Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. 

The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.   

EXPANSION OF TELEHEALTH WITH 1135 WAIVER: Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.  A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients.  

 KEY EXCEPTIONS to note for the duration of the COVID-19 Public Health Emergency

• At-Home Telemedicine is permissible: While patients must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.

• Providers *may* see new patients via telemedicine: To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency. 

​

• Good Faith HIPAA Waiver: Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.  Please visit Health & Human Services HIPAA, Civil Rights and Covid-19 page for more information. ​

Nineteen percent of Medicare Advantage beneficiaries said that they forget to take prescribed medications; of those, 24 percent said they forget at least once per week. 

Fifteen percent of respondents noted that a reminder system would help them with adherence. The survey results are based on a 2018 survey of 781 Medicare Advantage beneficiaries with at least one chronic condition conducted by Health Action as a Service company, HealthMine.

​For Medicare Advantage plans, drug adherence is a key factor in Star ratings. Star Ratings have been created to measure the performance of Medicare plans. These ratings include three measures of drug adherence targeting chronic disease: 1) Medication Adherence for Diabetes Medications, 2) Medication Adherence for Hypertension, 3) Medication Adherence for Cholesterol. This is indicated in the CMS, Medicare 2019 Part C & D Star Ratings Technical Notes, updated 11/08/2018, page 100. Those measures are given triple weight among all Star Ratings measures. 

The results are in line with a 2014 study of 586 Medicare beneficiaries entitled: Medication adherence behaviors of Medicare beneficiaries. It was conducted with the approval of the Institutional Review Board of the University of the Pacific. The study revealed 30 percent were non-adherent. The following reasons were provided: 73 percent, forgetfulness; 11 percent, side effects; 10 percent, the medication was not needed. Lower adherence rates were also associated with difficulty paying for medication, presence of a medication-related problem, and certain symptomatic chronic conditions. 

Medicare Advantage (MA) plans are not doing enough to motivate their members to improve their personal health, according to a new survey from HealthMine.

Sixty percent of members participating in the poll said that their MA plans do not offer any incentives for engaging with healthcare providers or making lifestyle improvements, leaving individuals on their own to meet their wellness goals. All of the beneficiaries participating in the survey have at least one chronic disease.  Yet respondents feel as if their MA health plans are not taking steps to make it easier to manage their conditions.

Three-quarters stated that instead of sending personalized recommendations, their plans will offer generalized advice, such as suggesting a flu shot during the winter. Just fifteen percent have received messaging specific to their diagnosed chronic disease.  Thirty-five percent said that they have never received a reminder of any kind from their MA plan.

Medicare Advantage enrollment is skyrocketing as more beneficiaries enter the over-65 age bracket.  From plan year 2018 to plan year 2019, enrollment in MA plans increased by 12 percent, according to a recent report from Mark Farrah Associates.  Since 2015, MA membership has seen a 125 percent increase.

With 21 million total members, MA plans represent a large segment of the overall insurance market – and a highly lucrative opportunity for payers who can attract and retain beneficiaries.

Personalization is likely to play an important role in generating consumer loyalty. Tailoring communication strategies to meet the preferences of each member is an important place to start. Generalizing, older Medicare Advantage beneficiaries may prefer phone communication, or email, while those between the ages of 65 to 70 years might gravitate more to texting and digital communications.

More than three-quarters of Medicare Advantage members are using Internet of Things devices, such as blood pressure monitors, fitness wearables, blood sugar monitors, and cardiac monitors, to keep track of their personal health and chronic diseases.

But only 8 percent said their health plan can harness this data to make suggestions about chronic disease management or connect them with resources that could help improve their quality of life. Almost half of respondents said they rarely or never get answers to their questions.  Thirty-one percent said they don’t have access to connected care services that could reduce their spending and improve their health.
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Bridging the divide between member preferences and MA plan capabilities will be essential for generating sustained engagement, equipping members with actionable tools, and, ultimately, lowering the costs of care. MA plans that wish to succeed in an increasingly competitive environment will need to take a more proactive stance towards communicating with members how and when they desire it to ensure that beneficiaries feel motivated to complete important chronic disease management tasks.

https://healthpayerintelligence.com/news/60-of-medicare-advantage-members-feel-little-motivation-from-plans

Model would reflect the number of conditions and add categories for mental health, substance use disorder, and chronic kidney disease.

The Centers for Medicare and Medicaid Services is proposing to phase-in changes to the way it calculates risk adjustment payment to Medicare Advantage plans. Starting in 2020, CMS will calculate payments using a blend of 50 percent of the risk adjustment model first used for payment in 2017 and 50 percent of the new risk adjustment model proposed, but not finalized, in the 2019 rate announcement.

