The American Journal of Managed Care August 2014
Synchronization of Coverage, Benefits, and Payment to Drive Innovation
For CMS to approve each supplemental benefit, the benefit must meet certain requirements—telemedicine should supplement and not replace face-to-face visits, for example, and all allied health professionals involved in providing care must be licensed and certified. CMS reviews and approves each supplemental benefit annually as part of the plan bidding process.
Along with defining eligible supplemental benefits, CMS defines services that are ineligible. For example, stand-alone brain training/memory fitness is ineligible as a supplemental benefit because according to CMS, no conclusive evidence proves that any such services improve memory or brain function. Therefore, these services are not accepted clinical treatment modalities.34
The criteria CMS uses to differentiate between eligible and ineligible supplemental benefits are not transparent. CMS “encourages plans to offer supplemental benefits to enrollees that are of value and based on sound medical practice,”35 and offers MA plans the opportunity to comment on changes to supplemental benefits. In the end, however, CMS retains the authority to determine what is considered an eligible new “health benefit.” Often, it provides limited documentation explaining its decision. While MA plans are paid on the basis of a broad bundle of services, they have limited flexibility to cover new services or modify existing coverage or benefit policies. CMS provides tight guidelines on what is eligible as a supplemental benefit, with minimal public discussion of its decisions.
Coverage and Benefits Under Original Medicare Payment Reform Initiatives
In contrast to the MA program in which Medicare benefits are provided through commercial insurance, the BPCI and MSSP Initiatives are part of Original Medicare. They are, therefore, directly insured by CMS. Under these initiatives, CMS plans to transfer a portion of the financial risk to PABs through shared savings and discount arrangements.
In the MSSP, CMS plans to eventually pay some participating providers a fully capitated payment similar to MA plans. In all cases, however, PABs remain bound to the established coverage requirements under Medicare Parts A and B.36,37
Under the BPCI initiative, in Model 1 (acute inpatient; retrospective), Model 2 (acute inpatient and post acute care; retrospective), and Model 3 (post acute care; retrospective), Medicare pays for all services, including waived services, using fee-for-service. In return, CMS generates savings based on prearranged discounted episode bundledpayment amounts. Under BPCI Model 4 (Acute inpatient; prospective), providers pay for the all services, including waived services, by drawing on their prospectively determined episode payment amount.