will not be responsible for the acquisition cost of organs, in this case the cost of a kidney. That will be paid for under the traditional fee-for-service Medicare program.
The finalized rate comes amid the novel coronavirus pandemic and a great deal of uncertainty regarding how long the crisis will last and what the ultimate effect will be on payers and providers.
Still, CMS said the rate release for next year is an example of how the agency is "focused on implementing the policies that matter most for ensuring continuous and predictable payments across the health care system."
MA is viewed as a significant growth driver for many of the nation's largest health insurers. More than 22 million seniors enrolled in MA plans in 2019. Given the popularity of the program, CMS has tried to provide more flexibility to plans allowing them to be reimbursed for services outside of the traditional scope of healthcare, including for meals and carpet cleaning for asthmatics.
However, insurers have been critical of CMS using more encounter data, or detailed information about visits to providers and the services delivered there. Insurers are concerned the encounter data will ultimately reduce payments. Traditionally, the program has relied on diagnoses for risk-score payments. For this year, the mix of encounter and RAPS data is 50/50.
But moving away from a reliance on diagnoses may help crack down on alleged fraud.
Last month, the nation's second largest private insurer, Anthem, was sued by the U.S. Department of Justice for allegedly failing to fix inaccurate diagnosis codes and in return receiving millions in overpayments. Anthem said it plans to vigorously defend its practices.