CMS has proposed important changes for the Medicare Part C risk adjustment model and has opened a 60-day window for review and comments. Here’s what you need to know:
1) CMS is requesting comments for two new alternative risk models
60 day comment period
One model will be chosen, finalized/published in announcement on April 2, 2018
Model will be fully phased in by 2022
2) Adding mental health, substance use, kidney disease
3) Models take into account the number of conditions an individual has (current model doesn’t do this)
4) New model will be used in 2019 for EDPS, old model for RAPS. Plans will likely have to change their analytics for this change because their EDPS scores will then be calculated differently than their RAPS scores.
5) RAPS/EDPS blend for 2018 will be 85/15 (using existing model)
6) RAPS/EDPS blend for 2019 will be 75/25 (using new model for EDPS only)
The biggest takeaway is that Medicare Advantage is going to get much more difficult. CMS’s seemingly never-ending changes to rules, risk policy, and schedule will create challenges for small to mid-sized plans’ abilities to comply, withstand audits and keep costs low. Offloading these tasks to black-box vendors is not a viable solution. The best course of action will be to bring many of these processes back in-house, using modern, cost-reducing, compliance-oriented automation and error correction.