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As background, Clover is a health care data and technology company currently offering a Medicare Advantage ("MA") insurance product. We are dedicated to advancing the way in which beneficiaries are cared for by capturing and analyzing data to identify at-risk beneficiaries, and proactively intervening with our care management teams and our provider network to improve health outcomes, fill care gaps, and reduce avoidable costs. The Clover business model is designed to rapidly generate new care delivery approaches and test their real-world effectiveness. We began offering MA plans in 2014, and, to date, have grown to manage over 55,000 beneficiaries in seven states./1
In these unprecedented times, with all areas of the healthcare system impacted by COVID-19, Medicare Advantage ("MA") plans are doing everything necessary to serve and provide care to our members, who, unfortunately, are some of the most vulnerable. The vast majority of our members are 65 and older, who the
Network Adequacy and Telehealth (Secs. 417.416 and 422.116)
CMS proposes to codify network adequacy and telehealth standards, including time/distance standards, into regulation. Specifically, CMS proposes to codify in Sec.422.116 the list of provider and facility specialty types subject to network adequacy reviews, county type designations and ratios, maximum time and distance standards, minimum number requirements, and exceptions.
CMS also proposes a 10% credit towards those time/distance standards for MA plans that contract with telehealth providers in the specified specialities. MA plans also would be permitted to cover telehealth services through a non-contracted provider as a basic benefit.
We support CMS's move in support of telehealth benefits to beneficiaries. Telehealth, during this COVID-19 pandemic, is often the only means by which many of our beneficiaries are able to access care at this time.
We urge CMS to reconsider finalizing time and distance network adequacy requirements at this time. We respectfully request that CMS evaluate these provisions following the COVID-19 pandemic, when there is more data and evidence of telehealth performance to address access and quality issues. Depending on the success of telehealth, it may support giving a larger credit for telehealth to help plans meet network adequacy standards.
CMS is proposing to further increase the weight of patient experience/complaints and access measures from a weight of 2 to 4. CMS is also proposing to directly remove outliers prior to calculating the cut points to further increase the predictability and stability of the Star Ratings system. CMS also proposes to clarify some of the current rules around assigning Quality Bonus Payment ("QBP") ratings and to codify existing policy for assigning QBP ratings for new contracts under existing parent organizations.
In light of COVID-19, we urge CMS to reconsider codifying these requirements in the final rule. Depending on the state of the pandemic, additional weight afforded to patient experience and complaints, as currently investigated in CAHPS questions, will not accurately capture plan performance during this public health emergency and crisis. Different areas of the country are experiencing, and are expected to experience, different limitations on, and availability of, health care resources. Because the STARS program compares plans across different geographic locales, differences in CAHPS and HOS survey outcomes are neither meaningful nor appropriate to consider when comparing plan performance. Moreover, Medicare Advantage plans must redeploy resources to our most vulnerable beneficiaries during the COVID-19 crisis. We request that CMS re-evaluate these measures after the COVID-19 crisis is resolved.
Withdrawal and Dismissal of Coverage Requests and Appeals
CMS proposes rules to govern procedures for withdrawals or dismissals of beneficiary coverage requests and appeals. Medicare Advantage Organizations ("MAOs") encounter situations where enrollees want to voluntarily withdraw a request for coverage, or where an improper appeal warrants dismissal on procedural grounds. Current CMS regulations do not set forth specific rights or processes for such withdrawals and dismissals.
Clover fully supports CMS's efforts to create a process to withdraw or dismiss coverage requests and appeals. Modeled after the fee-for-service rules, we believe the new rules provide a process where a MAO can appropriately dismiss a coverage request or appeal.
Clover appreciates your consideration of the concerns outlined above and looks forward to continuing work on these issues with CMS. If you have any questions regarding our comments or would like further information, please do not hesitate to contact me at [email protected].
Vice President, Legal and Government Affairs
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1/ In 2020, Clover offers MA plans in
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0010-0002
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