Announcement Of Calendar Year (CY) 2019 Medicare

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April 2, 2018NOTE TO: Medicare Advantage Organizations, Prescription Drug Plan Sponsors, andOther Interested PartiesAnnouncement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates andMedicare Advantage and Part D Payment Policies and Final Call LetterCMS received many submissions in response to our request for comments on Part I of theAdvance Notice, published on December 27, 2017 and Part II of the Advance Notice/Draft CallLetter, published on February 1, 2018. Comments were received from professionalorganizations, Medicare Advantage (MA) and Part D sponsors, advocacy groups, state Medicaidagencies, pharmaceutical manufacturers, pharmacy benefit managers, pharmacies, and concernedcitizens. In response to the comments, we made a number of changes in the Rate Announcementand Call Letter that reflect CMS’s continued commitment to providing Medicare AdvantageOrganizations and Part D Plan Sponsors with the flexibility to develop and implement innovativeapproaches for providing Medicare benefits to enrollees and empowering enrollees. CMSexpects the additional flexibility will result in additional and more affordable plan choices forMedicare beneficiaries. CMS is committed to exploring other avenues for simplifying andtransforming the MA and Part D programs in order to encourage innovation and expandbeneficiary choice, and is looking forward to working with stakeholders to achieve those sharedgoals.In accordance with section 1853(b)(1) of the Social Security Act, we are notifying you of theannual capitation rate for each MA payment area for CY 2019 and the risk and other factors to beused in adjusting such rates. The capitation rate tables for 2019 and supporting data are postedon the CMS website at tml. The statutory componentof the regional benchmarks, qualifying counties, and each county’s applicable percentage arealso posted on this section of the CMS website.Attachment I shows the final estimates of the National Per Capita MA Growth Percentage for2019 and the National Medicare Fee-for-Service (FFS) Growth Percentage for 2019. Thesegrowth rates were used to calculate the 2019 capitation rates. As discussed in Attachment I, thefinal estimate of the National Per Capita MA Growth Percentage for combined aged and disabledbeneficiaries is 5.93 percent, and the final estimate of the FFS Growth Percentage is 5.11percent. Attachment II provides a set of tables that summarizes many of the key Medicareassumptions used in the calculation of the growth percentages.Section 1853(b)(4) of the Act requires CMS to release county-specific per capita FFSexpenditure information on an annual basis, beginning with March 1, 2001. In accordance with

2this requirement, FFS data for CY 2016 were posted on the above website with Part II of theAdvance Notice.Attachment II details the key assumptions and financial information behind the growthpercentages presented in Attachment I.Attachment III presents responses to Part C payment related comments on both Parts I and II ofthe Advance Notice of Methodological Changes for CY 2019 MA Capitation Rates and Part Cand Part D Payment Policies (Advance Notice).Attachment IV presents responses to Part D payment related comments on the Advance Notice.Attachment V shows the final Part D benefit parameters and contains details on how they areupdated.Attachment VI shows the CMS-HCC and CMS-HCC ESRD Risk Adjustment FactorsAttachment VII presents the final Call Letter.

3Key Changes from the Advance Notice:Growth Percentages: Attachment I provides the final estimates of the National Per Capita MAGrowth Percentage and the FFS Growth Percentage and information on deductibles for MSAs.Calculation of FFS Cost: The Secretary has directed the CMS Office of the Actuary to adjust thefee-for-service experience for beneficiaries enrolled in Puerto Rico to reflect the propensity ofzero dollar beneficiaries nationwide.MA Employer Group Waiver Plans: This year, CMS will finalize the 100% phase in withadjustments based on the proportion of EGWP enrollment in PPOs vs. HMOs, but CMS intendsto seek comment on modifications for 2020 that include additional or different adjustments forregional PPOs and rural local PPOs. Therefore, for 2019, CMS will fully transition to using onlyindividual market plan bids to calculate the bid-to-benchmark ratios to set EGWP payments, asproposed in the 2019 Advance Notice, but with the adjustment proposed as an alternative. For2019, the individual market ratios will be adjusted to account for the difference in the proportionof beneficiaries enrolled in HMOs and PPOs between EGWPs and individual market plans.CMS-HCC Model: For 2019 CMS will use the updated CMS-HCC model without countvariables for the blended risk score calculation. Therefore, for 2019 we will calculate risk scoresas proposed, but with the updated CMS-HCC model without count variables. Specifically, wewill blend 75% of the risk score calculated with the 2017 CMS-HCC model, using diagnosesfrom RAPS and FFS, summed with 25% of the risk score calculated with the updated CMS-HCCmodel without count variables, using diagnoses from encounter data, RAPS inpatient records,and FFS as discussed in more detail in Attachment III, Sections H and L.RxHCC Risk Adjustment Model: CMS will not implement the updated model in 2019. Wewill continue to use the RxHCC model used in 2018, as published in the 2018 RateAnnouncement.Revised Normalization Factors:RxHCC model: 1.019Frailty Adjustment for PACE organizations and FIDE-SNPs: CMS will implement FIDE-SNPfrailty factors consistent with the version of the CMS-HCC model being finalized for 2019.Consistent with CMS’s proposal to blend risk scores, for FIDE SNPs a blended frailty score willbe compared with PACE frailty in the same manner as for 2018 to determine whether that FIDESNP has a similar average level of frailty as PACE.Beneficiary Coinsurance and Dispensing and Vaccine Administration Fees in the Coverage Gap:The Bipartisan Budget Act of 2018 enacted changes to the Part D benefit design for 2019 relatedto the coverage gap discount program. Attachment IV details those changes as they relate tobeneficiary costs in the coverage gap.

