CMS

This past Tuesday, the Centers for Medicare & Medicaid Services (CMS) announce the latest enrollment figures for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). As of October 24, 2022, over 65.2 million people are enrolled in Medicare, an increase of 132,757 since the last report. More than 35 million people are enrolled in Original or Fee-for-Service Medicare, and more than 30.2 million are enrolled in a Medicare Advantage or other health plan. Over 91.3 million enrollees have Medicaid (84.3+ million) and Children’s Health Insurance Program (CHIP) (7.0+ million), an increase of 462,322 since the last report. More than 12 million enrollees are eligible for both Medicare and Medicaid and are counted for both programs.

This past Wednesday, February 1st, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2024 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies.

On Monday, January 31st, CMS issued a final rule for the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program. The MA RADV program is used to identify improper risk adjustment payments made to Medicare Advantage Organizations (MAOs) for claims made to Medicare without supporting evidence from a beneficiary’s medical record. Payments to MAOs are adjusted based on the health status of a MAO’s enrollees using medical diagnoses reported by the insurer. The new policy will apply to plan contracts since 2018.

As part of the continuing efforts under President Biden’s initiative to improve nursing home transparency, safety and quality, and accountability, the U.S. Department of Health and Human Services announced new actions to reduce the inappropriate use of antipsychotic medications and to bring greater transparency about nursing home citations to families. Beginning this month, CMS will conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis.

The FDA recently granted accelerated approval for the drug Leqembi, a medication intended to slow the progression of Alzheimer’s disease. Leqembi, the brand name for lecanemab, is the second Alzheimer’s therapy for individuals with mild cognitive impairment. Lequembi targets the protein amyloid and can be prescribed to patients in early to mid-stages of Alzheimer’s disease. Eisai, the manufacturer of Leqembi, reports that the drug will be available by January 23, 2023 and estimates the cost of the biweekly infusion to be $26,500 annually. Medicare coverage of Leqembi and other drugs like it, such as Aduhelm, that have accelerated FDA approval are limited to beneficiaries enrolled in certain clinical trials.

CMS added a new telehealth indicator on clinician profile pages on Medicare Care Compare and in the Provider Data Catalog (PDC). The new indicator helps beneficiaries and caregivers find clinicians who provide telehealth services. This is especially helpful for patients seeking telehealth due to the ongoing public health emergency,

On January 5, 2023 CMS released a State Medicaid Director’s letter that provides a new reporting and oversight framework for states that permit managed care plans to deliver in-lieu-of services (ILOS) to their enrollees. ILOS are cost-effective substitutes for otherwise covered State plan services that may enhance enrollee’s health and wellbeing (for example, medically-tailored meals that enhance the ability of an enrollee to remain at home rather than in an institutional setting). States using ILOS will be required to limit them to no more than 5% of a managed care program’s total capitation payments and provide evaluative data to CMS about their effectiveness beginning in 2027.

On January 5, 2023 CMS released an Informational Bulletin providing further guidance on the Medicaid eligibility provisions in the recently-enacted Federal budget (Consolidated Appropriations Act of 2023). The CAA permits states to begin terminating Medicaid eligibility for current recipients on April 1, 2023 and provides gradually-decreased FMAP increases through December, 2023. This IB is the first in a series of written guidance from CMS on these provisions, focusing first on revised key due dates for certain state eligibility redetermination deliverables and activities.

On December 20, 2022 CMS released a report summarizing the public comments it received in response to the 2022 Request for Information (RFI): Access to Coverage and Care in Medicaid & CHIP. CMS framed the RFI questions across three dimensions of health care access: (1) enrolling in coverage, (2) maintaining coverage, and (3) accessing services and supports. This report includes counts of comments, types of respondents, summaries of common themes across objectives, and cross-cutting findings.

As part of the Biden-Harris Administration’s ongoing commitment to increasing health data exchange and investing in interoperability, CMS issued a proposed rule that would improve patient and provider access to health information and streamline processes related to prior authorization for medical items and services. CMS proposes to modernize the health care system by requiring certain payers to implement an electronic prior authorization process, shorten the time frames for certain payers to respond to prior authorization requests, and establish policies to make the prior authorization process more efficient and transparent.