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3 earth shakers from the 2016 Medicare plan announcement

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The Centers for Medicare & Medicaid Services (CMS) will be paying the insurers that provide Medicare Advantage plans a little more in 2016 than in 2015, and also making changes that will affect the cost and quality of the care your clients, friends and relatives get.

In some cases, the changes included in the final version of the 2016 Medicare Advantage bidding terms announcement packet may literally be a matter of life or death. In other cases, they may lead to hundreds of millions of dollars in additional costs, or cost reductions.

The changes could affect everything from what kind of care patients get, to how physicians code their claims, to whether nurses visit patients’ homes and notice that the patients have become reality TV show-class hoarders, and how everything works in the commercial market.

For a look at some of the less-publicized, but critically important, sections of the announcement packet, read on.

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1. CMS explained what Medicare Advantage plan issuers have to do about clinical trials.

Some commenters wrote in to complain about CMS exempting Medicare Advantage plans from the rules that help traditional Medicare program enrollees try experimental treatments.

Commenters “indicated that the policy creates barriers for Medicare enrollees with serious or life-threatening diseases, such as cancer, who may benefit from innovative treatments and health care services through clinical trials,” officials say in a summary of CMS responses to comments.

In reality, CMS says, CMS requires the Medicare Advantage plan issuers to provide coverage for services to diagnose conditions covered by clinical trial services, most of the follow-up care resulting from clinical trial services, and services already covered by the plan.

If a plan enrollee participates in a trial, the enrollee can stay in the plan while paying fee-for-service costs for the trial.

The plan must reimburse beneficiaries for clinical trial cost-sharing that exceeds the plan’s cost sharing for the same category of service.

The Medicare Advantage plan “owes this difference even if the beneficiary has not yet paid the clinical trial provider,” officials say. “The beneficiaries’ clinical trial cost sharing must also count towards their in-network out-of-pocket maximum.”

The clinical trial provider can submit traditional Medicare program paid claims to the Medicare Advantage plan to get reimbursement for the differences between the traditional Medicare cost-sharing amount and the in-network Medicare Advantage plan cost-sharing amount, officials say.

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2. CMS said the ICD-10 shift is going to happen later this year, for real.

CMS has been trying to get the U.S. health care system to switch to a more detailed diagnostic coding system, International Classification of Diseases-10 (ICD-10), since 2009. 

Insurers have welcomed the shift, but providers have resisted, arguing that adopting the new system will be costly and complicated.

CMS talked about implementation of a requirement that all entities subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) start using ICD-10 coding on Oct. 1, 2015.

Some commenters asked for CMS to establish a transition period during which CMS would hold plans harmless for any problems resulting from the shift, or shift-related inaccuracies.

CMS officials sniffed at that suggestion.

“Given the extended period providers and plans have had to transition to ICD-10, we do not believe a payment adjustment or hold harmless policy is warranted,” officials say.


3. CMS will impose new standards for in-home assessments.

Medicare Advantage reimbursement rates are higher for enrollees with more health problems.

CMS officials say they like the idea of plans doing in-home assessments but wants the assessments to have more to do with improving care than with increasing revenue.

To increase the likelihood that the assessments will be aimed at improving care, CMS announced in a draft version of the 2016 packet that it wants plan issuers to adopt a set of “best practices” for the assessments.

Some groups objected, arguing that the rules could clash with existing state rules, but CMS says it is going ahead with setting in-home assessment standards.

The list includes requiring that the assessments be done by physicians, or “qualified non-physician practitioners,” such as physician assistants or certified clinical nurse specialists.

The assessments should include an environmental scan of the enrollee’s home, a medication review, a process to verify that needed follow-up care is provided, a process to verify that assessment information is conveyed to the enrollee’s usual providers, and enrollment in in any case management programs that may be necessary, officials say.