The new model adds variables that count the number of conditions a beneficiary may have. It includes additional condition categories for mental health, substance use disorder, and chronic kidney disease. Building on the model being used for 2019, it includes technical updates such as calibrating the model with more recent data and selecting diagnoses with the same method used for encounter data.

WHY THIS MATTERS
The advance notice issued is Part I of the 2020 advance notice of methodological changes for Medicare Advantage capitation rates and Part D payment policies.Risk scores determine payment. The model is designed to reduce incentives for payers to enroll healthier members, by giving them reimbursement for higher-risk and costlier beneficiaries.

The 21st Century Cures Act requires CMS to make adjustments to the risk adjustment model to take into account the number of conditions an individual beneficiary may have, in addition to other factors in the existing model. Further, the 21st Century Cures Act requires that CMS fully phase in the required changes to the risk adjustment model by 2022.

THE TREND
CMS calculates risk scores using diagnoses submitted by Medicare fee-for-service providers and by Medicare Advantage organizations. Historically, CMS used diagnoses submitted by Medicare Advantage organizations.

In recent years, CMS began collecting encounter data from Medicare Advantage organizations.
In 2016, CMS began using diagnoses from encounter data to calculate risk scores, by blending 10 percent of the encounter data-based risk scores with 90 percent of the risk-adjustment processing system, or RAPS-based risk scores.

In 2017, CMS continued to use a blend to calculate risk scores, by calculating risk scores with 25 percent encounter data and 75 percent RAPS. In 2018, it used 15 percent encounter data and 85 percent RAPS; and in 2019, 25 percent encounter data and 75 percent RAPS. The new model will determine risk scores by adding 50 percent of the score calculated from diagnoses from encounter data, RAPS inpatient diagnoses and fee-for-service diagnoses, with 50 percent of the risk score calculated with diagnoses from RAPS and fee-for-service diagnoses.

​https://www.healthcarefinancenews.com/news/cms-releases-2020-medicare-advantage-risk-adjustment-payment-model

One the largest non-profit Medicare Advantage (MA) health insurance companies in the nation is open to working with senior living providers as new benefits are rolled out in 2019.

Senior housing operators across the country are evaluating Medicare Advantage opportunities in light of a change announced last April. That’s when the Centers for Medicare & Medicaid Services (CMS) stated that MA insurers would be allowed to cover non-skilled in-home care starting in 2019. Considering that assisted living providers often perform this type of care, such as helping residents with bathing and dressing, the CMS change opened up the possibility that MA dollars could start flowing to senior housing and care companies.

Only a small percentage of MA plans are offering these new supplemental benefits next year, according to data from AARP and health care consulting firm Avalere. However, a few insurance companies are offering some new benefits, including Long Beach, California-based SCAN, which announced its “Returning to Home” and “Home Advantage” offerings in mid-November.

SCAN serves more than 195,000 members in California, making it one of the largest nonprofit MA plan providers in the nation. SCAN was able to quickly add new supplemental home care benefits because it has covered similar services in the past, Jill Selby, corporate vice president of product development, told Senior Housing News.

From 1985 to 2004, SCAN operated as a social health maintenance organization (S/HMO), which allowed the company to offer some non-skilled in-home care benefits. In addition, SCAN covers these types of services in some of its existing special needs plans.

“We had an advantage because my playbook was wire-framed out already,” Selby told SHN.
The Home Advantage offering is focused on fall prevention, and involves an occupational therapist visiting a beneficiary’s home to evaluate risks and offer recommendations, such as removing hazardous carpeting or moving dishes to lower shelves.

Returning to Home is focused on reducing hospital readmissions. After an MA beneficiary returns home from a hospital or skilled nursing facility stay of at least one night, the individual can receive up to 16 hours of personal care, up to 84 meal deliveries per year, and support and advice from a care navigator.

These benefits will be open to SCAN Medicare Advantage members who live in senior housing communities, Selby said.

To provide these benefits, SCAN already has contracts in place with home care agencies across markets that it serves. It’s possible that SCAN would contract directly with an independent living or assisted living company that has caregivers on staff and residents signed up for these new plan offerings, Selby said. Certain conditions must be met, though.

To contract with SCAN, a senior living facility would need to meet criteria such as having intact liability coverage and proper, sufficient caregiver credentialing. Some of these requirements are in place because SCAN is contracted with the federal government, Selby noted.

Business considerations such as operational efficiencies will also come into play.

