November 9, 2023
WASHINGTON DC — Changes proposed this week by the Centers for Medicare & Medicaid Services (CMS) in the Medicare Advantage (MA) program would expand enrollees’ access to behavioral health providers; better inform them about the availability of supplemental benefits; help guide them to MA plans that best meet their needs; and overall make the MA program work better for enrollees and the physician groups that care for them, America’s Physician Groups (APG) said this week.
“Much of what CMS is proposing amounts to proactive changes to ensure that Medicare beneficiaries become enrolled in the plans best tailored to suit their needs and enable them to obtain the health care that they need,” said APG President and CEO Susan Dentzer. “Given the increasing enrollment in MA, it is essential that the program meet high expectations for providing access to quality health care and delivering a high level of customer service. Our APG member organizations serving MA patients stand only to gain as patients enroll in the plans best tailored to them as individuals, and plans and providers alike deliver high levels of performance and quality care.”
APG is the largest U.S. organization of physicians committed to being held accountable for costs and quality of health care, and who collectively care for roughly one-third of MA enrollees nationwide. More than half of Medicare beneficiaries who are enrolled in Parts A and B of Medicare are now enrolled in MA plans.
Beneficial improvements: The changes proposed by CMS were promulgated in the proposed rule governing Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Plan Program, the Medicare Prescription Drug Benefit Program, and other Medicare programs. Although some news media reports characterized the proposals as a “crackdown” on MA plans, APG believes that the changes are better understood as the latest in a series of ongoing improvements to the increasingly popular MA model.
APG cited these beneficial aspects of the proposed rule, as follows:
Proposed updates to MA network adequacy requirements that would include adding a category of “outpatient behavioral health” providers, including marriage and family therapists, mental health counselors, addiction or drug and alcohol counselors, opioid treatment program providers, and other behavioral health counseling and therapy services. APG strongly believes expanding access to these providers will benefit the MA enrollees that APG members treat.
Adding new guardrails to MA plan compensation for agents and brokers to ensure that they have the right incentives to enroll individuals in the MA plans that best meet their health care needs. CMS proposes a fixed national agent/broker compensation amount of $632 per MA enrollee – designed to eliminate variability and improve the predictability of compensation for agents and brokers – as well as a general prohibition on volume-based bonuses for enrollment into certain plans. APG agrees that it is essential to remove any incentives that could steer MA enrollees into plans that are not well suited to them.
Increasing the utilization and appropriateness of MA plans’ supplemental benefits – such as those aimed at providing healthful food or transportation – by requiring plans to send a personalized notification mid-year to alert beneficiaries of unused benefits. CMS also proposes to require that plans compile and maintain evidence from the research literature that Special Supplemental Benefits for Chronically Ill enrollees (SSBCI) are backed by evidence. APG also wants enrollees whom APG members treat as patients to make use of these valuable benefits, and encourages CMS to follow through on its obligations to create more detailed coding of these benefits so that the array of supplemental benefits can be better understood.
Streamlining enrollment options so that “dually eligible” individuals enrolled in both Medicare and Medicaid could sign up monthly for enrollment in integrated dual-eligible special needs plans (D-SNPs). Because the situation of older adults can change rapidly, APG agrees that regular special enrollment provisions for such individuals are essential.
Requiring MA plans to conduct an annual health equity analysis of their prior authorization policies and procedures. APG agrees that prior authorization is an important tool to limit unnecessary use of health care, but that it is also essential to make sure that prior authorization policies and procedures do not create a disproportionate impact on underserved populations and don’t unnecessarily delay or deny access to services.
Offering flexibility for Medicare Part D prescription drug plans to more quickly substitute lower-cost biosimilar products for a comparable branded product on their formularies. APG agrees that ensuring that MA enrollees have access to effective biological products at reasonable costs is a key ingredient in the provision of value-based health care.
APG will be consulting with its member organizations and submitting further comments to CMS on these and other aspects of the proposed rule by January 5, 2024.
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About America’s Physician Groups
America’s Physician Groups is a national association representing approximately 360 physician groups with 170,000 physicians providing care to nearly 90 million patients. APG’s motto, ‘Taking Responsibility for America’s Health,’ represents our members’ commitment to clinically integrated, coordinated, value-based health care in which physician groups are accountable for the costs and quality of patient care. Visit us at www.apg.org.
Contact: Greg Phillips, APG Director of Communications, 202-770-1901