Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject to public comment, and is finalized a few months later, usually in April. The draft 2016 Call Letter was released on February 20, 2015 (see: http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2016.pdf).
The Center, in collaboration with several other advocacy organizations, submitted comments to the Call Letter. There are proposals that we support, and hope are finalized, and others about which we have concerns. Here is quick overview of some of these provisions:
- We strongly support CMS’ proposals to improve the Part C Medicare Advantage and Part D appeals processes for Medicare beneficiaries. These proposals include improving Part D denial notices, clarifying plan sponsors’ obligations to seek out clinical information when needed to process a coverage request, expanding data collection regarding Part D appeals, and establishing a multi-stakeholder workgroup to develop a streamlined Part D appeals process that is initiated when a request for coverage of a prescription drug is denied at the pharmacy counter.
- We have significant reservations about CMS’ proposal to reduce the weights of certain quality measures in an attempt to account for differences in plans’ quality ratings due to enrollees’ dual eligibility for Medicare and Medicaid. Decreasing the weight of measures that CMS has found to disproportionately impact dual eligible will in essence increase the quality Start Ratings for plans without actually improving care for dual eligibles in these areas.
- On the one hand, we strongly support CMS’ proposal to enhance oversight of MA plan provider directories in an effort to, among other things, make them more accurate and timely concerning whether contracted providers are actually accepting new patients. On the other hand, we are very disappointed that CMS has taken no further action to strengthen consumer protections surrounding MA plan mid-year provider network terminations. The most effective way to protect consumers from being trapped in their plans after their own doctors are involuntarily terminated is to prohibit MA plans from terminating network providers mid-year without cause. CMS has stated they will not impose such a requirement on plans, and has not proposed any additional consumer safeguards or relief.
The Center’s full comments can be found at https://www.medicareadvocacy.org/newsroom/cma-comments-responses-and-letters/.