Medicare Advantage

*Among the ways by which ACHP advocates on behalf of our members is through comment letters. Read comment letters pertaining to Medicare Advantage and the Affordable Care Act.

As of March 2015, 31 percent of Medicare beneficiaries receive their Medicare benefits through a private health plan. Many ACHP members offer Medicare Advantage plans – in all, ACHP members enroll about 14 percent (nearly 2.4 million) of the 17.2 million Medicare Advantage members.

ACHP Medicare Advantage Plans Are Among the Highest-Quality Plans in the Nation

Building on Medicare’s Star Ratings that assess clinical quality, consumer satisfaction and regulatory compliance, the Medicare Advantage (MA) program “pays for performance” through a new system of quality incentive payments. CMS rates MA plans on a scale of one to five stars, with five stars representing the highest quality. These ratings provide Medicare beneficiaries with a tool to compare the quality of care and customer service that Medicare health plans offer, helping consumers make better health care choices. The ratings also are the basis for quality incentive payments.

Of 12 MA plans receiving 5 stars for the 2016 plan year, eight are ACHP members. ACHP organizations:

  • Enrolled nearly 93 percent of the beneficiaries in 5-star plans
  • Enrolled 40 percent of the beneficiaries in plans with 4.5 stars or better
  • Offered 4, 4.5 or 5 star plans in 18 states and the District of Columbia

Read more information on ACHP members’ performance on health care quality ratings:

For more information on the value of MA to beneficiaries, please see ACHP and the Medicare Advantage Value Proposition.

Medicare Advantage Benchmark Cap

To achieve cost savings in the Medicare Advantage (MA) program, Congress created a new methodology that reduces MA benchmarks, which are the basis for payment to MA health plans. Between 2012 and 2017, the new methodology is phased into counties over a two-year, four-year, or six-year period, depending on how large the county’s reduction is.

In addition to the benchmark reductions, Congress tied MA payments to plans’ quality ratings: plans that achieve 4 or more stars in the Star Ratings system receive quality incentive payments by increasing their benchmarks by 5 percent. With this provision, Congress made a major shift in Medicare payment policy that had been advocated by many health care stakeholders and experts (including ACHP): paying for quality of care.

Along with the new MA payment methodology and quality incentives, a cap on benchmarks was imposed, such that the new benchmarks – including quality incentive payments – cannot exceed the amount that they would be using pre-ACA methodology. Plans will first feel the effects of the benchmark cap in 2015.

The benchmark cap undermines the shift towards paying for quality that Congress enacted in the same package of Medicare changes. In some areas of the country, the cap reduces or completely eliminates the amount of the benchmark that would be attributable to the quality incentive payment – thus effectively eliminating the incentive to achieve a Star Rating of 4 stars and above. The cap, combined with other cuts to the MA program and plans’ unwillingness to increase premiums, creates a cumulative effect that makes it difficult for plans to maintain benefits and offer all MA options in all counties they currently serve.

The benchmark cap contravenes a programmatic improvement in Medicare, which is to reward the highest-quality health plans. ACHP recommends elimination of the benchmark cap in order to sustain the movement towards recognizing quality care, and to help beneficiaries maintain their benefits and keep their MA plans.

For more information on the MA benchmark cap, please see ACHP’s statement for the record to the House Ways and Means Committee (July 2014).

A Health Affairs blog post, A Glitch In The Road to Pay-For-Performance, authored by Margaret O’Kane, president of the National Committee for Quality Assurance (NCQA), also provides an overview of the issue.

Telehealth in Medicare

ACHP members and many other health plans increasingly utilize telehealth (also referred to as remote access technologies) to provide clinical care and strengthen coordination of services across settings; these efforts are enhanced by our members’ reliance on an electronic medical record. Health plans are using electronic visits, video technology, and remote monitoring to provide maintenance and preventive care for their enrollees, as well as diagnosis and treatment when it is clinically appropriate. ACHP members are finding very high enrollee satisfaction with this approach and no degradation in the quality of care; in fact, remote technologies provide the opportunity for improvements in the quality of care because they increase the amount of interaction between the patient and health care team and the information available on the patient’s health status.

A combination of statutory and regulatory restrictions inhibit the use of these technologies in both the traditional Medicare program and in Medicare Advantage (MA). Currently, the use of remote access technologies is considered a mandatory supplemental benefit in MA. ACHP believes that telehealth technologies should be considered an alternative modality or complementary means of providing clinical services, and not a service itself. Telehealth is a different way of delivering an already covered service, whether that is a physician visit or preventive service. Most state Medicaid programs recognize that telehealth is a different way of delivering the covered service – not merely a supplement or complement to face-to-face encounters – so they provide some level of reimbursement for telehealth, particularly for real-time interactive video visits. Many states also require commercial health plans to provide reimbursement for services provided via telehealth, although not necessarily at parity with services provided in person.

For more information on telehealth, please see ACHP’s statement for the record to the House Ways and Means Committee (July 2014).

Chronic Care in Medicare Advantage

ACHP responded to a request from the Senate Finance Committee on what changes need to be made to Medicare to enable better and more efficient, lower cost care for beneficiaries with multiple chronic illnesses. Our comments focused on possible changes to the Medicare Advantage program. Read the letter here.