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Medicare Advantage cost-sharing, benefits will change in some states in 2017

Expect some wrinkles to your Medicare Advantage billing process if you operate in one of the seven states that's on track to launch a "value-based" insurance model next year.
Eligible Medicare Advantage plans in those states -- Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee -- "may offer varied plan benefit designs for enrollees who fall into certain clinical categories," according to a CMS fact sheet on the program, known as the Medicare Advantage Value-Based Insurance Design Model (VBID).
Medicare, through its private payer plans, is encouraging MA plans to offer condition-specific benefits as a way to tamp down on the overall cost of care for patients with chronic conditions, a group of beneficiaries widely viewed as a leading driver of health care costs.
In Medicare's terms, the agency wants patients to use "high-value clinical services" to ultimately help control costs, and MA carriers are invited to mold their benefits to incresae the use of these services. In practice, that may result in reduced or eliminated cost-sharing for patients when they receive certain services or elect to receive care from a "high-value provider."
The conditions under scope in 2017 include:
  • Diabetes
  • Chronic obstructive pulmonary disease (COPD)                                                                          
  • Congestive heart failure (CHF)
  • Patient with past stroke                                    
  • Hypertension
  • Coronary artery disease                                   
  • Mood disorders
In 2018, CMS will expand the VBID program to three additional states -- Alabama, Michigan and Texas -- and add rheumatoid arthritis and dementia to the list of clinical conditions.
"The MA-VBID model supports 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," states the fact sheet.
MA carriers also may limit cost-sharing for patients who participate in a disease management program or for their use of prescription drugs. In total, Medicare suggests four approaches to plan design, revolving around limiting cost-sharing and adding supplemental benefits, that will encourage patient buy-in.
Keep an eye our for the specific MA plans participating in VBID; CMS said it will announce the participating plans in September.
Editor's note: Overcome challenges with Medicare Advantage billing with the webinar Solving Medicare Advantage challenges: Identify and overcome pain points from pre-auth to denials on Sept. 20 or on demand. For more information, visit
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