CMS released its final 2023 Medicare Advantage capitation and Part C and D rate announcement on April 5, and now America’s Health Insurance Plans are raising some concerns.

“We appreciate that with this final rate notice, the Administration continues to support innovation and flexibility in Medicare Advantage to improve affordability, access, and value for enrollees and taxpayers,” AHIP said in an April 4 press release. “However, we are concerned that due to separate and ongoing rulemaking, several policies remain in question, which if finalized would be unworkable and could negatively impact seniors by increasing premiums or reducing benefits.”

AHIP elaborated on its concerns in a March 4 letter to CMS regarding the 2023 advance notice of the changes:

Fee-for-service normalization: CMS should explain its assumptions about 2023 fee-for-service risk scores, provide more information about the impact of not using 2020 in calculating the normalization factor and describe how it will address 2020 data in calculations for future years.

Provider diagnoses: CMS should allow plans to carry over diagnosis codes for non-curable chronic conditions documented in prior years for purposes of determining enrollee risk scores, allow diagnosis codes documented during audio-only telehealth visits to be counted for purposes of risk scores where clinically appropriate and permit the use of prescription drug data to support diagnoses.

Star ratings: CMS should issue an interim final rule with comments that maintain the weighting of patient experience/complaints and access measures at 2 for 2023 star ratings. CMS should also extend its COVID-19 disaster relief policy and special rules through an interim final rule to all applicable measures for 2023 star ratings.

Parts A and B fee-for-service costs: CMS calculates benchmarks by including people enrolled in fee-for-service who are ineligible to enroll in Medicare Advantage plans, artificially reducing rates in many counties. This approach fails to adequately determine the cost of providing a benefit to Medicare Advantage enrollees comparable to the cost of providing the benefit under original Medicare.

End-stage renal disease payments: CMS does not propose any material change to how it calculates expected costs for enrollees with end-stage renal disease. CMS should provide more details about the state-based rates study and work with stakeholders to study alternatives.

Medicare Advantage risk scores: CMS does not describe the methodology or assumptions used in developing its Medicare Advantage risk score trend estimate, the data used for the estimate, how the estimate compares to estimated coding in the fee-for-service program, or whether/how the estimate accounts for COVID-19’s impacts. CMS should share that information.

Source: Beckers Payer

Payers and healthcare organizations publicly announced their support of President Joe Biden’s proposal to expand the Affordable Care Act to include more families.

The proposal announced on April 5 aims to fix the “family glitch.” Currently, people who do not have access to affordable health coverage through their employers can qualify for subsidies to purchase coverage through the ACA marketplace. The federal definition of affordable employer-provided coverage is only for single individuals and not for family members.

The proposal directs the Treasury Department and Internal Revenue Service to allow family members of employees who are offered affordable self-only coverage but unaffordable family coverage to qualify for the subsidies to purchase family health coverage through the ACA marketplace.

These organizations shared their support this week:

Blue Cross Blue Shield Association:

“We share the White House’s goal of accessible, affordable quality health care for all Americans. That’s why Blue Cross and Blue Shield companies were part of the ACA marketplace from the very beginning and stayed in — bringing new health insurance options to families across the country. Now that there’s a path to get everyone covered, we call on Congress to make the American Rescue Plan Act tax credits permanent.”

America’s Health Insurance Plans:

“Every American deserves access to affordable coverage and high-quality care, and health insurance providers are committed to delivering for them with more choices, better quality, and lower costs. AHIP supports proposals to fix the ‘family glitch’ in the ACA, and affordability and access both in the employer and individual markets will remain our core values as we review this proposed rule. We applaud the Administration for maintaining their focus on making health care more accessible and available, and we are confident that by working together, we can ensure that more families will benefit from affordable coverage that protects their health and financial stability.”

American Medical Association:

“With the announcement today, the Biden Administration has taken a crucial step in the campaign to cover the 5 million people who fall into the family glitch. The family glitch is inconsistent with the goals of the Affordable Care Act and unfairly penalizes family members of lower-income workers. The American Medical Association has repeatedly asked Congress and administrations to fix the glitch, and the Biden Administration has made good on its promise to make health care coverage more affordable.”

American Hospital Association:

“All Americans deserve access to comprehensive health care and coverage. We can get there by building on the Affordable Care Act. Hospitals and health systems strongly support the Biden administration’s efforts to help more Americans secure affordable health insurance by proposing to eliminate the ‘family glitch.’ The AHA will continue to work with the administration to preserve and expand enrollment in comprehensive coverage.”

Source: Beckers Payer

Today Sensely announced a multi-year partnership with Keralty S.A.S, a multinational health organization, and its American affiliate Sanitas USA, Inc. In the United States, Sanitas plans to integrate white-labeled Sensely technology into its patient-facing mySanitas app, a full-featured integrated solution that modernizes the patient experience by offering one-tap or one-click access to complete care, disease and wellness programs, real-time and virtual assistance, access to patient’s medical history, records, and health and social services resources. Best of all, patients are seen by the same Sanitas doctors and care teams whether they connect remotely or come in for a visit at a Sanitas Medical Center.

Delivered via an SDK, Sensely’s character-based chat interface utilizes a customized brand ambassador. The solution has been fully localized into both English and Spanish, ensuring equity of access across Sanitas’ diverse member base.

An optional voice mode features state-of-the-art text-to-speech technology to ensure a natural and lifelike patient experience, as well as speech recognition so that patients can describe their symptoms using a common language. In addition, using Google’s Dialogflow, the Keralty and Sensely teams have jointly created a unique natural language database of the most frequently requested intents to best meet the specific requests of the Sanitas patient population.

The Sensely Symptom Checker is a key triage element that Sanitas patients can use to quickly check their symptoms, and then find out what to do next. Clinical outcomes are seamlessly mapped to Sanitas’ various appointment booking and telemedicine service, chat, and phone offerings in a single elegant consumer journey that offers unparalleled convenience and speed. Across all of the channels of care, mySanitas users benefit from increased satisfaction and enhanced care management.

“With the advancements in value-based payment models as well as emerging consumer preferences for virtual primary care options, Keralty is well situated to leverage our digital global care delivery experience and capabilities in the US market,” said Santiago Thovar, Keralty’s Global Chief Information Officer. “Our enhanced mySanitas offering reflects years of careful preparation, and we’re delighted to include Sensely’s proven suite of solutions as an important part of Keralty’ suite of capabilities”

Adam Odessky, CEO and Co-founder of Sensely added, “Keralty has proven to be a uniquely thoughtful partner in the course of our collaboration, and the navigational customizations that they are implementing using the Sensely tools provide an important source of patient experience and care delivery differentiation. What’s even more impressive is that all of their technology decisions are intentionally informed by their uncompromising vision of both comprehensive and culturally relevant medical care.”

Source: PR Newswire