4Part D Benefit Parameters: Attachment V provides the final 2019 Part D benefit parameters forthe defined standard benefit, low-income subsidy, and retiree drug subsidy. The estimate fortotal covered Part D spending at the out-of-pocket threshold for applicable beneficiaries has beenupdated to reflect the coverage gap discount program-related changes to the 2019 Part D benefitdesign enacted in the Bipartisan Budget Act of 2018.Enhanced Medication Therapy Management (MTM) Model: Given timing and operationalconsiderations, we have determined that it will not be possible for the model’s premiumreductions to be considered when determining the 2019 low-income premium benchmarks.Proposals Adopted as Issued in the Advance Notice:As in past years, policies proposed in the Advance Notice that are not modified or retracted inthe Rate Announcement become effective in the upcoming payment year. Clarifications in theRate Announcement supersede materials in the Advance Notice and prior Rate Announcements.MA Benchmark, Quality Bonus Payments and Rebate: We will continue to implement themethodology used to derive the benchmark county rates, how the qualifying bonus counties willbe identified, and the applicability of the star rating system.IME Phase Out: We will continue phasing out indirect medical education amounts from the MAcapitation rates.End Stage Renal Disease (ESRD) State Rates: We will determine the ESRD dialysis rates bystate as we specified in the Advance Notice.Clinical Trials: We are continuing the policy of paying on a FFS basis for qualified clinical trialitems and services provided to MA plan members that are covered under the National CoverageDetermination (NCD) for Routine Costs in Clinical Trials (Medicare NCD Manual, Pub. 100-3,Part 4, Section 310.1), as described in the Advance Notice.Location of Network Areas for Private Fee-for-Service (PFFS) Plans in Plan Year 2020: The listof network areas for plan year 2020 is available on the CMS website at ent for MA Coding Pattern Differences: We will implement an MA coding patterndifference adjustment of 5.90 percent for 2019.ESRD Risk Adjustment Models: We will implement the updated ESRD dialysis and ESRDfunctioning graft models as proposed in the Advance Notice.

5Final 2019 Normalization Factors:CMS-HCC model without count variable being implemented in 2019, for blended riskscore calculations: 1.0381CMS-HCC model implemented in 2017, for blended risk score calculations: 1.041CMS-HCC model used for PACE organizations: 1.159CMS-HCC ESRD Dialysis model: 1.033CMS-HCC ESRD Functioning Graft model: 1.048Medical Loss Ratio Credibility Adjustment: We are finalizing the credibility adjustment factorsas published in the Medical Loss Ratio final rule (CMS-4173-F), 78 FR 31284 (May 23, 2013).Encounter Data as a Diagnosis Source for 2019 (non-PACE): CMS will calculate 2019 riskscores by adding 25% of the risk score calculated using encounter data (supplemented withRAPS inpatient data) and FFS diagnoses with 75% of the risk score calculated using RAPS andFFS diagnoses.Encounter Data as a Diagnosis Source for 2019 (PACE): As proposed, we will continue tocalculate risk scores for PACE organizations by pooling risk adjustment-eligible diagnoses fromencounter data, RAPS and FFS claims (with no weighting) to calculate a single risk score.Part D Risk Sharing: The 2019 threshold risk percentages and payment adjustments for Part Drisk sharing will be finalized as stated in the Advance Notice.Part D Calendar Year Employer Group Waiver Plans: We are finalizing the Part D CalendarYear EGWP prospective reinsurance policy as proposed./s/Demetrios KouzoukasPrincipal Deputy Administratorand Director, Center for MedicareI, Jennifer Wuggazer Lazio, am a Member of the American Academy of Actuaries. I meet theQualification Standards of the American Academy of Actuaries to render the actuarial opinioncontained in this Rate Announcement. My opinion is limited to the following sections of this1Note that the CMS-HCC normalization factor has been updated to reflect the model finalizedfor 2019. Since the factor we are finalizing is the same as the proposed factor for the PaymentCount model, we are categorizing this with other policies that are being finalized as proposed.

