Summary
Beginning in 2011, prohibits MA plans from imposing cost-sharing rates higher than
traditional fee-for-service for chemotherapy, dialysis, skilled nursing and other services as defined by CMS.
Implementation Status
On April 15, 2011, CMS published a Final Rule implementing several provisions of the ACA, including the cost-sharing rules under this section (see pp. 21440-42).
On Apr. 6, 2015 CMS released the CY 2016 MA Rate Announcement (press release; fact sheet) delineating the agency’s changes in the MA capitation rate methodology and risk adjustment methodology, as well as some policy changes under Part D. Citing a non-discretionary change to expected growth rates, CMS estimates that, on average, MA plans will see a +1.25% revenue increase relative to CY15 and +3.25% when coupled with an additional 2.0% expectation for coding trend. This compares to -0.95% from policy-driven changes the Advance Notice (+1.05% with the same coding expectation)
2016
On Nov. 4, MedPAC held a discussion on coding intensity and calculating benchmarks in Medicare Advantage (MA). The Commission has long-sought to keep MA spending on par with fee-for-service (FFS) levels.
2017
On Feb. 1, CMS posted the CY2018 Advance Noticedelineating proposed methodological and payment changes for MA plans, as well as key policies under Part D.
Statutory Text
SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION. (a) LIMITATION ON VARIATION OF COST SHARING FOR CERTAIN BENEFITS.— (1) IN GENERAL.—Section 1852(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w–22(a)(1)(B)) is amended— (A) in clause (i), by inserting ‘‘, subject to clause (iii),’’ after ‘‘and B or’’; and (B) by adding at the end the following new clauses: ‘‘(iii) LIMITATION ON VARIATION OF COST SHARING FOR CERTAIN BENEFITS.—Subject to clause (v), costsharing for services described in clause (iv) shall not exceed the cost-sharing required for those services under parts A and B. ‘‘(iv) SERVICES DESCRIBED.—The following services are described in this clause: ‘‘(I) Chemotherapy administration services. ‘‘(II) Renal dialysis services (as defined in section 1881(b)(14)(B)). ‘‘(III) Skilled nursing care. ‘‘(IV) Such other services that the Secretary determines appropriate (including services that the Secretary determines require a high level of predictability and transparency for beneficiaries). ‘‘(v) EXCEPTION.—In the case of services described in clause (iv) for which there is no cost-sharing required under parts A and B, cost-sharing may be required for those services in accordance with clause (i).’’. (2) EFFECTIVE DATE.—The amendments made by this subsection shall apply to plan years beginning on or after January 1, 2011. (b) APPLICATION OF REBATES, PERFORMANCE BONUSES, AND PREMIUMS.—(1) APPLICATION OF REBATES.—Section 1854(b)(1)(C) of the Social Security Act (42 U.S.C. 1395w–24(b)(1)(C)) is amended— (A) in clause (ii), by striking ‘‘REBATE.—A rebate’’ and inserting ‘‘REBATE FOR PLAN YEARS BEFORE 2012.—For plan years before 2012, a rebate’’; (B) by redesignating clauses (iii) and (iv) as clauses (vii) and (viii) øReflects subsequent redesignation made by section 1102(d)(2) of HCERA¿; and (C) by inserting after clause (ii) the following new clause: øAs revised by section 1102(d)(2) of HCERA¿ ‘‘(iii) APPLICABLE REBATE PERCENTAGE.—The applicable rebate percentage specified in this clause for a plan for a year, based on the system under section 1853(o)(4)(A), is the sum of— ‘‘(I) the product of the old phase-in proportion for the year under clause (iv) and 75 percent; and ‘‘(II) the product of the new phase-in proportion for the year under clause (iv) and the final applicable rebate percentage under clause (v). ‘‘(iv) OLD AND NEW PHASE-IN PROPORTIONS.—For purposes of clause (iv)— ‘‘(I) for 2012, the old phase-in proportion is 2⁄3 and the new phase-in proportion is 1⁄3; ‘‘(II) for 2013, the old phase-in proportion is 1⁄3 and the new phase-in proportion is 2⁄3; and ‘‘(III) for 2014 and any subsequent year, the old phase-in proportion is 0 and the new phase-in proportion is 1. ‘‘(v) FINAL APPLICABLE REBATE PERCENTAGE.—Subject to clause (vi), the final applicable rebate percentage under this clause is— ‘‘(I) in the case of a plan with a quality rating under such system of at least 4.5 stars, 70 percent; ‘‘(II) in the case of a plan with a quality rating under such system of at least 3.5 stars and less than 4.5 stars, 65 percent; and ‘‘(III) in the case of a plan with a quality rating under such system of less than 3.5 stars, 50 percent. ‘‘(vi) TREATMENT OF LOW ENROLLMENT AND NEW PLANS.—For purposes of clause (v)— ‘‘(I) for 2012, in the case of a plan described in subclause (I) of subsection (o)(3)(A)(ii), the plan shall be treated as having a rating of 4.5 stars; and ‘‘(II) for 2012 or a subsequent year, in the case of a new MA plan (as defined under subclause (III) of subsection (o)(3)(A)(iii)) that is treated as a qualifying plan pursuant to subclause (I) of such subsection, the plan shall be treated as having a rating of 3.5 stars.’’. (2) APPLICATION OF PERFORMANCE BONUSES.—Section 1853(n) of the Social Security Act, as added by section 3201(f), is amended by adding at the end the following new paragraph: ‘‘(6) APPLICATION OF PERFORMANCE BONUSES.—For plan years beginning on or after January 1, 2014, any performance bonus paid to an MA plan under this subsection shall be used for the purposes, and in the priority order, described in subclauses (I) through (III) of section 1854(b)(1)(C)(iii).’’. (3) APPLICATION OF MA MONTHLY SUPPLEMENTARY BENE- FICIARY PREMIUM.—Section 1854(b)(2)(C) of the Social Security Act (42 U.S.C. 1395w–24(b)(2)(C)) is amended— (A) by striking ‘‘PREMIUM.—The term’’ and inserting ‘‘PREMIUM.— ‘‘(i) IN GENERAL.—The term’’; and (B) by adding at the end the following new clause: ‘‘(ii) APPLICATION OF MA MONTHLY SUPPLEMENTARY BENEFICIARY PREMIUM.—For plan years beginning on or after January 1, 2012, any MA monthly supplementary beneficiary premium charged to an individual enrolled in an MA plan shall be used for the purposes, and in the priority order, described in subclauses (I) through (III) of paragraph (1)(C)(iii).’’.