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Analyzing CMS 2025 Medicare Advantage Advance Notice

Analyzing CMS 2025 Medicare Advantage Advance Notice

Analyzing the CMS 2025 Medicare Advantage Advance Notice

On January 31, 2024, CMS unveiled the 2025 Medicare Advantage Advance Notice, outlining proposed changes to various Star Ratings measures and reaffirming its transition to the V28 Risk Adjustment Model. This Notice serves as a call for feedback from payers, providers, and stakeholders, fostering a collaborative approach to shaping healthcare policies.

Star Ratings

While the list of proposed 2025 measure additions remains unchanged, organizations should be aware of the following updates:

Proposed Changes and Retirements

  • Breast Cancer Screening Measure - New age criteria shift from 50 to 40 years old, creating a larger denominator pool. This adjusted version will remain a display measure for at least two years.
  • Care for Older Adults - Pain Assessment Measure - CMS proposes retiring this measure beginning in MY2025, which aligns with action NCQA has already taken.
  • Statin Therapy for Patients with Cardiovascular Disease Measure - New exclusion criteria for individuals with statin intolerance. This change will be effective MY2025.
  • Plan Makes Timely Decisions about Appeals and Review Appeals Decision Measure- New criteria remove the five-day grace period allowing for mailing of case files. This adjusted version will remain a display measure for at least two years.
  • Members Choosing to Leave the Plan Measure - CMS proposes new criteria effective MY2024 to remove members who move out of the plan’s service area or who move to (DSNP) plans.
  • Care Coordination Measure - New questions added to the survey regarding diagnostic testing included in the composite score.

Measures Transitioning to Common Medicare Environment (CME) for Enrollment Data

The following measures will use CME to flag members in Hospice or with ESRD status for exclusion:

  • Medication Adherence Measures (Diabetes, Hypertension, Cholesterol)
  • Statin Use in Persons with Diabetes
  • Medication Therapy Management Program Completion Rate for Comprehensive Medical Review Measure

Changes and Additions on the Horizon

  • Implementation of Universal Foundation Measure Set - This consists of a standardized set of measures and methodology used across all lines of business.
  • Blood Pressure Control for Patients with Hypertension Measure - CMS is transitioning to EDCS to leverage standardized data formats. This update will result in a larger denominator pool as it will only require one encounter-based diagnosis and for anti-hypertensive drugs to be dispensed once. Additionally, a new lower compliance threshold will reduce numerator pools.

New Measures Under Consideration

  • Initiation of Substance Use Disorder Treatment Measure – “Adolescents and adults who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication-assisted treatment (MAT) within 14 days of diagnosis.” (NCQA, 2024)
  • Engagement of Substance Use Disorder Treatment Measure - “Adolescents and adults who initiated treatment and had two or more additional AOD services or MAT within 34 days of the initiation visit.” (NCQA, 2024)
  • Initial Opioid Prescribing for Long Duration Measure- “This PQA measure (NQF-endorsed measure #3558) evaluates the percentage of individuals 18 years of age and older with one or more initial opioid prescriptions for more than seven cumulative days’ supply, in alignment with the CDC Guideline for Prescribing Opioids for Chronic Pain.” (PQA, 2021)

Risk Adjustment

CMS finalized the CY 2024 Part C Risk Adjustment Model, beginning a phased implementation of the 2024 CMS-HCC model. Technical enhancements include restructuring condition categories using ICD-10, updating FFS data to 2018 diagnoses and 2019 expenditures, and revising per capita predicted expenditure calculations.

Risk Model Transition Highlights

  • Model Blend Calculations: For CY 2025, CMS proposes to blend 67% of the risk score from the 2024 model with 33% from the 2020 model.
  • Normalization Factor: CMS considers a refined FFS normalization factor calculation, addressing COVID-19 impacts while retaining all data years.
  • CY2025 Risk Score Trend: The MA risk score trend represents the average increase in MA risk scores across plans, without adjustments for normalization and coding patterns. For CY 2025, the blended MA risk score trend is 3.86 percent derived from the model blend.
  • Part D Model: To align with the Inflation Reduction Act, the model will be updated to reflect the new plan responsibility, which considers the $2,000 annual out-of-pocket cap.

Timeline and Stakeholder Influence

Feedback submission is integral, as CMS will consider all comments received to finalize 2025 rates and policies by April 1, 2024. Providers and organizations are encouraged to actively participate, recognizing the impact their feedback has in shaping CMS decisions and healthcare policymaking.

In conclusion, the 2025 Medicare Advantage Advance Notice underscores the importance of collaboration between CMS and stakeholders in refining healthcare measures, promoting transparency, and enhancing the quality-of-care delivery.

To talk more about how to prepare for regulatory updates and how ZeOmega can help, please reach out.