CMS Archives - EMPLOYEE BENEFITS BLOG

CMS Issues Guidance on Usage of AI in Making Coverage Determinations

by McDermott Will & Emery | Apr 25, 2024 | Employee Benefits, Health and Welfare Plans

On February 6, 2024, the US Centers for Medicare & Medicaid Services (CMS) issued a letter to all Medicare Advantage (MA) organizations and Medicare-Medicaid plans. The letter covered frequently asked questions and answers related to the coverage criteria and utilization management requirements in the CMS Final Rule issued on April 5, 2023.

Among the FAQs was guidance related to the use of artificial intelligence (AI) and other technologies to assess coverage decisions. CMS wrote, “An algorithm or software tool can be used to assist MA plans in making coverage determinations, but it is the responsibility of the MA organization to ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made.” For example, in a decision to terminate post-acute care services, an algorithm or software tool can be used to predict the potential length of stay, but that prediction alone cannot be used as the basis to terminate services.

CMS also expressed concern that algorithms and AI technologies can exacerbate discrimination and biases, emphasizing that MA organizations must comply with nondiscrimination requirements of Section 1557 of the Affordable Care Act.

2024 Chart of Healthcare Regulations

by Kristen O'Brien, Rachel Stauffer, Katie Waldo and Jeffrey Davis | Apr 24, 2024 | Employee Benefits, Health and Welfare Plans

During this election year, McDermottPlus is actively monitoring annual regulations that federal agencies are expected to release, as well as “ad hoc” regulations that will be released at the discretion of federal agencies.

This chart displays health-related regulations that may be issued this year, organized by federal agency and date of potential release.

Access the chart.

CMS Releases CY 2025 Advance Notice for Medicare Advantage and Part D

by Emily Curran and Kristen O'Brien | Mar 21, 2024 | Employee Benefits, Health and Welfare Plans

On January 31, 2024, the US Centers for Medicare & Medicaid Services (CMS) released the Advance Notice of Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and D Payment Policies. CMS also released a press release and fact sheet. The advance notice is released on an annual basis and includes proposed updates to the capitation and risk adjustment methodologies used to calculate payments to MA plans, as well as other payment policies that impact Part D. The final CY 2025 rate announcement will be published no later than April 1, 2024.

The advance notice discusses several updates the Inflation Reduction Act of 2022 (IRA) made for 2025, including:

Newly defined Part D benefit design composed of three phases: annual deductible, initial coverage and catastrophic coverage
Lower out-of-pocket threshold of $2,000
Sunset of the Coverage Gap Discount Program and establishment of the Manufacturer Discount Program, and
Changes to the liability of enrollees, sponsors, manufacturers and CMS (Draft Part D Redesign Program Instructions, Draft Part D Redesign Program Instructions Fact Sheet)

As a result of the IRA, CMS proposes updates to the Part D risk adjustment model to reflect the Part D benefit design.

CMS is annually required to update the parameters for the defined standard Part D drug benefit. This is meant to ensure that the actuarial value of the drug benefit tracks changes in Part D expenses. For non-low-income subsidy beneficiaries, the advance notice outlines the benefit parameters for defined standard benefits in 2025 as follows:

CMS Approves New York 1115 Medicaid Redesign Waiver

by Katie Waldo and Kayla Holgash | Mar 7, 2024 | Employee Benefits, Health and Welfare Plans

On January 9, 2024, the Centers for Medicare and Medicaid Services (CMS) approved the New York State (NY) 1115 Medicaid waiver “Medicaid Redesign Team” (MRT). The MRT is a long-standing waiver in NY that has continuously evolved to improve the administration, structure and financing of the NY Medicaid program; enhance Medicaid beneficiaries’ access to services; and improve health outcomes across the state. The recently approved waiver represents the next step in Medicaid redesign in NY and builds on the previous Delivery System Reform Incentive Payment (DSRIP) program.

This article reviews the major initiatives included in the MRT, components of the MRT that were excluded from the approval, implications for stakeholders and more.

