Medicare Advantage plans are gaining in popularity. PYA Principal Robert Paskowski, CPA will provided an overview, discussed the business model, and offered contracting strategies at the South Carolina Hospital Association Managed Care Conference.
2. Prepared for South Carolina Hospital Association Page 1
Agenda
1. National Overview
2. Traditional Medicare v. Medicare Advantage
(MA)
3. Medicare Advantage Business Model
a) Enrollment
b) Revenue Cycle
c) Star Ratings
d) Risk Adjustment
e) Provider Payments
4. Provider Interactions β Strategy and Contracting
5. Questions & Answers
12. Prepared for South Carolina Hospital Association Page 11
Definition
ο§ Medicare Advantage
ο§ Insurance plans offered by private insurance companies to
Medicare beneficiaries
ο§ Beneficiaries elect to join a MA plan or stay with traditional
fee-for-service
ο§ Managed care with a health plan network
13. Prepared for South Carolina Hospital Association Page 12
MA v. Traditional Medicare
Feature MA Traditional
Eligibility and
Enrollment
Age 65 - Enrolled in Parts
A and B
Standard enrollment from
October 15 β December 7
Age 65 β Enrolled in Parts
A and B
Network Customized by Payer Providers participating in
Medicare
Benefits Parts A and B
Supplemental benefits
Parts A and B
Beneficiary
Premiums
Various: Part B premiums
+ MA premiums
Part A ($0) + Part B
premiums ($135.50 in
2019)
Claims
Adjudication
Follow Payer payment
guidelines
Follow CMS payment
guidelines
Future Outlook Stable Transitional
16. Prepared for South Carolina Hospital Association Page 15
Payment to MA Plans
β’ Submit an annual bid to CMS
β’ Receive a fixed (or capitated) monthly payment from
CMS per enrollee (beneficiary)
β’ Monthly payments are based upon the following factors:
β’ Geographic benchmarks as determined during the
annual bid process
β’ MA planβs Star rating
β’ Enrolleeβs Risk Adjustment Factor (RAF) scores
CMS payments
β’ Fixed monthly premium payments based on benefit
plan selected
Enrollee payments
17. Prepared for South Carolina Hospital Association Page 16
Star Ratings
ο§ βStar Ratingsβ system measures the
quality performance on a scale of one to
five stars (one being the lowest and five
being the highest)
ο§ MA Planβs monthly payments are
influenced by its overall star rating
ο§ 4 stars or greater, monthly benchmark rate is
increased by 5%
ο§ Less than 4 stars, no increase
ο§ New Plans and/or not yet qualified due to low
membership:
ο§ Benchmark rate increased initially by 3.5%
until the minimum data requirements are met
18. Prepared for South Carolina Hospital Association Page 17
Star Ratings
The program consists of 48 measures across 9 domains:
1. Staying healthy: screening tests and vaccines
2. Managing chronic (long-term) conditions
3. Member experience with the health plan
4. Member complaints and changes in the health planβs
performance
5. Health plan customer service
6. Drug plan customer service
7. Member complaints and changes in the drug planβs performance
8. Member experience with the drug plan
9. Drug safety and accuracy of drug pricing
19. Prepared for South Carolina Hospital Association Page 18
RAF Scores
ο§ A RAF score is assigned to each MA enrollee during a
benefit year.
ο§ Prospective: historical diagnoses are used as a measure to
predict future expenses
ο§ Example: 2019 monthly payments made by CMS to an MA
Plan are based on the enrolleeβs claims and respective
diagnoses from 2018
ο§ The RAF score is based on the MA enrolleeβs:
ο§ Demographics (i.e., age, gender, etc.)
ο§ Disease burden as measured by chronic conditions
ο§ Number of disease interactions
ο§ The RAF score is reset each year and does not carry over to
subsequent benefit years
20. Prepared for South Carolina Hospital Association Page 19
Payment to Providers
How do MA Plans pay for Medical Services on behalf of
their Enrollees?
ο§ MA Plan directly contracts with Providers in their network to
provide covered services for their enrollees
ο§ MA Plans can pay for such services under various methods
ο§ FFS
ο§ Capitation
ο§ Other Payments (Quality, Shared Savings)
21. Prepared for South Carolina Hospital Association Page 20
Success Factors
What are the Major Success Factors for an MA
Plan?
