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 Association Concerned About Additional Flexibilities for Medicare Advantage Plans

The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) is voicing its concerns with the Medicare Advantage (MA) program and its effects on beneficiary populations needing post-acute care.

In prepared comments after receiving a request for information (RFI) from the Centers for Medicare & Medicaid Services (CMS), AHCA/NCAL cites issues that have arisen for providers and beneficiaries under the current MA program, and expresses concerns with CMS’ intention to increase flexibilities for MA plans.

The RFI was included in the CMS Announcement of Calendar Year (CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter, and requests feedback from stakeholders on ways CMS can increase flexibility and provider opportunities for innovation in the MA and Medicare Part D programs.

“Providers and beneficiaries are already experiencing issues with Medicare Advantage under the existing framework,” says Narda Ipakchi, senior director, managed markets, at AHCA. “Increased flexibilities, or providing plans with additional opportunities to innovate without taking into consideration certain factors, might only exacerbate these existing issues.”
Currently, MA plans have latitude to develop unique processes and criteria for functions such as utilization management, care coordination, network adequacy grievances and appeals, quality improvement, and claims payment. AHCA says that this variation causes confusion and administrative burdens for providers, especially those serving high-cost, high-need beneficiaries.
Some of the issues experienced by post-acute care providers include confusing appeals and grievance processes, standards for provider networks that do not sufficiently account for the complex needs of beneficiaries receiving post-acute care, and the use of utilization management tools and other protocols to make coverage determinations that emphasize cost rather than quality of care, AHCA/NCAL says.
It also is concerned about the MA program’s delegation of plan responsibilities to subcontracted entities, citing communication issues and confusion among providers and beneficiaries, and that the lack of available data inhibits CMS’ ability to properly oversee MA operations.
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