Better Medicare Alliance Issues Public Comment on Centers for Medicare & Medicaid Services Notice

WASHINGTON, March 16 -- Allyson Y. Schwartz, president and CEO of the Better Medicare Alliance, has issued a public comment on the Centers for Medicare and Medicaid Services notice entitled "Advance Notice of Methodological Changes for Calendar Year (CY) 2021 for Medicare Advantage (MA) Capitation Rates and Part C Part D Payment Policies Part I. CMS-HCC Risk Adjustment Model.". The comment was written on March 6, 2020, and posted on March 13, 2020:

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Better Medicare Alliance (BMA) is pleased to submit the following comments on the Advance Notice for Calendar Year (CY) 2021 ("Advance Notice") on behalf of our Alliance and the 24 million beneficiaries enrolled in Medicare Advantage. BMA is a community of more than 140 ally organizations and 460,000 beneficiary advocates who value Medicare Advantage and the affordable, high-quality and coordinated care it provides millions of seniors and those with disabilities across the country. Together, our alliance of health plans, provider groups, aging service organizations, and beneficiaries share a commitment to ensuring Medicare Advantage is a high-quality, cost-effective option for current and future beneficiaries.

Seniors and individuals with disabilities eligible for Medicare deserve the value-driven, affordable, quality, and innovative health care available in Medicare Advantage. Through value-based payment and care management that results in quality care, improved health outcomes, extra benefits, and lower costs for consumers, Medicare Advantage is addressing the needs of today's beneficiaries. With growing enrollment and high consumer satisfaction, Medicare Advantage is building the future of Medicare.

Today, Medicare Advantage covers more than 24 million American seniors and people with disabilities, or about 35 percent of all eligible beneficiaries. This year Medicare Advantage beneficiaries were able to choose from nearly 4,300 plans with the average beneficiary having access to 39 plan choices in their county. For 2020, Medicare Advantage reported the lowest average premiums since 2007 and the third consecutive year of premium decreases, while 94 percent of beneficiaries have access to at least one $0 premium plan./1

The decline in premiums over the last three years is estimated to save taxpayers $6 billion in lower Medicare premium subsidies./2

In addition, 97 percent of Medicare Advantage beneficiaries have access to a plan with dental vision, hearing, or fitness benefits, and nearly 6-in-10 plans provide all four supplemental benefits. Further, 81 percent of Medicare Advantage beneficiaries are enrolled in four- or five-star plans, the highest ratings for quality./3

In a recent study, Medicare Advantage beneficiaries reported $1,598 less in total spending than those in Traditional Fee-for-Service (FFS) Medicare./4

And, beneficiaries are highly satisfied, with Medicare Advantage earning a 94 percent satisfaction rating in a recent poll./5

This year, a record-setting 403 Members of Congress sent bipartisan companion letters to the Administration expressing strong support for Medicare Advantage, which serves both as a testament to constituents' satisfaction as well as increasing recognition by policymakers of the value and success of this option for Medicare./6

We appreciate CMS' support of Medicare Advantage and believe that this Advance Notice creates a positive environment for Medicare Advantage plans, providers, and community partners to offer Medicare Advantage beneficiaries innovative, high-quality, cost-effective care that improves beneficiaries' experiences and health outcomes. We have comments on several provisions both in strong support of changes, such as greater flexibility in network adequacy and telehealth, and expressing concerns such as implementation of expanded enrollment opportunities in Medicare Advantage for individuals with End Stage Renal Disease (ESRD) in 2021, among others. These issues are briefly highlighted in this letter, with detailed comments offered in the attachments.

As CMS considers stakeholder comments and finalizes the Rate Notice for CY 2021, we note CMS has also proposed a separate rule (CMS-4190-P) which includes substantial policy and technical changes that will affect Medicare Advantage beneficiaries, plans, providers, and partners. BMA will share our comments on this proposed rule by the April 6 deadline which is the same day by which CMS intends to finalize the CY 2021 Rate Notice. With so many moving parts, we are concerned Medicare Advantage stakeholders may have an incomplete understanding of rules and regulations governing 2021 bid proposals. In the future, we urge CMS to stage its proposals such that plans have all relevant information for plan design and bid submission and that all stakeholders are better able to offer a full set of comments based on more complete information on proposed changes for the following year.

BMA asks CMS to consider our comments on the following key issues in the final Rate Notice, including reference to related concerns in the MA-PD proposed rule:

End-Stage Renal Disease. BMA shares the Administration's goal to improve care for those with Chronic Kidney Disease (CKD) and welcomes the opportunity for Medicare Advantage to care for beneficiaries with ESRD, as well as to work to slow disease progression for those at risk, and expand access to transplantation. Medicare Advantage is well-positioned to provide high-quality, integrated care for beneficiaries with ESRD. However, in order to ensure a smooth transition and successful implementation of this new policy, CMS must address the chronic underfunding and fluctuating nature of ESRD payment in Medicare Advantage. CMS must ensure the ESRD benchmark calculations and risk scores reflect actual costs and provide accurate and adequate payment for this high-need, high-cost patient population.

BMA recommends updating the Bid Pricing Tool instructions so that the ESRD subsidy falls under Medicare covered benefits rather than under Mandatory Supplemental benefits. The benchmark must also be adjusted to account for the fact that Medicare Advantage payments to dialysis providers are significantly higher than Traditional FFS Medicare rates due to market concentration. In addition, risk adjustment should account for the high cost of the first year of entry into renal failure in recognition of the care and services which are so important to the health and well-being of these chronically ill beneficiaries. We ask CMS to attend to these and other comments to ensure appropriate payment without adding cost burden to all Medicare Advantage beneficiaries. Low premiums and low out-of-pocket costs for consumers have been the hallmark of Medicare Advantage. Ensuring payment accuracy and stability in ways that acknowledge the real costs of care is essential to enabling plans and providers to offer high-quality, innovative care and services to those with ESRD, and protect all beneficiaries from increased costs.

