CMS proposed rule expands telehealth for Medicare Advantage plans, beefs up payment audits

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule on Friday that would allow Medicare Advantage plans greater flexibility to offer telehealth benefits.

The proposed rule (PDF) would also update the Star Ratings methodology, streamline benefits for Dual Eligible Special Needs Plans (D-SNP) and give auditors more latitude to recover improper payments. In doing so, the agency would codify multiple sections of the Bipartisan Budget Act of 2018 (BBA) passed earlier this year. 

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Perhaps the biggest change, which would take effect in 2020, would allow plans to offer "government-funded" telehealth benefits to all members whether they live in rural or urban areas. Beneficiaries could also receive telehealth services in their home rather than a medical facility. 

Industry groups have been clamoring for the government to rethink the limitations around telehealth reimbursement that limited services to rural patients. In a press release, CMS suggested the telehealth provision may steer more Medicare enrollees toward MA, since traditional Medicare’s telehealth benefits are somewhat limited by location and clinical need. 

"Today’s proposed changes would give Medicare Advantage plans more flexibility to innovate in response to patients’ needs,” Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma said in a statement. “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote access to care in a more convenient and cost-effective manner for patients.”

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The proposed rule would also add new measures to Medicare Advantage and Part D Star Ratings, including controlling high blood pressure, Medicare Plan Finder price accuracy and all-cause readmission. CMS would begin collecting data for those measures beginning in 2020 for plan year 2022.

CMS also took aim at Medicare Advantage program integrity, where several plans are under investigation for risk adjustment calculation. The agency proposed using extrapolation for Risk Adjustment Data Validation audits, used to verify the accuracy of payments made to Medicare Advantage sponsors. 

Those payment integrity changes are expected to return an estimated $4.5 billion to Medicare over the next 10 years.