6Rate Announcement: The growth percentages and United States per capita cost estimatesprovided and discussed in Attachments I, II and III; the qualifying county determination andcalculations of Fee for Service cost, IME phase out, MA benchmarks, EGWP rates, and ESRDrates discussed in Attachment III; and Medicare Part D Benefit Parameters: Annual Adjustmentsfor Defined Standard Benefit in 2019 described in Attachment IV and in Attachment V./s/Jennifer Wuggazer Lazio, F.S.A., M.A.A.A.DirectorParts C & D Actuarial GroupOffice of the ActuaryAttachments

72019 ANNOUNCEMENTTABLE OF CONTENTSAnnouncement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates andMedicare Advantage and Part D Payment Policies and Final Call Letter . . . . . . . . . . . . 1Attachment II. Key Assumptions and Financial Information . . . . . . . . . . . . . . . . . . . . . . . . . 10Attachment III. Responses to Public Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section A. Final Estimate of the National Per Capita Growth Percentage and the Fee-forService (FFS) Growth Percentage for Calendar Year 2019 . . . . . . . . . . . . . . . . . . .Section B. MA Benchmark, Quality Bonus Payments and Rebate . . . . . . . . . . . . . . . . . .Section C. Calculation of Fee for Service Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section D. IME Phase Out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section E. ESRD Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section F. MA Employer Group Waiver Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section G. Medicare Advantage Coding Pattern Adjustment . . . . . . . . . . . . . . . . . . . . . .Section H. CMS-HCC Risk Adjustment Model for CY 2019 . . . . . . . . . . . . . . . . . . . . . .Section I. ESRD Risk Adjustment Model for CY 2019 . . . . . . . . . . . . . . . . . . . . . . . . . .Section J. Frailty Adjustment for PACE organizations and FIDE SNPs . . . . . . . . . . . . . .Section K. Normalization Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section L. Encounter Data as a Diagnosis Source for 2019 . . . . . . . . . . . . . . . . . . . . . . .Section M. Quality Payment Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Attachment IV. Responses to Public Comments on Part D Payment Policy . . . . . . . . . . . . . .Section A. Update of the RxHCC Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section B. Encounter Data as a Diagnosis Source for 2019 . . . . . . . . . . . . . . . . . . . . . . .Section C. Part D Risk Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section D. Medicare Part D Benefit Parameters: Annual Adjustments for DefinedStandard Benefit in 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section E. Reduced Coinsurance for Applicable Beneficiaries in the Coverage Gap . . . . .Section F. Dispensing Fees and Vaccine Administration Fees for Applicable Drugs inthe Coverage Gap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section G. Part D Calendar Year Employer Group Waiver Plans . . . . . . . . . . . . . . . . . . .Section H. Enhanced Medication Therapy Management (MTM) Model . . . . . . . . . . . . . .60606161Attachment V. Final Updated Part D Benefit Parameters for Defined Standard Benefit, LowIncome Subsidy, and Retiree Drug Subsidy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section A. Annual Percentage Increase in Average Expenditures for Part D Drugs perEligible Beneficiary (API) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section B. Annual Percentage Increase in Consumer Price Index (CPI) . . . . . . . . . . . . . .Section C. Calculation Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section D. Retiree Drug Subsidy Amounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1921222626283639445052545761616565656769697073

8Section E. Estimated Total Covered Part D Spending at Out-of-Pocket Threshold forApplicable Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Attachment VI. CMS-HCC and ESRD Risk Adjustment Factors . . . . . . . . . . . . . . . . . . . . . . 76Attachment VII. CY 2019 Final Call Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .How to Use This Call Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section I – Parts C and D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section II – Part C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section III – Part D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Section IV – Medicare-Medicaid Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111113114188222259Appendix 1: Methodology for Plan Finder (PF) Composite Price Accuracy Display Measure 266Contract Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266PF Composite Price Accuracy Score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

