INSIGHTS

Expert Perspective

March 03, 2020

Valuable Insights: News You Can Use

Kathleen Gravelle – Chief Risk Officer, CareAllies

Regulatory Upate

Advance Notice Part I

On January 6, 2020, the Centers for Medicare and Medicaid Services (CMS) released Part I of the Advance Notice for Calendar Year 2021 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies.

Advance Notice Part II

On February 5, Part II of the Advance Notice was released. In Part II, CMS seeks to improve rural access to MA plans by allowing plans to count telehealth providers in certain specialty areas such as psychiatry, neurology and cardiology towards network adequacy standards. CMS also proposes to increase the weighting of patient experience and access measures in a plan’s MA and Part D Star Rating. CMS seeks comment on developing measures of generic and biosimilar utilization in Medicare Part D. These measures would be used to calculate part of a plan’s Star Rating, with the aim of rewarding plans for encouraging the adoption of generic and biosimilar drugs.

CMS estimates proposals in the notice will result in an average increase to plan payments of 0.93 percent for 2021. As the CMS actuaries process year-end FFS data, this estimate often changes from the notice to the Final Rate Announcement (could increase or decrease). Please also note that individual plans will be affected by how policies influence rates in each individual county. The 0.93 percent rate update includes a coding pattern adjustment of 5.9 percent. Each year, as required by the Affordable Care Act, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding intensity between MA organizations and FFS providers.

What Does The Interoperability Rule Mean For You?

On March 9, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator of Health Information Technology (ONC) released the long awaited final interoperability in IT health regulations. Together, the rules implement provisions of the bipartisan 21st Century Cures Act that improve the ability of patients to access their personal electronic health data and prevent health care systems from engaging in "information blocking." Notably, the ONC final regulation implements eight exceptions to the information blocking ban, which generally involve protecting patient safety and privacy, protecting providers from unreasonable or infeasible requests, and allowing actors to charge certain fees for accessing or transmitting electronic health information.


By January 1, 2021, the CMS regulation requires payers to implement a secure, standards-based interface that allows patients to easily access claims and encounter information, including costs. It also requires provider directory information be publicly available via the same interface. Beginning January 1, 2022 payers must exchange certain clinical data at the patient's request, allowing the patient to take their information with them as they move from payer to payer over time to create a cumulative health record. Beginning in late 2020, CMS will also publicly report eligible clinicians, hospitals, and critical access hospitals that may be information blocking based on how they attested to program requirements. In addition, CMS will report providers who do not list or update their digital contact information in the National Plan and Provider Enumeration System.


Why Is This Important? The CMS rule puts new requirements on all CMS-regulated payers, including Medicare Advantage organizations, Medicaid fee-for-service and managed care plans, CHIP programs, and Qualified Health Insurance Plan issuers participating in health insurance exchanges. Both the CMS and ONC rules may require payers to make significant investments in new technology to come into compliance with the new standards, or face monetary penalties.

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