“Oftentimes, there isn’t a great enough concentration of SCAN members in a facility, [and] what ends up happening is we have 1,000 contracts spread across all these facilities, and managing a contract that serves one member isn’t really efficient,” Selby said. “But I never say never. Hear me say that, but I also want to be realistic.”

Customer satisfaction is also important to Medicare Advantage plans, so this could help drive decision making.

DaVita Medical Group has agreed to pay $270 million to the Medicare program after identifying suspect billing practices that incorrectly raised its Medicare Advantage payments, says the Department of Justice (DOJ).

The improper MA payments stemmed from actions taken by HealthCare Partners, a large California-based independent physician association acquired by DaVita in 2012.
HealthCare Partners allegedly used tactics like improper coding guidance to gain additional reimbursements from MA. In one example, the DOJ said HealthCare Partners instructed physicians to use improper diagnosis codes for spinal conditions that yielded increased reimbursement from CMS. DaVita then received a share of HealthCare Partners improperly coded payments from Medicare Advantage payers.

DaVita learned of HealthCare Partners’ activity and voluntarily disclosed the provider’s group practices to the government. Law enforcement officials responded by agreeing to a favorable resolution since DaVita cooperated extensively with CMS and the DOJ.
“This settlement demonstrates our tireless commitment to rooting out fraud that drains too many taxpayer dollars from public health programs like Medicare,” said United States Attorney Nick Hanna.

“This case involved illegal conduct in which patients’ medical conditions were improperly reported and were not corrected after further review – all for the purpose of boosting the bottom line. We will continue to pursue and hold accountable any entity that seeks to illegally increase revenue at the expense of the Medicare Advantage so that the program may continue to remain viable for all who need it.”

DaVita’s $270 million settlement also resolves whistleblower allegations of additional reimbursement improprieties.

The whistleblower said that HealthCare Partners purposely added medical diagnoses that providers did not code during chart reviews. HealthCare Partners then submitted falsely coded diagnoses to inflate Medicare payments from their Medicare Advantage payers. HealthCare Partners also ignored inaccurate diagnoses that should have been removed.
The whistleblower will receive $10,199,100 of the DaVita settlement for his cooperation with federal lawmakers.

“DaVita’s alleged conduct was irresponsible and compromised the integrity of the Medicare program,” said Special Agent in Charge Scott J. Lampert of the US Department of Health and Human Services, Office of Inspector General’s New York Region.
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 “HHS-OIG will continue to ensure that companies that do business with federally funded health care programs do so in an honest fashion.”

​https://healthpayerintelligence.com/news/davita-medical-to-pay-270m-for-improper-medicare-advantage-payments

For more than 22 years, I served as mayor and a councilperson of Philadelphia. Now, at the age of 61, I have been looking at my AARP newsletters, and listening to my daughter tell me that I'll soon be able to ride SEPTA as a senior for free! I've also been reflective, thinking about next steps, always with the goal of making things better for the people who live and work here. People my age start taking stock of their lives — and asking themselves, "What do I want to do next?"

Many of my fellow baby boomers likely relate to this sentiment – that there is still so much to do, things to accomplish, people to help, more life to experience.

I've been thinking about this constantly since I left City Hall in 2016 and I recently realized that ensuring the most vulnerable in Philadelphia have access to the same kind of high-quality health care that I have should be my focus. While I was in public service, I was passionate about improving our health-care system. The Affordable Care Act made major advancements, but more needs to be done.

In particular, far too many senior citizens in Philadelphia are still struggling with paying their medical bills. Yes, all Americans over age 65 have access to Medicare, but traditional Medicare has many gaps. It doesn't cover dental, vision or hearing – and you have to sign up and pay for Medicare Part D if you want it to include prescription drugs. Then there is the 20 percent coinsurance  in traditional Medicare. The costs add up, quickly, especially if you're a senior on a fixed income, or if you're hospitalized.

There is a solution for this dilemma – and it's not complicated: Medicare Advantage. Medicare Advantage is a part of the Medicare system, but it functions much more like employer-based health insurance. Medicare Advantage covers drugs, vision, dental, and hearing, and has an out-of-pocket cap to protect consumers from huge co-pays. In most cases Medicare Advantage plans cost the same or less than traditional Medicare premiums.

The problem is that not enough of our seniors sign up for Medicare Advantage. More than 250,000 people in Philadelphia qualify for Medicare, but only 112,000 – less than half of the eligible population – are on a Medicare Advantage plan. That means nearly 10 percent of Philadelphians aren't getting the most comprehensive health coverage that is readily available to them.

Part of my work in this next phase of my life will be dedicated to spreading the word about the benefits of Medicare Advantage in Philadelphia. To do this, I decided to partner with Clover Health, a health-tech company that operates extensively in New Jersey and is now expanding into Philadelphia.