Network Adequacy. BMA supports CMS' proposed changes to network adequacy standards included in the Policy and Technical Changes proposed rule (CMS-4190-P) and agrees that revisions to telehealth and maximum time and distance standards would improve access to Medicare Advantage plans for those in rural and underserved areas. We recommend CMS finalize the network adequacy policy updates as soon as possible to allow Medicare Advantage plans to incorporate this change into their CY 2021 bids. Further, such changes will encourage the use of telehealth services that can better ensure access to services and continuity of care for beneficiaries, especially in rural areas. We support and encourage the innovation in treatment for ESRD beneficiaries that may result from these changes including the increased utilization of home dialysis, mobile dialysis units, and other innovative means of delivering care.

We look forward to offering additional feedback in our comments on the proposed rule, but in the interim, we encourage CMS to expand the proposed 10 percent credit towards the percentage of beneficiaries residing within published time and distance standards to include telehealth nephrologists, in addition to other proposed specialists. Expanding the credit to include nephrologists may assist plans and providers in ensuring access to care and services for beneficiaries with CKD and ESRD. We also support CMS' proposal to modify network adequacy standards by lowering the percentage of beneficiaries that must reside within the maximum time and distance standards in Micro, Rural, and Counties with Extreme Access Considerations (CEAC) counties. Additionally, we support the proposal for Medicare Advantage plans to attest to providing dialysis as part of their application and support other ways to modify network requirements that could increase access to a diversity of outpatient facilities, such as hospital outpatient dialysis units.

Star Ratings - Patient Experience/Complaints and Access Measures. Medicare Advantage demonstrates high-quality performance with 81 percent of beneficiaries enrolling in a high-performance plan. BMA, with our 460,000 beneficiary advocates, agrees that patient experience measures can offer important insights into consumer satisfaction with their Medicare Advantage plan. However, critical concerns about the accuracy and usefulness of the current methodologies used to assess all consumer experience remain. In the Policy and Technical Changes proposed rule (CMS-4190-P), CMS proposes to double the weight of Consumer Assessment of Healthcare Provides and Systems (CAHPS) patient experience/complaints and access measures in the Star Ratings program, from a current weight of two to a proposed weight of four. BMA encourages CMS to not increase the weight of these measures until the serious methodological concerns with the calculation of these measures are resolved or replaced with a better methodology.

Growth Rates. We encourage CMS to finalize a strong and stable rate environment for the Medicare Advantage program, and we ask CMS to provide more transparency into the calculation of the FFS Growth Percentage. CMS projects a FFS USPCC--Non-ESRD growth percentage of 2.57 percent for 2021, which is substantially lower than the 4.46 percent FFS growth percentage projection included in the December 3, 2019 early preview. This is a significant change in a short period of time that impacts the payments to Medicare Advantage plans. BMA encourages CMS to provide transparency into the rate calculation and promote payment stability as it finalizes rates for CY 2021.

Our more detailed comments on these priorities and other policy proposals follow in Attachments A and B. Also attached is a list of our 143 ally organizations (Attachment C) and selected quotes from ally organizations sharing their strong support for successful integration of beneficiaries with ESRD into Medicare Advantage, support for proposed changes to network adequacy and telehealth, and the need to improve the methodology for consumer experience measures in the Star Rating System (Attachment D).

BMA shares the Administration's commitment to Medicare Advantage payment and policies that ensure adequate and stable resources to offer beneficiaries the care and services they deserve. Recent changes in law and regulations for Medicare Advantage have led to increased enrollment, higher provider engagement in value-based payment arrangements, new relationships with community partners, lower consumer costs, and wider support from policymakers. CMS' support for this integrated care model has driven innovation in financing and care delivery for millions of Medicare beneficiaries. We appreciate your efforts and we look forward to working with you and your staff to ensure Medicare Advantage is able to offer high quality care, lower consumer costs, and extra benefits tailored to meet the needs of current and future Medicare beneficiaries.

Thank you for the opportunity to submit comments and we welcome further discussion.

Sincerely,

Allyson Y. Schwartz

President & CEO

Better Medicare Alliance

CC: Demetrios Kouzoukas, Director, Center for Medicare;

Cheri Rice, Deputy Director, Center for Medicare

View full comment at: https://www.regulations.gov/contentStreamer?documentId=CMS-2020-0003-0812&attachmentNumber=1&contentType=pdf

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Footnotes:

1/ https://www.bettermedicarealliance.org/policy-research/resource-library/medicare-advantage-2020-fact-sheet

2/ https://www.cms.gov/newsroom/press-releases/trump-administration-drives-down-medicare-advantage-and-part-dpremiums- seniors

3/ https://www.bettermedicarealliance.org/policy-research/resource-library/medicare-advantage-2020-fact-sheet

4/ Medicare Advantage Outperforms Traditional Medicare on Cost Protections for Low- and Modest-Income Populations, March 2020: Better Medicare Alliance.

5/ https://www.bettermedicarealliance.org/policy-research/resource-library/medicare-advantage-2020-fact-sheet

6/ https://www.bettermedicarealliance.org/newsroom/press-releases/better-medicare-alliance-helps-set-new-recordbipartisan- congressional

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The notice can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0003-0001

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