9Attachment I. Final Estimates of the National Per Capita Growth Percentage and the NationalMedicare Fee-for-Service Growth Percentage for Calendar Year 2019The Table I-1 below shows the National Per Capita MA Growth Percentage (NPCMAGP) for2019. An adjustment of 1.786 percent for the combined aged and disabled is included in theNPCMAGP to account for corrections to prior years’ estimates as required by section1853(c)(6)(C). The combined aged and disabled change is used in the development of theratebook.Table I-1. Increase in the National Per Capita MA Growth Percentages for 2019Prior increasesAged Disabled12003 to 201858.758%Current increases2003 to 201861.593%2018 to 20194.075%2003 to 201968.178%NPCMAGP for 2019with §1853(c)(6)(C)adjustment15.93%Current increases for 2003-2019 divided by the prior increases for 2003-2018.Table I-2 below provides the change in the FFS United States Per Capita Cost (USPCC) whichwas used in the development of the county benchmark. The percentage change in the FFSUSPCC is shown as the current projected FFS USPCC for 2019 divided by projected FFSUSPCC for 2018 as estimated in the 2018 Rate Announcement released on April 3, 2017.Table I-2 – FFS USPCC Growth Percentage for CY 2019Aged Disabled 891.07847.735.11%Current projected 2019 FFS USPCCPrior projected 2018 FFS USPCCPercent changeDialysis–only ESRD 7,833.287,133.429.81%Table I-3 below shows the monthly actuarial value of the Medicare deductible and coinsurancefor 2018 and 2019. In addition, for 2019, the actuarial value of deductibles and coinsurance isbeing shown for non-ESRD only, since the plan bids will not include ESRD benefits in 2019.These data were furnished by the Office of the Actuary.Table I-3 - Monthly Actuarial Value of Medicare Deductible and Coinsurancefor 2018 and 20192018Part A Benefits1Part B BenefitsTotal Medicare12019Change2019 non-ESRD 37.16 36.59 1.5% ludes the amounts for outpatient psychiatric charges.Medical Savings Account (MSA) Plans. The maximum deductible for current law MSA plansfor 2019 is 12,650.

10Attachment II. Key Assumptions and Financial InformationThe United States Per Capita Costs (USPCCs) are the basis for the National Per Capita MAGrowth Percentage. Attached is a table that compares last year’s estimates of USPCCs withcurrent estimates for 2003 to 2020. In addition, this table shows the current projections of theUSPCCs through 2021. We are also providing an attached set of tables that summarize many ofthe key Medicare assumptions used in the calculation of the USPCCs. Most of the tables includeinformation for the years 2003 through 2021.Most of the tables in this attachment present combined aged and disabled non-ESRD data. TheESRD information presented is for the combined aged-ESRD, disabled-ESRD and ESRD only.All of the information provided in this attachment applies to the Medicare Part A and Part Bprograms. Caution should be employed in the use of this information. It is based uponnationwide averages, and local conditions can differ substantially from conditions nationwide.None of the data presented here pertain to the Medicare prescription drug benefit.Comparison of Current & Previous Estimates of the Total USPCC – non-ESRDPart mate 52412.19427.98Lastyear’sestimate 50412.63Part BCurrentestimate 10537.91568.79Lastyear’sestimate 10538.17Part A & Part BLastCurrentyear’sestimate estimate 543.84 81.0080.999

11Comparison of Current & Previous Estimates of the FFS USPCC – non-ESRDPart 01920202021Currentestimate 1.58391.63403.45417.97Part BLastyear’sestimate 7.28390.42405.85Currentestimate 4.83499.44523.29552.01Lastyear’sestimate 0.45498.55524.10Part A & Part BLastCurrentyear’sestimate estimate 746.12 73891.07888.97926.74929.95969.98Comparison of Current & Previous Estimatesof the ESRD Dialysis-only FFS 018201920202021Currentestimate 977.187,067.897,586.287,833.288,099.118,439.59Part A BLastyear’sestimate sis for ESRD Dialysis-only FFS USPCC TrendPart A BCalendaryear20172018201920202021All ESRDcumulativeFFS r 1.0091.0101.0020.997

