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This Week in Health Care Reform - February 26th, 2016

CMS releases its annual proposed changes to the popular Medicare Advantage program; meanwhile, the Administration tightens the rules governing eligibility for signing up for coverage on the exchanges outside of the open enrollment period; and, a new public-private partnership is announced with a focus on quality.


Week in Review

Medicare Advantage: As expected, last Friday, the Centers for Medicare & Medicaid Services (CMS) released their latest proposed changes to the underlying funding structure for the popular Medicare Advantage program.  For those following along, Medicare Advantage serves nearly 17 million American seniors and persons with disabilities – nearly one-third of the total Medicare population.  Through its emphasis on coordinated care, the program is able to connect beneficiaries to the right care at the right time.  And, by helping already vulnerable populations manage multiple chronic conditions, Medicare Advantage has proven to be more effective than traditional fee-for-service Medicare.  It’s no wonder the program is so popular with enrollees.  However, changes to how the program is structured and paid for, particularly in recent years, have only served to unravel the blanket of care that so many millions of beneficiaries have come to depend on.  For instance, year-to-year changes to the risk adjustment model – which incentivizes plans to take on the sickest, most care-intensive beneficiaries – have disproportionately impacted plans serving some of the most vulnerable patients and their ability to connect these patients to the kinds of treatments they need most when they’re most likely to produce the greatest health outcome.  So, while initial reaction to CMS’ announcement has been generally positive, it’s worth exercising caution as the cumulative effects of these latest changes are tied back to how they impact beneficiaries at the point of care.  Prior to last week’s release, stakeholders from across the health care spectrum, including lawmakers, reached out to CMS urging the agency to protect Medicare Advantage and its long-term sustainability.  With the egg-timer having started ahead of CMS’ final determinations regarding its proposed changes being released on April 4th, efforts continue to support the popular program and protect its beneficiaries from further harmful cuts.  Keep up with the latest and be on the lookout for ways to add your voice to the fight.

Special Enrollment:
On Wednesday, CMS announced that it was tightening the loopholes that had allowed consumers to buy coverage via the health insurance exchange marketplace outside the established open enrollment period.  While the health care law defines what life events qualify individuals to purchase coverage during these so-called ‘special enrollment periods,' prior to the announcement, consumers had been able to claim eligibility without having to produce documentary proof of the qualifying event.  Going forward, though, CMS’ proposed implementation of a new confirmation process would require consumers who enroll or change their coverage due to these triggering events to provide documentation verifying their eligibility.  The change was precipitated by the need to address the “enrollment gaming” which had been undermining the stability of the exchanges.  The new rules represent a “major overhaul of the special enrollment process” and will serve to “enhance program integrity and contribute to a stable rate environment,” said Administration official and CEO Kevin Counihan.

Quality Collaboration:
As our health care system continues to embrace a more value-based approach to design and delivery, a new collaborative between CMS and America’s Health Insurance Plans (AHIP), looks to help support this transition.  Announced last week, the new sets of measures from CMS and AHIP – as well as from primary care and physician specialty groups, and consumer and employer groups – seek to align quality standards between public and private payers.  Broadly, the goal of this effort is to establish agreed-upon core quality measures, leading to less complexity in reporting and decreasing the overall cost burden on consumers and our health care system, while ensuring high-quality care for patients.

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Looking Ahead

With Super Tuesday looming, the race to capture the nomination for the White House promises to kick into high gear.

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