After several April Fools jokes, these takeaways the @Health Data Decisions SMEs shared with me on the Final CMS 2025 Notice are no joke. https://lnkd.in/e_-sxHbQ
1. MA Plans will see a 3.651% increase in revenue reflecting an increase from the effective growth rate and MA risk score trend. The increase in FFS is likely to be offset by risk adjustment model changes. This means that payors need to prioritize and maintain a rigorous documentation process under v28.
2. Risk Model changes will continue to be phased in with member Part C risk scores calculated based on 67% from the v28 model, CMS-HCC 2024, and 33% from v24, CMS-HCC 2020.
A. The increase in HCC detail and LIS impact requires documentation of conditions at the highest level of specificity and verification of member status. With the majority of the risk score derived from v28 payors need to make sure coding practices line up with v28 diagnoses.
3. An updated Part D model will also be released using 2021 diagnoses and 2022 expenditures. Part D payments will incorporate Inflation Reduction Act changes that eliminate the coverage gap, reduce out of pocket threshold to $2,000 and offer OOP payment flexibility to members.
A. Changes in benefit design will impact utilization and medication adherence. Payors must actively and closely monitor their drug utilization data to understand how to respond to these changes.
B. The Inflation Reduction Act of 2022 has led to the Medicare Prescription Plan Payment (M3P) to be effective January 1, 2025, in which members will have the option to pay for their out-of-pocket RX costs in monthly amounts that are spread throughout the plan year and are subject to maximum monthly caps. Plans will need to educate members who are likely to benefit from this option, enrollment staff, and PBM and pharmacy partners on these changes for enrollees who elect this benefit. Plans should consider the Star Ratings impact for the key med adherence measures that are likely to be impacted.
4. Future Stars model changes are likely to be influenced by measures in the "Universal Foundation". For info on Universal Foundation click https://lnkd.in/ejbUe7QM
5. 51% of eligible enrollees are now in MA plans, with competitive plan options at the county level. Future expansion for MA enrollment is likely greatest in rural areas, and in counties with less than 10,000 eligible members. Reaching and serving these eligible enrollees should go a long way to increasing health equity. #CMS #MedicareAdvantage #StarRatings #M3P
Retired: Large Group Health Plan Professional ( 1972-2022)
1moNOT A THREAT. One of the high quality Independent Internist Clinic in Greater Milwaukee IS NOT accepting Medicare Advantage patients.