12Summary of Key ProjectionsPart 20142015201620172018201920202021Calendar yearCPI percent change2.2%2.63.53.22.94.1 0.72.13.62.11.41.5 0.41.02.12.22.52.62.6FY inpatientPPS update factor3.0%3.43.33.73.42.72.71.9 0.6 0.12.80.91.40.90.151.812.553.63.6FY Part A total 50.45.00.73.34.23.83.35.66.06.6Part B2Calendar 1420152016201720182019202020211Physician fee scheduleFees3Residual41.4%4.5%3.85.92.13.20.24.6 1.43.5 0.34.01.41.62.31.60.82.3 1.21.0 0.10.20.50.6 0.50.7 0.4 0.90.30.60.71.30.43.2 0.53.30.13.0Outpatient .31.70.83.42.71.93.14.84.84.65.6Percent change over prior year.Percent change in charges per aged Part B enrollee.3Reflects the physician update and all legislation affecting physician services—for example, the addition of newpreventive services enacted in 1997, 2000, and 2010.4Residual factors are factors other than price, including volume of services, intensity of services, andage/sex changes.2

13Medicare Enrollment Projections (In millions)Non-ESRD TotalPart ACalendar rt ESRD Fee-for-ServicePart ACalendar rt .614

14ESRDCalendar 142015201620172018201920202021ESRD - TotalTotal Part ATotal Part 20.5210.5040.5350.5170.5490.5310.5620.543ESRD - Fee-for-ServiceTotal Part ATotal Part 40.4020.3840.4100.3920.4240.4050.4330.413Part A Projections for non-ESRD (Aged Disabled)Calendar 142015201620172018201920202021Inpatient hospital 71SNF 45512.83535.42Home health agency 62133.69140.05Average reimbursement per enrollee on an incurred basis, except where noted.Managed care 491,596.201,693.071,772.691,837.301,932.19Hospice: Totalreimbursement(in millions) ,95524,844

15Part B Projections for non-ESRD (Aged Disabled)Calendar 142015201620172018201920202021Physician fee schedule 70Outpatient hospital 070.391,153.041,243.05Durable medical equipment 46128.26132.23Calendar 142015201620172018201920202021Carrier lab 02.20Other carrier 31506.99528.70Intermediary lab ge reimbursement per enrollee on an incurred basis, except where noted.

16Calendar 142015201620172018201920202021Other intermediary 95246.11256.02Home health agency 75238.88250.10Managed care 992,100.212,355.932,524.122,659.532,846.86Average reimbursement per enrollee on an incurred basis, except where noted.2019 Projections by Service Category for non-ESRD (Aged Disabled)*Service typePart AInpatient hospitalSNFHome health agencyManaged carePart BPhysician fee scheduleOutpatient hospitalDurable medical equipmentCarrier labOther carrierIntermediary labOther intermediaryHome health agencyManaged careLast year’sestimateRatio 2,404.48495.45129.621,772.69 0.9501.050CurrentestimateAverage reimbursement per enrollee on an incurred basis, except where noted.

17Claims Processing Costs as a Fraction of 1020112012201320142015201620172018201920202021Part 833Part 111Approximate Calculation of the USPCC, the National MA Growth Percentage forCombined (Aged Disabled) Beneficiaries, and the FFS USPCC (Aged Disabled)The following procedure will approximate the actual calculation of the USPCCs from theunderlying assumptions for the contract year for both Part A and Part B.Part A:The Part A USPCC can be approximated by using the assumptions in the tables titled “Part AProjections under Present Law for non-ESRD (Aged Disabled)” and “Claims Processing Costsas a Fraction of Benefits.” Information in the “Part A Projections” table is presented on acalendar year per capita basis. First, add the per capita amounts over all types of providers(excluding hospice). Next, multiply this amount by 1 plus the loading factor for administrativeexpenses from the “Claims Processing Costs” table. Then, divide by 12 to put this amount on amonthly basis.Part B:The Part B USPCC can be approximated by using the assumptions in the tables titled “Part BProjections under Present Law for non-ESRD (Aged Disabled)” and “Claims Processing Costsas a Fraction of Benefits.” Information in the “Part B Projections” table is presented on acalendar year per capita basis. First, add the per capita amounts over all types of providers.Next, multiply by 1 plus the loading factor for administrative expenses and divide by 12

Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter CMS received many submissions in response to our request for comments on Part I of the Advance Notice, published on December

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