While the healthcare industry is generally supportive of the CMS' efforts to expand telehealth services under Medicare Advantage, it has some problems with the policy details.
It's also split on network adequacy standards for dialysis patients and united against the agency's proposal to change how it weighs patient experience in its star-rating system.
In February, the CMS proposed modifications to its existing rules on additional telehealth benefits for Medicare Advantage plans allowing plan sponsors to make them accessible through noncontracted providers. The agency thinks that so long as noncontracted providers meet the same standards as contracted providers, plans should be able to offer telehealth services through them.
But critics of the proposal worry that without a contract, it would be difficult for the CMS to verify that telehealth providers meet state credentialing or licensing requirements since telehealth services can be delivered from anywhere. They also wonder how plans would be able to make sure that beneficiaries are getting the care they need from out-of-network telehealth providers.
When the CMS issued its new rules to allow for additional telehealth services last year, both concerns underpinned the agency's motivation for mandating that plans only offer additional telehealth services through contracted providers. Now officials argue that the agency would be able to monitor and respond to any problems stemming from its more flexible proposal.
"There should be a means of preventing the provision of inappropriate care rather than addressing an issue after the fact," according to a letter from the Medicare Payment Advisory Commission.
Providers also urged the agency to broaden its interpretation of face-to-face encounters to include all telehealth visits. Under the proposed rule, the CMS would only include annual visits for Medicare Advantage special needs plans, which are specially designed for specific populations like dual-eligibles or people with a severe or disabling chronic condition.
"Such a policy critically would reduce burden and improve access to care for patients who may otherwise have to travel significant distances to receive in-person treatment," Ochsner Health System said. "MA organizations … would have additional incentive to increase the availability of telehealth in their plan offerings."
Plan sponsors, health systems and specialty associations were also supportive of the agency's proposal to allow plans to use more telehealth services to meet Medicare Advantage network adequacy standards.
But providers want the CMS to include more specialties, especially in rural and underserved areas that don't have MA plans available because they can't meet network adequacy standards. Only dermatology, psychiatry, neurology, cardiology and otolaryngology are included in the CMS' proposal.
"Without changes, MA networks in nonmetropolitan counties will fail to provide enrollees with sufficient health service access," the National Organization of State Offices of Rural Health said.
Medicare Advantage enrollment grew faster in rural counties than the national average, according to a University of Iowa study. But many rural counties have low levels of MA participation, due to smaller operating margins and plans' lowered ability to negotiate because there are fewer providers. Increased telehealth use could address both problems but come with complications like ensuring high quality of care.
Insurers and leading policy experts took issue with the CMS' proposal to increase how heavily it weighs patient experience and access under its star-rating system for Medicare Advantage and Part D plans, citing a host of problems with the CMS' approach. For example, outcome measures could make up just 9% of a Medicare Advantage plan's score, even though they're the most important factor, according to MedPAC.
"Increasing the weights for these measures has the potential to erode the integrity of the star-rating program—by basing the majority of the Star Rating score on such measures where the correlation between average contract performance and Star Ratings is unclear," America's Health Insurance Plans said in a letter.
Payers were generally supportive of the CMS' proposal to allow Part D plan sponsors to create up to two specialty tiers for prescription drugs, including a preferred and nonpreferred tiers. Under a preferred tier, beneficiaries would have lower cost-sharing, which could encourage providers and beneficiaries to use lower-cost biosimilars and increase price competition among drugmakers that want access to the preferred tier.
Consumer advocates, plans and healthcare experts support the agency's plan to compel Plan D sponsors to give beneficiaries real-time access to their formulary and benefit information, including cost-sharing. Plans would be able to use rewards and other incentives to encourage enrollees to access the information through portals, apps or a call center. The idea is to improve how practitioners and their patients select drugs, ease the prior-authorization process and cut back on claims denials.
The CMS' proposal to eliminate or change Medicare Advantage time and distance standards for dialysis centers met stiff opposition from patient advocates and healthcare experts, despite support from the insurance industry. Critics note that Medicare Advantage enrollees with end-stage renal disease already have to travel farther, on average, for in-center dialysis treatment.
Payers argue that they need more flexibility around network adequacy standards to counteract provider consolidation among dialysis centers. Without it, insurers say that they don't have enough negotiating power. The Trump administration has pushed for increased use of home dialysis to give patients more choice and payers more leverage.
But "a 50-mile drive does not become shorter as (market consolidation) rises. As such, network adequacy requirements cannot be used as a 'dial' to be adjusted up or down to influence provider reimbursement," said Dialysis Patient Citizens, an organization representing kidney disease patients and their families.