Quality β measured under
the CMS Star rating system
For a Payer that has a 4+ Star rating,
the Payer earns a 5% bonus, which
amounts to $500 per member per year
on an average $10,000 annual
capitation payment
Accurate risk coding β
direct impact on CMS
capitated revenue
For every 10 basis points (1.0 to 1.1 risk
score) = $1,000 per member per year
based on an average $10,000 annual
capitation payment
Utilization risk
management
Acute care utilization β ensure right care
in right setting
End-of-life care β use of robust palliative
and hospice care programs
23. Prepared for South Carolina Hospital Association Page 22
Strategic Considerations
MA landscape Infrastructure
Market
dynamics
Network
considerations
Risk tolerance
24. Prepared for South Carolina Hospital Association Page 23
Contracting Options
ο§ FFS only (traditional)
ο§ FFS + quality incentives
ο§ FFS + shared savings
ο§ FFS + risk-sharing
ο§ Full capitation
ο§ Joint-venture with a payer
ο§ Provider-sponsored plan
R
I
S
K
25. Prepared for South Carolina Hospital Association Page 24
FFS Contracting
Market rates
Uncompensated Care Pool (UCP) payments
Audits
Prior authorizations
Site of care
Inpatient v. observation
26. Prepared for South Carolina Hospital Association Page 25
Value-Based Contracting
Quality metrics that align with MA Star Rating measures
Accurate coding for risk adjustment
Alignment with physicians to effect total cost of care
Care management
Data analytics
28. PYA, P.C.
800.270.9629 | www.pyapc.com
Robert S. Paskowski
Principal β Healthcare Consulting
bpaskowski@pyapc.com
Editor's Notes
Star Ratings β MA Planβs monthly payments are also influenced by its overall star rating. For plans with an overall rating of 4 stars or greater, their monthly benchmark rate (as previously described) is increased by 5Β Β % based on achieving this rating based on their performance. For MA Plans with an overall rating of less than 4 stars, there is no increase. For plans that are new and have not yet qualified due to low membership, their benchmark rate is increased initially by 3.5% until the minimum data requirements are met. This initial rate is established for newer plans and allow them to be successful in the earlier years as they compete against the established MA Plans with 4+ star ratings.
The star ratings program consists of 48 measures across 9 Β domains: 1) Staying healthy: screening tests and vaccines; 2) Managing chronic (long-term) conditions; 3) Member experience with the health plan; 4) Member complaints and changes in the health planβs performance; 5) Health plan customer service; 6) Drug plan customer service; 7) Member complaints and changes in the drug planβs performance; 8) Member experience with the drug plan; and 9) Drug safety and accuracy of drug pricing.Β Β The findings are aggregated into the following categories: Outcomes, Intermediate Outcomes, Patient Experience, Access, and Process.
RAF Scores β In general, a RAF score is assigned to each MA enrollee during a benefit year. The RAF score is prospective, meaning that historical diagnoses are used as a measure to predict future expenses. For example, the 2019 monthly payments made by CMS to a MA Plan are based on the enrolleeβs claims and respective diagnoses from 2018. The RAF score is based on the MA enrolleeβs demographics (i.e. age, gender, etc.) and their disease burden as measured by chronic conditions and the number of disease interactions. It should be noted that a RAF score is reset each year for an enrollee and does not carry over to subsequent benefit years. See the section on risk adjustment methodology for more detail.
Fee-for-service (βFFSβ) β This is the most common form of payment. MA Plans contract directly or indirectly with the providers in their network and typically follow the methodology and fee schedules established by CMS. MA Plans do not have to follow CMSβ methodology under the FFS model.
Capitation β For some MA Plans, they will pay for a certain service on a pre-determined per member per month (βPMPMβ) amount. The Provider continues to submit the claims for such services but bears the risk if the claims (on a FFS basis) are greater than the monthly capitation amount.
Other payments β There are other forms of payments made by the MA Plan to Providers. Those payments include quality payments for achieving certain quality measurements and shared savings when the Provider manages their enrolleesβ overall cost of care below a pre-determined claims target.
Quality β For MA Plans that focus their efforts on the quality measures established under CMSβ star rating system, the MA Plan can realize a competitive advantage in the market. As illustrated earlier, MA Plans can earn additional rebates (difference between the bid and the benchmark rates, which are increased by the Star rating) and apply those rebates by providing additional benefits and premium reductions to its enrolleesΒ Β . For example, an MA Plan that earns a 4-star rating could earn an additional $40 PMPM based on a monthly benchmark rate of $800 PMPM.
Accurate risk codingΒ β As illustrated previously, the enrolleeβs RAF score is multiplied by the MA Planβs benchmark capitation rate. Therefore, for every 10 basis points (1.0 to 1.1 risk score), the MA Plan will earn approximately $80 PMPM based on a monthly payment rate of $800 PMPM.
Utilization Management (UM) β Due to the risk profile of MA enrollees, MA Plans must manage overall utilization of health care within their networks. There are typically two significant UM programs administered by the MA Plan: (1) acute care utilization β to ensure enrollees receive the right care in the right setting: and (2) palliative and hospice care program for end of life care.Β Β Investments are currently being made by MA Plans regarding social determinants of health and managing patient populations with these factors as a consideration for coverage and benefits.
Β Discuss chronic care management as well.