Read more here.

2024: The Year of the Telehealth Cliff

by Lisa Schmitz Mazur, Rachel Stauffer, Debra Curtis and Leigh Feldman | Feb 5, 2024 | Digital Health, Employee Benefits, Health and Welfare Plans

What does December 31, 2024, mean to you? New Year’s Eve? Post-2024 election? Too far away to know?

Our answer: December 31, 2024, is when we will go over a “telehealth cliff” if Congress fails to act before that date, directly impacting care and access for Medicare beneficiaries. What is this telehealth cliff?

Read more here.

CMS Proposes to Prohibit Overrides in Medicare Advantage

by Mary Moll Alexandre, Jeremy Earl, Kate McDonald and Fabiola Díaz Vera | Jan 16, 2024 | Employee Benefits, Health and Welfare Plans

On November 6, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for the Medicare Advantage and Part D programs. Among other proposals, CMS proposed significant changes to longstanding rules on permissible payment structures for agents and brokers. Specifically, CMS proposes to prohibit “overrides” or administrative fees paid to agents and brokers outside of the fair market value enrollment compensation limits established by CMS. This could have a significant impact on MA and Part D plan arrangements with agents and brokers.

Read more here.

Remote Monitoring and Digital Therapies: CMS Updates Coverage and Payment Policies

by Caroline Reignley, Michael Ryan and Deborah Godes | Dec 26, 2023 | Employee Benefits, Health and Welfare Plans

In recent years, the Centers for Medicare & Medicaid Services (CMS) has expanded payment for remote monitoring services in an effort to pay for non-face-to-face services that improve care coordination for Medicare beneficiaries. On November 2, 2023, CMS released the calendar year 2024 final rule for services reimbursed under the Medicare Physician Fee Schedule. In the final rule, CMS clarified certain guidance for remote monitoring services, finalized separate reimbursement for remote monitoring provided by rural health centers and federally qualified health centers, and discussed a recent request for information for digital therapies.

Read more here.

CMS Announces New GUIDE Model to Support People Living with Dementia and Their Caregivers

by Gregory Mitchell, Fabiola Díaz Vera and Casey Li | Oct 31, 2023 | Employee Benefits, Health and Welfare Plans

To support people living with dementia and their unpaid caregivers, the US Centers for Medicare & Medicaid Services recently announced the Guiding an Improved Dementia Experience (GUIDE) Model, a new, voluntary and nationwide test model designed specifically for these two rapidly growing demographic groups. The model will offer care coordination and care management for individuals living with dementia and provide education, support and respite services for their caregivers.

The GUIDE model will launch on July 1, 2024.

Read more here.

A Look into House Efforts on Hospital and Health Plan Price Transparency

by Leigh Feldman and Rachel Stauffer | Sep 19, 2023 | Employee Benefits, Health and Welfare Plans

In the 118th Congress, the US House of Representatives is keenly interested in healthcare price transparency. Three House committees—Energy and Commerce, Ways and Means, and Education and the Workforce—each approved legislation that would advance price transparency objectives. Generally, these bills seek to codify (or modify) the requirements around hospital and health plan price transparency as previously implemented by the Centers for Medicare & Medicaid Services.

While there are many similarities between the three bills, the committees and House leadership will need to negotiate certain key differences before a bill is brought to the House floor for a vote. It remains unclear which of the competing bills might get a vote.

This +Insight examines the hospital and health plan transparency provisions of these primary pieces of legislation and compares them with current regulations.

Read full analysis.

Medicare Advantage Plan Requirements Post-PHE: Ensuring a Smooth Transition

by Brian Stimson and Fabiola Díaz Vera | Jun 6, 2023 | Employee Benefits, Health and Welfare Plans

Medicare Advantage (MA) plans are facing both regulatory and business risks following the conclusion of the COVID-19 Public Health Emergency (PHE). What are the major MA flexibilities and requirements related to the pandemic, and have they ended along with the PHE?

Read more here.

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