The Centers for Medicare & Medicaid Services (CMS) on Monday released its final policy and payment updates to Medicare Advantage (MA) and Part D programs for 2020. In addition to updated payment rates, the agency outlined policy changes to address the opioid crisis, star ratings enhancements, and social determinants of health. Here ‘s what you need to know about the Call Letter and payment updates:

1. New policies aim to help prevent and combat prescription opioid overuse

In response to the nationwide opioid epidemic, CMS will continue policies it put in place in 2019, including Part D drug management programs for high-risk opioid users and improved safety alerts, such as the seven-day supply limit for opioid naïve patients. The agency will evaluate those policies while they implement new ones for 2020, including the following:

  • MA plans may offer pain management/complementary and integrative treatments: These targeted benefits and cost-sharing reductions are for patients with chronic pain or those undergoing addiction treatment.
  • Part D sponsors may provide more access to opioid reversal agents: CMS wants sponsors to provide lower cost sharing for agents, such as naloxone.
  • CMS will incorporate Part D opioid-related measures through the star ratings development process: The agency said it will update specifications for the use of opioids at high dosage and/or from multiple providers, and for concurrent use of opioids and Benzodiazepines measures, and add them to the display page. This is the first step before the measures can be formally adopted.

2. Changes to star ratings include expansion, removal of measures

This is the final year that CMS will announce changes to the methodology for calculating the ratings and any changes in the measurement set via the Call Letter. Among the enhancements the agency plans to make in 2020 is a policy to adjust the ratings in the event of extreme and uncontrollable circumstances, such as major hurricanes or other natural disasters. It will also:

  • Expand the number of measures used to determine Categorical Adjustment Index to include all star ratings measures that remain after applying the exclusion criteria for a candidate measure for adjustment. This will provide for a more comprehensive adjustment for socio-economic status and disability by including all measures that may be sensitive to the composition of enrollees in a contract and will align with the methodology finalized in the 2019 Final Rule for the 2021 Star Ratings.
  • Remove three measures from the 2022 Star Ratings:
    CMS said it is removing these measures because they have low statistical reliability:
    • Adult BMI Assessment (Part C)
    • Appeals Auto-Forward (Part D)
    • Appeals Upheld (Part D)
  • Temporarily remove one measure:
    CMS will temporarily remove the Controlling High Blood Pressure (Part C) measure from the 2020- and 2021-Star Ratings due to a substantive measure specification change to align with new hypertension treatment guidelines from the American College of Cardiology and American Heart Association.

3. New guidance for special supplemental benefits to address social determinants of health for the chronically ill

MA plans now may offer chronically ill patients a broader range of supplemental benefits tailored to their specific needs, such as providing meals beyond a limited basis, transportation for non-medical needs like grocery shopping, and home environment services that will improve or maintain the health or overall function of the patient as it relates to his or her chronic condition or illness. For example, MA plans could cover the cost of home air cleaners and carpet cleaning to reduce irritants that may trigger a patient’s asthma attacks, provide heart-healthy food or produce to a patient with heart disease, or provide a diabetic patient with transportation to a doctor’s appointment, education program, or to see a nutritionist.

“Today’s changes give plans the ability to be innovative and offer benefits and services that address social determinants of health for people with chronic disease,” said CMS Administrator Seema Verma in an announcement. “With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that focus on preventing disease and keeping people healthy.”

4. Payment rates will also be adjusted for MA plans.

MA plans will see an increase of 2.53 percent on average 2020 payments, according to the 2020 Rate Announcement Fact Sheet. The agency originally planned on a rate increase of 1.59 percent.

5. Risk scores for the 2020 Part C Risk Adjustment model will be calculated differently than in the past.

CMS plans to calculate risk scores by blending 50 percent of the risk score calculated using diagnoses from the encounter data, Risk Adjustment Process System (RAPS) inpatient diagnoses, and fee-for-service (FFS) diagnoses with the other 50 percent of the risk score calculated with diagnoses from RAPS and FFS. CMS will also phase-in a new risk adjustment model by calculating the encounter data-based risk scores exclusively with the new risk adjustment model, while it continues to use the 2017 model for payment by calculating the RAPS-based risk scores.