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CMS to Expand Tailored Benefits for Medicare Advantage Plans

CMS is proposing new personalization options for Medicare Advantage plans aimed at improving value for members with chronic conditions.

Medicare Advantage and chronic conditions

Source: CMS

By Jennifer Bresnick

- CMS is proposing significant changes to Medicare Advantage geared towards expanding choice and increasing competitiveness in a highly lucrative market.

The proposals would increase the number and scope of supplemental benefits available to Medicare Advantage (MA) members and would open up the option of tailoring benefit packages to patients with certain chronic conditions.

“CMS is committed to modernizing Medicare and our top priority is to ensure that seniors have more choices and affordable options in receiving their Medicare benefits,” said CMS Administrator Seema Verma.

“Medicare Advantage enrollment is at an all-time high as more and more seniors are choosing to enroll in private Medicare health and drug plans, and we need to maximize competition by providing plans the flexibility to meet patients’ needs.”

CMS is soliciting comment on changes that would take place for the 2020 plan year, including the option to create customizable plans to address the social determinants of health for chronic disease patients. 

Plans may have the opportunity to add tailored coverage for non-emergency transportation or home delivery of meals for individuals with food insecurity in an effort to prevent crisis events and expensive utilization of emergency and inpatient services.

“The Bipartisan Budget Act of 2018 amended the statute to allow MA plans, beginning CY2020, to offer non-primarily health related supplemental benefits to chronically ill enrollees,” CMS explained.

“The law also permits the Secretary, only with respect to supplemental benefits provided to a chronically ill enrollee under the new provision, to waive uniformity requirements, allowing MA plans to vary these supplemental benefits based on the individual enrollee’s specific medical condition and needs.”

Because plans do not have to be uniform, payers have the opportunity to create coverage specifically suited for individuals with common challenges, such as a plan for diabetics that focuses on offering dietary support.

“In the draft Call Letter, we provide guidance about these new special supplemental benefits for the chronically ill, including the definition of a chronic condition and how to submit these benefits in the MA bid. We are soliciting stakeholder feedback on this proposed guidance.”

The proposals also suggest new ways to address opioid abuse within Medicare Advantage.

“CMS is encouraging Medicare Advantage plans to take advantage of new flexibilities to offer targeted benefits and cost sharing reductions for patients with chronic pain or undergoing addiction treatment, and encouraging Part D plans to provide lower cost sharing for opioid-1reversal agents,” the agency said.

Previous changes to overutilization policies resulted in a 14 percent decrease in the share of Part D beneficiaries using opioids between 2010 and 2017.  The largest decrease, 5 percent, took place between 2016 and 2017 as the focus on opioid abuse sharpened at the federal and local levels.

CMS is proposing that opioid use measures be included in the Star Ratings for Medicare Advantage plans.

“We are updating the methodology for measures currently on or under consideration for our display page, including: Use of Opioids at High Dosage and from Multiple Providers (OHDMP) (current display measure); Use of Opioids at High Dosage (OHD) and Use of Opioids from Multiple Providers (OMP) measures (proposed display measure); and Concurrent Use of Opioids and Benzodiazepines (COB) (proposed display measure),” the agency stated.

“Reporting measures on the display page is a necessary step before the measure can be formally adopted as part of the Star Ratings through rulemaking.” 

Additional changes to the Star Ratings program include rating adjustments in 2020 for plans experiencing “extreme and uncontrollable circumstances,” such as hurricanes and other natural disasters.

The proposals would also remove several measures in 2022, such as adult BMI assessment and the number of appeals upheld, and would implement a temporary suspension of the “controlling high blood pressure” measure to account for recent major changes in clinical guidelines.

The changes are intended to give beneficiaries a clearer understanding of how Medicare Advantage plans operate while bringing additional value to consumers through more personalized benefit options.

The public comment period is open until March 1, 2019.  The document will be published in its finalized form no later than April 1, 2019.  To share commentary on the proposals, go to and enter docket number “CMS-2018-0154” in the search field.


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