Advance Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2017 Call Letter

Mr. Sean Cavanaugh
Deputy Administrator,
Centers for Medicare & Medicaid Services
Director, Center for Medicare


Dear Mr. Cavanaugh:

We appreciate the opportunity to submit comments to the Advance Notice and Call Letter for CY 2017 referenced above. Our organization, California Health Advocates, is an independent, not-for-profit organization advocating on behalf of Medicare beneficiaries. We provide quality Medicare and related healthcare coverage information, education and policy advocacy. CHA works closely with local State Health Insurance Assistance Programs (SHIP) in California by providing technical assistance, training and policy advocacy.

Attachment II, Section I: Medicare Advantage Coding Pattern Adjustment

We support CMS’ work in correcting the problem of higher levels of diagnostic documentation leading to higher levels of payment if a plan’s motivation is merely to generate higher revenue. One way to document diagnosis is health risk assessments. In a previous Advance Notice and Call Letter, CMS proposed to exclude the in-home risk assessment from risk scores, but this proposal was not in the final Notice and Call Letter. If an MA plan conducts health assessments, it should follow-up with appropriate care or treatment to improve the enrollees’ health. Thus we suggest that, at least for CY 2017, CMS exclude health assessments from risk score calculations. Until and unless MA plans can document that follow-up and appropriate care or treatment was provided based on health assessments, health assessments should not be included in risk score calculations.

Section I – Parts C and D

Contracting Organizations with Ratings of Fewer Than Three Stars in Three Consecutive Years – Timeline for Application of Termination Authority

CMS advised that after it has notified plans that meet the criteria for a star rating-based termination, in March 2016 “beneficiaries enrolled in plans offered under the non-renewed contracts will receive notices advising them that they will need to choose a new plan during the next annual election period to continue their Part C and Part D plan enrollment without interruption during the following benefit year.” Since our organization works closely with local California SHIPs, we request CMS to provide all SHIPs and other organizations that serve Medicare beneficiaries an advance copy of the notice beneficiaries will receive. In previous years, enrollees in plans rated fewer than 3 stars received a February notice (CMS Prod. No. 11633) informing them about a one-time chance to change to a plan with better ratings. Would beneficiaries who receive the aforementioned notice in March 2016 also have a chance to change plans

Attachment VI, Section II – Part C

Guidance on the Future of Provider Directory Requirements and Best Practices

We applaud CMS’ emphasis on accurate provider directories so that beneficiaries and caregivers can rely on them to make informed decisions to meet their health care needs. We support the use of new technology to simplify the process of updating provider directories; a comprehensive process to monitor provider director accuracy; increasing the number of data elements in Medicare Advantage provider directories to be consistent with managed care programs in QHP and Medicaid; and requiring, not only encouraging, MA plans to incorporate a “warm transfer” policy to their customer service centers.

We would like to raise an issue regarding limited access from local California SHIP cases. In these cases, beneficiaries choose to join an MA plan after checking that their providers are in the plan’s network. However, after they join the plan, they learn that they are not allowed to see any provider in the plan’s network, only providers in their primary care provider’s group. For example, a beneficiary checks that her primary care provider (PCP) and specialist are in Health Plan Alpha’s network. She joins Health Plan Alpha then learns that she cannot see her specialist because her specialist is not in the same medical group as her PCP even though the specialist is in Health Plan Alpha’s network. To see her specialist, she would need to change to a PCP in the specialist’s group. Or she would have to change specialists to one in her PCP’s group. Although beneficiaries are allowed to change PCPs and other providers, changing providers invariably disrupts care.

Although the beneficiary did her homework and checked that her providers are in the plan’s network before joining, it was not enough to ensure that she can see her providers. The provider directory may have been accurate, but it was misleading. The problem of limited access is due to providers being in different medical groups, or referred to as “delegation.” Where can a beneficiary find information about different medical groups and which providers are in which group? One solution may be to include medical group information in provider directories and explain to beneficiaries that they may be limited to certain providers in the network. However, this would not only increase the difficulty of ensuring that provider directories are accurate but, worse, places an unreasonable burden on beneficiaries.

We question whether “delegation” nullifies the purpose of network adequacy standards which is to provide adequate access to covered services to meet the needs of the population served. Section 110.1.1 Provider Network Standards (chapter 4, Medicare Managed Care Manual) states, “Plans may not implement utilization management protocols that create inappropriate barriers to needed care.” We would argue that delegation creates an inappropriate barrier to needed care. We urge CMS to examine plans that use “delegation” and work with these plans to allow all enrollees access to any provider in the plan’s network.

