The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation is announcing the Medicare Advantage Value-Based Insurance Design (MA-VBID) model, an opportunity for Medicare Advantage plans (MA plans), including Medicare Advantage plans offering Part D benefits (MA-PD plans), to offer clinically-nuanced benefit packages aimed at improving quality of care while also reducing costs.
Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure enrollee cost sharing and other health plan design elements to encourage enrollees to use high-value clinical services – those that have the greatest potential to positively impact enrollee health. VBID approaches are increasingly used in the commercial market, and evidence suggests that the inclusion of clinically-nuanced VBID elements in health insurance benefit design may be an effective tool to improve the quality of care while reducing its cost for Medicare Advantage enrollees with chronic diseases. As part of the “better care, smarter spending, healthier people” approach to improving health care delivery, CMS will test VBID in Medicare Advantage and measure whether structuring patient cost sharing and other health plan design elements does encourage enrollees to use health care services in a way that reduces costs.
The MA-VBID model will begin January 1, 2017 and run for five years. CMS will test the model in 7 states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. These states have been selected in order to be generally representative of the national Medicare Advantage market; they include urban and rural areas, areas with both high and low average Medicare expenditures, high and low prevalence of Low-Income Subsidies and areas with varying levels of penetration of and competition within Medicare Advantage. Test states have also been selected based on the availability of appropriate paired comparison areas for the purposes of evaluation. Eligible MA plans in these states, upon CMS approval, may offer varied plan benefit designs for enrollees who fall into certain clinical categories identified and defined by CMS. Benefit design changes made through this model may reduce cost sharing and/or offer additional services to targeted enrollees; however, targeted enrollees can never receive fewer benefits or be charged higher cost sharing than other MA enrollees as a result of the model.
The Medicare Advantage Value-Based Insurance Design Model is authorized under Section 1115A of the Social Security Act (added by section 3021 of the Affordable Care Act) (42 U.S.C. 1315a), which authorizes the Center for Medicare and Medicaid Innovation to test innovative health care payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while preserving or enhancing the quality of beneficiaries’ care. CMS will exercise this authority to test this model in the Medicare program through a limited waiver of the Medicare Advantage and Part D uniformity requirements.
The MA-VBID model supports high-value clinical services, improved health outcomes, and health care cost savings or cost neutrality through the use of structured patient cost sharing and other health plan design elements that encourage enrollees to use high-value clinical services. The MA-VBID model will provide flexibility for Medicare Advantage plans accepted into the model to develop clinically-nuanced benefit designs for enrollee populations that fall within certain clinical categories.
The conditions are:
– Chronic Obstructive Pulmonary Disease (COPD)
– Congestive Heart Failure (CHF)
– Patient with Past Stroke
– Coronary Artery Disease
– Mood disorders
In addition to developing interventions targeted at all enrollees in one or more of the above categories, participating MA plans will have the flexibility to identify specific combinations of the listed chronic conditions for one or more “multiple co-morbidities” groups and establish tailored VBID interventions for each group. Participating MA plans are required to provide VBID benefits to all VBID-eligible enrollees in the selected group.
For each of the selected enrollee groups, participating plans may select one or more plan design modifications from a menu of four general approaches. Within each approach, plans have significant flexibility on how (and to what extent) to implement that approach. Plans may vary their proposed interventions from one target population to another, and from one participating plan to another.
The four approaches are:
1. Reduced Cost Sharing for High-Value Services: Plans can choose to reduce or eliminate cost sharing for items or services, including covered Part D drugs, that they have identified as high-value for a given target population. Participating plans have broad flexibility to choose which items or services are eligible for cost-sharing reductions; however, these services must be clearly identified and defined in advance, and cost-sharing reductions must be available to all enrollees within the target population. Examples of interventions within this category include eliminating co-pays for eye exams for diabetics and eliminating co-pays for ACE inhibitors for enrollees who have previously experienced an acute myocardial infarction.
2. Reduced Cost Sharing for High-Value Providers: Plans can choose to reduce or eliminate cost sharing when providers that the plan has identified as high-value treat targeted enrollees. Plans may identify high-value providers, not solely based on cost, across all Medicare provider types, including physicians/practices, hospitals, skilled-nursing facilities, home health agencies, ambulatory surgical centers, etc. Examples of interventions within this category include reducing cost sharing for diabetics who see a physician who has historically achieved strong results in controlling patients’ Hba1c levels and eliminating cost sharing for heart disease patients who elect to receive non-emergency surgeries at high-performing cardiac centers.
3. Reduced Cost Sharing for Enrollees Participating in Disease Management or Related Programs: Participating plans can reduce cost sharing for an item or service, including covered Part D drugs, for enrollees who choose to participate in a plan-sponsored disease management or similar program. This could include an enhanced disease management program, offered by the plan as a supplemental benefit, or it could refer to specific activities that are offered or recommended as part of a plan’s basic care coordination activities. Plans using this approach can condition enrollee eligibility for cost-sharing reductions on meeting certain participation milestones. For instance, a plan may require that enrollees meet with a case manager at regular intervals in order to qualify. However, plans cannot make cost-sharing reductions conditional on achieving any specific clinical goals – e.g., a plan cannot condition cost-sharing reductions on enrollees achieving certain thresholds in Hba1c levels or body-mass index. Examples of interventions within this category include elimination of primary care co-pays for diabetes patients who meet regularly with a case manager and reduction of drug co-pays for patients with heart disease who regularly monitor and report their blood pressure.
4. Coverage of Additional Supplemental Benefits: Under this approach, participating plans can make coverage for supplemental benefits available only to targeted populations. Such benefits may include any service consistent with existing Medicare Advantage rules for supplemental benefits. Examples of interventions within this category include physician consultations via real-time interactive audio and video technologies for diabetics, or supplemental tobacco cessation assistance for enrollees with COPD.
The MA-VBID model test is open to all qualifying Medicare Advantage and MA-PD plans in the test states that submit acceptable programmatic proposals to CMS. Only HMO, HMO-POS or local PPO plan types are eligible to participate. Special Needs Plans (SNP), Regional PPO plans, Medicare-Medicaid Plans (MMP) or other demonstration plans, cost plans, Medical Savings Account Plans (MSA), Private Fee-For-Service Plans, and Employer Group Waiver Plans (EGWP)) are ineligible. CMS will restrict the model test to plans with a minimum enrollment in the test states of 2,000 enrollees, with at least 50% of the total plan enrollment within target states and all or part of the plan’s service area lying within one of the model test states identified. The plan must not be offered in more than two states total. Plans must meet minimum quality thresholds: plans must be rated by CMS at three stars or higher, not consistently low-performing, not an outlier in the CMS past performance analysis, not under sanction, and pass a program integrity screening. The plan must have been offered in at least three annual coordinated election (open enrollment) periods prior to the open enrollment period for CY 2017. All applicants who meet these criteria and who submit proposals that meet CMS minimum criteria will be accepted into the model – there is no cap on the total number of participating plans.