NCQA Proposed Medicare Advantage Rule Comments

NCQA supports proposals to expand telehealth, unify D-SNP appeals and share Parts A & B data with Part D-only drug plans.

December 18, 2018

Seema Verma, Administrator
Center for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244

Attention: CMS-4185-P

Dear Administrator Verma

Thank you for the opportunity to comment on proposed Medicare Advantage and Medicare Prescription Drug Benefit changes for 2020 and 2021 that implement the Bipartisan Budget Act of 2018.

The National Committee for Quality Assurance (NCQA) supports these changes, including expanding telehealth, unifying Medicare/Medicaid appeals and grievances procedures for Duals Special Needs Plans (D-SNPs) and sharing Parts A and B claims data with Part D-only plans. We support use of extrapolation in contract-level audits to apply the percentage of patients with inflated risk scores to the entire plan population. Finally, we thank you for clarifying that CMS may deem Quality Improvement Programs for plans with private accreditation from entities such as NCQA.

Details comments on these issues are below.

Telehealth: We support expanding telehealth as a basic benefit without limits on types of services provided and without the limitations in traditional Medicare because of program integrity concerns under fee-for-service. While we understand that telehealth technology and acceptance is advancing more quickly, it is premature to count telehealth providers when assessing network adequacy. Telehealth access should especially not count toward network adequacy for primary care clinicians for whom patients’ direct and comprehensive access can be essential. However, we urge you to monitor telehealth progress closely and consider including telehealth providers in the future for network adequacy, especially in areas lacking needed clinicians such as behavioral health professionals. We also urge you to require all plans – both HMOs and PPOs alike – to use only contracted providers for telehealth to prevent surprise medical bills that undermine the affordability of care.

Duals Special Needs Plans (D-SNPs): We support a unified appeals and grievance process for D-SNPs and commend you for working to identify and incorporate the most protective policies for enrollees both Medicare and Medicaid. A unified, enrollee-focused process will be much better for people in both Medicare and Medicaid who now must navigate separate processes, often without knowing which program covers what benefit.

For post-plan appeals where current law prevents a fully unified process, we urge you to work with Congress to obtain authority to use the New York State Fully Integrated Duals Advantage model developed under 1115A demonstration authority. As noted in the proposed rule, the New York model is the only fully-integrated Medicare/Medicaid appeals and grievance process.
Given clear Congressional interest and the great need for a fully unified process, this approach offers the best way to ensure D-SNP enrollees have a truly patient-centered appeals and grievance processes.

We further support the proposed requirements for Medicare/Medicaid integration by D-SNPs. These include:

  • Integrating Medicaid long-term services and supports (LTSS), behavioral care or both for high-risk enrollees in plans not highly integrated by notifying the state of hospitalizations, emergency department visits, hospital and skilled nursing facility discharges, assigning one primary care provider for each enrollee, or sharing data for coordination of Medicare/ Medicaid services;
  • Meeting fully integrated D-SNP requirements or having capitated state contract for LTSS, behavioral care or both; or
  • Having parent organizations, if also a Medicaid plan providing LTSS or behavioral care, assume clinical and financial responsibility for D-SNP & Medicaid benefits.

We further support requiring plans to have state contracts if states have managed care for dual enrollees. This is the best way to ensure integration and address concerns about duplicated health risk assessment requirements from both Medicaid and D-SNP plans. We also believe you should require data sharing between D-SNPs and Medicaid in states that do not have managed care for dual enrollees.

Part D-only Plan Access to Part A & Part B Claims: We support establishing a process in which Part D-only prescription drug plans can get electronic, standardized Part A and Part B claims extracts. This can help improve the effectiveness of medication management programs that improve enrollee medication use, care coordination and outcomes.

Star Measures Measure Cut Point Methodology: We appreciate your desire to enhance the cut point methodology for non-CAHPS Star Measures to better account for outliers. We have also struggled with this issue and are exploring an alternative approach to see if it yields more stability than a hierarchical cluster analysis, which still yields significant year-to-year instability. We would be happy to update you if, after further testing, our alternative approach provides better results.

Medicare Advantage Deeming: Finally, we thank you for clarifying that you may deem Quality Improvement Programs for plans with private accreditation from entities such as NCQA. This supports recent CMS approval of our Special Needs Plans Model of Care audits deeming crosswalk, which we intend to launch in 2019. We thank you for you diligent and conscientious assistance on this, and look forward to working with you further to reinstate and expand our full Medicare Advantage deeming program.

Thank you again for the opportunity to comment on your proposals. If you have questions, please contact Paul Cotton, Director of Federal Affairs, at or (202) 955-5162.



Margaret O’Kane,

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