Total Beneficiary Cost (TBC)

CMS alerted MAOs that it will exercise its authority to deny MAO bids if it determines the bid proposes too significant an increase in cost sharing or decrease in benefits from one plan year to the next through the use of the TBC standard. We appreciate CMS’ concern that enrollees who continue enrollment in the same plan are not exposed to significant cost increases. We urge CMS to extend its concern to enrollees in stand-alone Part D plans. In particular, we would like to highlight situations that cross-walk beneficiaries from one plan to another, as in plan consolidation.

Example: An enhanced PDP and a basic PDP offered in 2015 were consolidated to a basic PDP offered in 2016. The premium of the 2016 basic PDP was 400% of the 2015 basic PDP and 330% of the 2015 enhanced PDP. Since it was a consolidation, enrollees in both the 2015 plans were cross-walked to the 2016 basic PDP with no Special Election Period. They were expected to read the Annual Notice of Change (ANoC) and use the Annual Election Period to change plans, like other beneficiaries. Several beneficiaries complained that they did not know that the enhanced plan was ending. Since they were cross-walked to another plan with the same sponsor, they assumed they were covered and did not pay attention to the much higher cost: not only was the premium much higher, the 2016 basic plan PDP had a $360 deductible whereas the 2015 enhanced PDP had no deductible.

We suggest that beneficiaries who are cross-walked receive a notice separate from the ANoC; that the notice refer them to SHIP for counseling about their options; and that a Special Election Period be granted, similar to what enrollees in non-renewing plans have, from December 8 to the last day of February.

Policy Updates

Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost-Sharing

We thank CMS for reminding all MAOs of their obligation to protect dual eligible beneficiaries from incurring liability for Medicare cost-sharing. The study’s findings confirm that more outreach and education are needed to ensure that dually eligible beneficiaries are protected from balance billing.

As CMS and MAOs take affirmative steps to address common points of confusion among providers regarding balance billing, we take the opportunity to raise some questions and concerns:

  1. Assumption that dually eligible beneficiaries join only D-SNPs – Dually eligible beneficiaries can and do join MA plans that are not D-SNPs. However, MAOs do not seem to consider dually eligible beneficiaries as members when they design plans that are not D-SNPs.
  2. Providers’ lack of knowledge about patient’s dually eligible status – Some cases from local CA SHIPs seem to suggest that providers do not know that a patient in an MA plan is dually eligible for Medicare and Medicaid. When a beneficiary present his/her plan membership card at an appointment, does the card indicate that the beneficiary is dually eligible, whether QMB or FBDE?
  3. Instructions to bill the State Medicaid Program – Suppose a provider has information that a patient is dually eligible thus protected from balance billing. How does a provider know to bill the State Medicaid Program? We suggest that MAOs include instructions on how to bill the State Medicaid Program and information that the State Medicaid Program may not pay the full Medicare cost-sharing amount.
  4. Providers who are not contracted – MAOs may be able to reach contracted providers, but what about non-contracted providers such as in non-network PFFS plans and PPOs which allow members to see out-of-network providers? In some rural areas in California, only PFFS plans are available. Since there are no coordinated care plans available, the PFFS plans are not required to contract with providers to form a network. PFFS plan members may go to any provider willing to accept the plan’s payment terms and condition. If a plan member is dually eligible, how do these providers know the patient’s dually eligible status and not to collect a copayment but to bill the State Medicaid Program? In the PPO-type of MA plan, plan members may see out-of-network providers at a higher cost-sharing. Since dually eligible beneficiaries are protected from all cost-sharing, how do out-of-network providers know the patient’s dually eligible status and not to collect a copayment but to bill the State Medicaid Program?

Section III – Part D

Part D Benefit Parameters for Non-Defined Standard Plans

Tier Labeling and Composition

CMS started the section with a statement that it expects “Drug Tier Labels to be representative of the drugs that make up that tier.” Adhering to that statement, tier labeling that would be less confusing to beneficiaries would be labeling used prior to CY 2016: preferred generic, non-preferred generic, preferred brand, and non-preferred brand. Although the proposal to have a tier with both generic and brand drugs labeled “non-preferred drugs” would be more representative than the label “non-preferred brand drugs,” our experience leads us to believe it would be equally confusing to beneficiaries. We recommend that CMS not allow both generic and brand drugs be placed in the same tier, whatever the label.

Neither the draft Call Letter for CY 2017 nor the final Call Letter for CY 2016 provides guidance on which generic drugs can be placed with brand drugs in the “non-preferred brand drug” tier or the proposed “non-preferred drug” tier. The main concern seems to be the increasing cost of generic drugs. In chapter 6 of the Medicare Prescription Drug Benefit Manual,
§30.2.7 states, “Best practices in existing formularies and preferred drug lists generally place drugs in a less preferable position only when drugs that are therapeutically similar (i.e., drugs that provide similar treatment outcomes) are in more preferable positions on the formulary.” We respectfully ask if sponsors check that therapeutically similar drugs are in preferred tiers before placing generic drugs in the “non-preferred brand drug” tier or the proposed “non-preferred drug” tier.

