hospital patient


Proposed changes to Medicare Advantage and Part D plans

Expands telehealth, changes quality ratings

The proposed rule implements several provisions stemming from the 2018 Bipartisan Budget Act that expand telemedicine applications, as well as streamlining the relationship between Medicare Advantage and other programs.

November 1, 2018 | Health care

Proposed rule moves to implement expanded telehealth reimbursement in Medicare Advantage, changes to quality ratings, dual-eligible plans, among others

The proposed rule implements several provisions stemming from the 2018 Bipartisan Budget Act that expand telemedicine applications, as well as streamlining the relationship between Medicare Advantage and other programs.

MA and telehealth

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) published a proposed rule in the Federal Register that lays the groundwork for implementation of provisions of the 2018 Bipartisan Budget Act (BBA), including provisions related to telemedicine, dual eligible special needs plans (D-SNPs), quality ratings, MA participation, and risk adjustment.

The BBA granted CMS authorities to allow MA plans to provide additional telehealth benefits starting in the plan year 2020. Notably, the proposed rule considers telehealth to be a basic benefit for the purposes of bid submission and payment for MA, potentially increasing the likelihood that MA plans will offer such benefits. The proposed rule would not apply the reimbursement restrictions related to geography or care setting that apply to Part B payments for telehealth services.

To be considered a basic benefit, a telehealth service would need to be classified as clinically appropriate to provide through electronic information and telecommunications technology. Clinical appropriateness remains undefined in the regulation, leaving it to MA plans to interpret.

Although the proposed rule grants MA plans new flexibility to offer telehealth services, plans also must cover the service on an in-person basis, and to inform current and potential enrollees of this option in plans' explanations of coverage. The proposed rule would require telehealth providers to be fully contracted with the MA plan in order to be considered an additional benefit, although the rule requests comment on whether this should apply to a preferred provider or other open network plan arrangements.

CMS also solicits comment on what items or services should be considered additional telehealth benefits. For that reason, the proposed rule requests comment on whether there ought to be limitations on certain Part B items and services, such as primary care visits, routine and/or specialty consultations, dermatological examinations, or behavioral health counseling.

The proposed rule would permit cost sharing to vary between a service delivered in person or via a telehealth arrangement.

In addition, the proposed rule would maintain regulatory authorities to offer supplemental benefits such as remote monitoring in instances where a service does not meet the additional benefits requirements.

Dual eligible special needs plans (D-SNPs)

The BBA requires that D-SNPs more fully integrate across Medicare and Medicaid by developing a unified grievance and appeals process, and setting new standards for integrating benefits across the two programs. HHS is required to establish a newly unified grievance and appeals procedures by April 1, 2020, with the new procedures used by D-SNP contracts and state Medicaid agencies starting in 2021. Benefits integration requirements also will take effect starting in 2021.

Beginning in 2021, D-SNPs will be required to meet the following standards for integration of benefits:

  • Coordinate long-term services and supports (LTSS), behavioral health services, or both, by meeting an additional minimum set of requirements for integration
  • Either meet the requirements of a fully integrated dual eligible special needs plan described in section 1853(a)(1)(B)(iv)(II) of the Social Security Act, or enter into a capitated contract with the state Medicaid agency to provide LTSS, behavioral health services, or both
  • The parent organization of a D-SNP that is also the parent organization of a Medicaid managed care organization providing LTSS or behavioral services must assume "clinical and financial responsibility" for benefits provided to beneficiaries enrolled in both the D-SNP and Medicaid managed care organization
MA and Part D quality rating system

The proposed rule makes methodological changes for the non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures effective for the 2020 plan year. Several updates are also made to measures that will be used to establish 2022 and 2023 star ratings, which correspond to the 2020 and 2021 measurement periods.

The proposed rule would modify the following existing measures:

  • Controlling high blood pressure (Part C) to align with new clinical guidelines related to hypertension
  • Medicare Plan Finder Price Accuracy (Part D) to better measure the reliability of a contract's advertised prices
  • Plan All-Cause Readmissions (Part C) to include observation stays and remove individuals with high-frequency hospitalizations
  • Improvement measures (Part C and D) to exclude from the improvement calculation any measure that receives a measure-level star rating reduction for data integrity concerns for either the current or prior year
Preclusion list requirements

The MA and Part D final rule for 2019 first established a policy to prevent MA and Part D payments to individuals and entities found to be "demonstrably problematic" to the programs. Under the final rule, these entities would be placed on a "preclusion list," and payment for MA services and items would be rejected or denied.

The Preclusion List approach creates a blanket list of ineligible individuals and entities identified at the point of payment, instead of relying on MA and Part D enrollment requirements. The proposed rule for 2020 would make several revisions and additions to the preclusion list provisions with the purpose of clarifying CMS' expectations on the preclusion list, including the timing for inclusion on the list, and the appeals process.

MA risk adjustment data validation (RADV)

Pursuant to three statutes passed between 2002 and 2012, the RADV system is the primary means for CMS to implement corrective action reducing improper payments under MA. The proposed rule establishes a new procedure to use extrapolation as part of MA contract-level audits beginning with the payment year 2011. The RADV changes do not apply to fee-for-service adjuster findings.

Contact us

Anne Phelps

Deloitte Risk and Financial Advisory
US Health Care Regulatory leader
Deloitte & Touche LLP


Daniel Esquibel
Senior manager

Deloitte Risk and Financial Advisory
Deloitte & Touche LLP


Ethan Joselow

Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor.

Deloitte shall not be responsible for any loss sustained by any person who relies on this publication.

Fullwidth SCC. Do not delete! This box/component contains JavaScript that is needed on this page. This message will not be visible when page is activated.

Site-within-site Navigation. Do not delete! This box/component contains JavaScript that is needed on this page. This message will not be visible when page is activated.

Did you find this useful?