Federal officials want to hear whether providers think adding dementia and pressure ulcers as risk factors in managed Medicare plans is a good idea.
“Without an adjustment for health status there is a strong incentive for Medicare Advantage plans to target the enrollment of beneficiaries who are healthier than average,” the Centers for Medicare & Medicaid Services explained in a recent report to Congress on risk adjustment in Medicare Advantage.
CMS is seeking comment on the proposal. It’s doing so under requirements of the 21st Century Cures Act, which mandate that CMS make changes to the risk adjustment model to account for the number of conditions an individual beneficiary might have.
The agency is considering whether to add pressure ulcers and dementia to the list of conditions that might increase a resident’s risk to a private Medicare insurer. Different from traditional fee-for-service Medicare, insurers that run managed care plans are paid based on an assessment of risk in their total patient pool.
Higher risk scores — based on beneficiaries’ health and other characteristics — are tied to larger reimbursements. CMS’ new model would add variables that count the number of conditions a beneficiary may have, including categories for mental health, substance use and chronic kidney disease. Building on the model used for 2019, it includes technical updates, calibrating the model with more recent data, Health Care Finance reported.
The agency also is presenting an alternative payment condition count model that would incorporate categories for pressure ulcers and dementia. CMS is asking for feedback on which version to use starting with 2020 payments by Feb. 19. To submit comments or questions electronically, go to www.regulations.gov and enter the docket number “CMS-2018-0154” in the search field.
The final rate announcement will be issued April 1.