Section 30.2.7 also states: “The CMS review will focus on identifying drug categories that may substantially discourage enrollment of certain beneficiaries by placing drugs in non-preferred tiers in the absence of commonly used therapeutically similar drugs in more preferred positions.” The concern expressed was on not discouraging enrollment. In our experience, we have observed that most beneficiaries do not delve into such details when deciding whether to enroll in a plan. Rather, the more likely scenario is beneficiaries finding out about higher than expected cost-sharing at the pharmacy, after they have enrolled in a plan. We are not persuaded that using a coinsurance cost-sharing structure instead of a copayment cost-sharing structure would lower beneficiary cost. We assume, and would like confirmation, that requests for a tiering exception apply to drugs in the “non-preferred brand drug” tier or the proposed “non-preferred drug” tier. However, many beneficiaries do not know they have a right to request a tiering exception and more beneficiary education is needed. Thus our concern is that beneficiaries forego medications, whether generic, brand or other, if they cannot afford them.

Specialty Tiers

We commend CMS for considering increasing the specialty tier threshold in CY 2017, which has not been increased since CY 2008, and we support the new threshold of $670. Given the significant increase in the cost of Part D drugs, especially drugs that may be placed in the specialty tier, we hope CMS will consider increasing the threshold on an annual basis moving forward.

We also support CMS’ initiatives to raise awareness and educate beneficiaries on the cost of prescription drugs and their impact on the Part D program. We respectfully ask that CMS involve stakeholders in the process so that our efforts and the message are coordinated and consistent.
We continue to be concerned that the Part D enrollees are not allowed to request a tiering exception for drugs in the specialty tier. When beneficiaries cannot afford a drug, many forego medications putting their health and even their life at risk.

Generic Tier $0 Copay Plans

CMS encouraged Part D sponsors to offer generic tier $0 copay plans to increase the use of generics which “could mean significant savings to beneficiaries and to the Medicare Part D program.” We support CMS’ encouragement to have more generic tier $0 copay plans and appreciate CMS’ study and report “Does Enrollment in Generic-Tier Zero Co-pay Plans Improve Generic Use Within the Part D Program?” In particular, we strongly suggest that benchmark plans offer $0 copay for generic drugs.

CMS noted that “low-income subsidy (LIS) enrollees continue to have lower use of generics compared to enrollees without subsidies.” CMS referred to the small differential between the LIS statutory copay amounts for generic and brand drugs as a possible explanation for the lower use of generic drugs among LIS-eligible beneficiaries. CMS postulated that if more beneficiaries enrolled in generic tier $0 copay plans, generic use could potentially increase.

The study found: “About 1.2 million LIS beneficiaries or 10.9% of the LIS Part D population were enrolled in generic-tier $0 copay plans.” (p.3) The study compared enrollment in Enhanced plans to Basic plans, MA-PD to stand-alone Part D plans, and found that most (91.7%) LIS-eligible beneficiaries were enrolled in basic plans, rather than enhanced plans, with a $0 copay generic tier. This finding is not surprising because LIS-eligible beneficiaries, especially those with full subsidy, tend to be in benchmark plans, which are basic plans. Beneficiaries with full LIS are auto-enrolled in benchmark plans or choose benchmark plans since full LIS covers the premium and deductible in benchmark plans completely. In our experience, LIS-eligible beneficiaries who choose their own Part D plan tend not to see if a plan has a $0 copay tier before enrolling in the plan. Thus for more LIS-eligible beneficiaries to enroll in generic tier $0 copay plans, there needs to be more benchmark plans with $0 copay for generic drugs.
To increase higher enrollment in generic tier $0 copay plans, more education may help to direct beneficiaries to compare cost-sharing and not just premiums before they enroll in plans.

We support CMS encouraging plan sponsors to offer $0 copayment generic tiers and to exempt the $0 cost-sharing tier from a plan’s deductible. First-dollar coverage for generic medications may increase generic prescription drug use over brand medications and may also increase overall medication adherence.

We appreciate the chance to comment on the Advance Notice and Call Letter for CY 2017. We welcome your questions as you finalize this document.


Elaine Wong Eakin
Executive Director

Karen Joy Fletcher

Our blogger Karen Joy Fletcher is CHA’s Communications Director. With a Masters in Public Health from UC Berkeley, she is the online “public face” of the organization, provides technical expertise, writing and research on Medicare and other health care issues. She is responsible for digital content creation, management of CHA’s editorial calendar, and managing all aspects of CHA’s social media presence. She loves being a “communicator” and enjoys networking and collaborating with the passionate people and agencies in the health advocacy field. See her current articles.