The COVID-19 pandemic could affect MA enrollees’ risk scores, and AHIP is asking the Biden administration to take steps to address the issue and provide clarity on how the scores are calculated.1
In comments on the Advance Notice of Methodological Changes for Calendar Year 2023 for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies, the group cites inconsistent use of 2020 data and raises concerns about how CMS will address the effects of the pandemic. AHIP also notes that delayed care during the pandemic may have affected providers’ ability to document enrollee health conditions, potentially compromising the accuracy of risk scores.
CMS has proposed excluding 2020 data when calculating the annual fee-for-service normalization factor, as 2020 saw reduced risk scores and would result in lower projected risk score growth for 2023 and a lower normalization factor. This in turn would result in lower financial payments for Medicare Advantage plans. The agency expects 2023 FFS risk scores to be similar to those seen before the pandemic.
AHIP has requested that CMS:
- provide detail on its assumptions about 2023 FFS risk scores
- discuss the implications of not including 2020 data in the normalization factor
- address the potential use of 2020 data in future calculations
- allow plans to use previously documented diagnosis codes for noncurable chronic conditions in determining enrollee risk scores
- allow diagnosis codes documented during audio-only telehealth visits to be used for risk scores where clinically appropriate
- allow the use of prescription drug data to support diagnoses.
The agency should also share the data, methodology and assumptions behind its estimate of MA risk score trends for 2023, state whether it accounts for COVID-19 impacts, and discuss how it compares with estimated coding in the FFS program.
Of particular importance to MA plans are Star Ratings, and it is likely that the ongoing pandemic could affect patient experience survey response rates, as well as the responses themselves, AHIP says. To avoid a negative impact on Star Ratings, the group recommends an interim final rule that maintains the weighting of patient experience/complaints and access measures at 2 for 2023 Star Ratings.
More clarity and allowances for pandemic-related impacts like those sought by AHIP will enable plans to manage the operational and health consequences of the pandemic as they plan for a better future.
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