Value-Based Insurance Design Test Model

What is the Medicare Advantage Value-Based Insurance Design Test Model and how does it impact you as a rheumatologists?

The first year of the Medicare Advantage Value-Based Insurance Design Test Model (MA-VBID), which allows Medicare Advantage (MA) Plans in seven states to offer supplemental benefits or reduced cost-sharing to targeted groups of enrollees with certain specified chronic conditions, starts in January 2017.

CMS announced this month that the second year of the Model, to take effect in 2018, will include three newly eligible states and adds rheumatoid arthritis (RA) to the eligible clinical categories.

It is unknown which MA Plans will apply and ultimately participate in programs impacting RA patients. Those who do may include benefit design adjustments that would: decrease patient cost-sharing for specific items or services; decrease patient cost-sharing for services from pre-determined high value providers; reduce cost-sharing for patients enrolled in disease management or similar programs; and/or provide coverage of additional supplemental benefits. These changes are not expected to impact provider reimbursement, but could impact where certain patients seek care, and for which services.

ABOUT THE MA-VBID MODEL

Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure patient cost-sharing and benefit design to encourage patients to consume “high-value” clinical services, usually by lowering or eliminating cost-sharing for efficient and effective treatments.2 While VBID has become increasingly popular among commercial plans, the “uniformity requirement,” which stipulates that MA Plans offer uniform benefits to all enrollees residing in the service area of the plan, has generally precluded MA Plans from varying benefit design based on beneficiary characteristics such as underlying health status.

The MA-VBID Test Model , launched by the CMS Innovation Center , will start in January 2017. The Model, as described by CMS , is intended to test the hypothesis that granting MA Plan flexibility to offer supplemental benefits or reduced cost-sharing to targeted groups of enrollees with certain specified chronic conditions will lead to higher quality and more cost-efficient care. MA-VBID Models may not increase the patient’s cost-sharing requirements and must be approved by CMS.

What are Medicare Advantage Plans able to offer under the MA-VBID Test Model?

The Model will provide flexibility for Plans accepted into the model to develop clinically-nuanced benefit designs for enrollee populations that fit within the following clinical categories:

1) Diabetes
2) Chronic Obstructive Pulmonary Disease (COPD)
3) Congestive Heart Failure
4) Patient with Past Stroke
5) Hypertension
6) Coronary Artery Disease
7) Mood disorders
8) Rheumatoid Arthritis (starting in 2018)
9) Dementia (starting in 2018)

A plan may not alter benefit design in a way that increases patient cost-sharing, and may apply to use one or a combination of four approaches:

1) Reduced Cost-sharing for High Value Services allows Plans to reduce or eliminate cost-sharing for items or services, including covered Part D drugs, that they have identified as high value for a given target population. While Plans may pick the items or services to include, they must be clearly defined in advance, and cost-sharing reductions must be available to all enrollees within the target population.
2) Reduced Cost-sharing for High Value Providers allows Plans to reduce or eliminate cost-sharing for items or services when pre-identified high-value providers deliver those services. High value providers must be determined by both quality and cost and include all Medicare provider types (e.g., nursing homes, physicians/practices, hospitals, etc.)
3) Reduced Cost-sharing for Enrollees Participating in Disease Management or Related Programs allows plans to reduce cost-sharing for an item or service for enrollees who choose to participate in a disease management or similar program, but may not make cost-sharing reductions contingent on achieving any specific clinical goals.
4) Coverage of Additional Supplemental Benefits allows Plans to make coverage for
specific supplemental benefits available only to targeted populations

Which Medicare Advantage Plans are participating?

States were selected to test the model based on general representation of the national Medicare Advantage market, collectively meeting criteria such as inclusion of urban and rural areas, areas with both high and low average expenditures, etc. The states now included are listed in the table below, as are the Plans enrolled in 2017 . The Request for Applications for 2018 participation has not yet been released, but is anticipated to come out this month.

State in Which MA Organizations May Apply

2017 MA-VBID Participant Organizations

Massachusetts

BCBS of Massachusetts; Fallon Community Health Plan; Tufts Associated Health Plan

Indiana

Indiana University Health Plan

Pennsylvania

Geisinger Health Plan; Aetna; Independence Blue Cross; Highmark; UPMC Health Plan

Arizona

No Plan participants in 2017

Iowa

No Plan participants in 2017

Oregon

No Plan participants in 2017

Tennessee

No Plan participants in 2017

Alabama – newly eligible in 2018

N/A – may apply to participate in 2018

Michigan – newly eligible in 2018

N/A – may apply to participate in 2018

Texas – newly eligible in 2018

N/A – may apply to participate in 2018

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