What makes Clover Health unique, and why I chose to work with them, is how they combine technology with compassion, quality medical care, and a focus on prevention.

They go beyond normal Medicare Advantage, using a high-tech approach to deliver proactive results to their members – keeping them healthy and enjoying their lives. They serve seniors by sending nurse practitioners for in-home visits when they feel a person is at risk of high blood pressure, hasn't taken their medicine, or is having trouble managing their sugar and diabetes.
Seeing the Clover staff in action providing personalized, caring, inclusive and affordable healthcare made it clear to me that they were the right partner for me and for Philadelphia. The timing is also right. Everyone on Medicare is able to switch to a Medicare Advantage plan during the Annual Enrollment Period, which begins Oct.  15.

So, Philadelphia, you may start hearing my voice on the radio or seeing me on TV talking about my new cause. And if you or your parents sign up for our Medicare Advantage plan, then I'll know the message is getting through.

Michael Nutter was the mayor of Philadelphia from 2008 to 2016, and is a senior adviser for Clover Health.
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http://www2.philly.com/philly/opinion/commentary/philadelphia-medicare-advantage-michael-nutter-clover-health-seniors-healthcare-20181001.html

A variety of traditional and non-traditional investors are starting to capitalize on the stability of the Medicare Advantage program and expansion of the Medicare Advantage health plan market. These companies are leveraging sophisticated technological interfaces, data, and telemedicine to help improve the patient experience and to maximize the Triple Aim.

​Why Medicare Advantage?
Medicare Advantage plans (“MA Plans”) are offered by private insurance companies subject to certain standards established by the Centers for Medicare & Medicaid Services. While the Medicare Advantage health plans are responsible for meeting specified levels of benefits and service standards and receive premium funding from the government, they have a high degree of autonomy on how they administer the plans to cover enrolled Medicare beneficiaries. Medicare Advantage funding is risk adjusted for the health status of the enrollee; as a result, effective MA Plans are highly dependent upon real-time data sharing.

Disfavored No More
Recent developments show that Medicare Advantage has more bipartisan support than the Affordable Care Act marketplace and is less susceptible to political intrigues. However, this was not always the case. Not too long ago, Medicare Advantage was considered a “privatization of Medicare,” and insurance companies were accused of making a profit off the Medicare program. In February 2013, federal officials announced a 2.2 percent cut to Medicare Advantage reimbursement. The political attacks on Medicare Advantage were not well received by the Medicare Advantage-enrolled seniors who vocally began to defend their beleaguered program. The patients began a campaign of communication to members of Congress, touting the benefits of engaged Medicare Advantage health care providers and health-related initiatives, such as fitness and nutrition counseling. This caught the skeptics between a rock and a hard place. Some members of Congress were torn because while they wanted to end the program, they could not do so because their senior constituents love it. After significant grassroots lobbying, coalition building, and industry efforts, the proposed 2.2 percent reduction was transformed into a minor increase by April 2013. This turnaround was primarily due to patient and provider advocacy with the campaign of communication resulting in letters from thousands of seniors to Congress, asking for protection of “their” Medicare Advantage program. Medicare Advantage went from a political pariah to a bipartisan tolerated program within a few years.

Medicare Advantage Is Here to Stay
Fast forward to 2018; Medicare Advantage is marketed as an innovative health care option that will provide more choices and lower premiums. The Trump administration is providing greater flexibility to companies offering benefits in MA Plans. Medicare Advantage is expanding beyond the retiree states of Florida, Arizona, and California with significant inroads in all 50 states. The growth has caught the eye of innovative health care investors, and market consolidation has produced larger plans with stronger infrastructure, including captive staff-model delivery systems. Medicare Advantage continues to grow with 33 percent of Medicare-eligible beneficiaries currently enrolled in MA Plans.
Significant opportunities exist for companies that already possess sophisticated data analytics and coordinated care systems. Notably, one such player, Clover Health, announced on August 27, 2018, that it will also be launching MA Plans in six new markets in 2019. Clover Health is a San Francisco-based startup that uses data analytics and artificial intelligence to deliver health care. Currently, Clover Health provides services for 30,000 seniors and others eligible for Medicare in parts of Georgia, New Jersey, Pennsylvania, and Texas. Only time will tell how successful startups, such as Clover Health, will be in the Medicare Advantage marketplace. However, this investment is one indicator that, despite the rhetoric around health care in America, Medicare Advantage is here to stay.


https://www.jdsupra.com/legalnews/medicare-advantage-solidifies-its-38220/