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Payers, States at Odds on CMS Plan to Fix Dual-Eligible Underpayment

Aimee Sharp
Author | Shield HealthCare
12/10/15  10:06 AM PST
Dual-Eligible Underpayment

By Virgil Dickson for Modern Healthcare

Health plans and state Medicaid directors disagree on how the CMS should fix its problem of underpaying plans with high numbers of dually eligible Medicare and Medicaid beneficiaries.

In October, the CMS announced it would modify its risk-adjustment model after an analysis of reimbursement data revealed that some health plans were being underpaid.

To address the discrepancy, the CMS suggested separating Medicare Advantage beneficiaries into six categories that identify whether they receive full or partial dual eligibility, and whether those classifications are made because they are disabled or elderly. There are also categories for elderly and disabled beneficiaries who are not dually eligible.

Aetna Executive Vice President of Corporate Affairs Steven Kelmar said in a letter that Aetna was concerned that including non-dual eligibles in the CMS’ proposed revisions could unfavorably disrupt the largely accurate predictions the model makes for that population.

Instead, the CMS should simply rebalance the model to accurately reflect the costs between full dual eligibles and partial dual eligibles, Kelmar said.

The agency took comments on the proposed tweaks through Nov. 25.

Payers shared their comments with Modern Healthcare, since the agency has yet to post their responses. A CMS spokesman said the agency is still working through the logistics and timing of posting comments.

America’s Health Insurance Plans suggested recalibrating Medicaid factors within the existing model to account for the differences between full and partial dual eligibles instead of creating six categories, said Mark Hamelburg, AHIP’s senior vice president of federal programs.

The CMS has released few details on how the revised model will work, making it difficult for insurers to anticipate how the changes will affect their revenue needs.

Others praised the proposed new model, saying it would more accurately pay for vulnerable populations, according to a comment submitted by the SNP Alliance, which represents special-needs health plans.

Read the Full Article at Modern Healthcare.