CMS: Proposed rule would expand Medicare Advantage telehealth benefits to urban locations, strengthen auditing

October 31, 2018
Medicare Web

CMS is proposing to expand Medicare Advantage (MA) telehealth benefits and to increase auditing and recovery of overpayments made to MA plans, according to a proposed rule released October 26. The CY 2020 Medicare Advantage and Part D Flexibility proposed rule would go into effect January 1, 2020.

CMS has expanded telehealth benefits for Medicare beneficiaries over the past several years. However, building on the Bipartisan Budget Act of 2018, the proposed rule would offer MA beneficiaries certain telehealth benefits that are not available to traditional Medicare beneficiaries, CMS said in a press release. Currently, Medicare generally restricts telehealth coverage to beneficiaries located in nonurban settings and requires beneficiaries to receive services at an originating site such as a physician office. The proposed rule would allow MA beneficiaries in urban locations to obtain telehealth coverage and would allow MA beneficiaries to receive telehealth in their homes.

Another proposed change would bolster CMS’ monitoring of MA plans. A recent Office of Inspector General report suggested that Medicare Advantage organizations (MAO) – the organizations that administer MA plans -- could be abusing the capitated payment system by inappropriately denying claims. Although the proposed rule does not directly address inappropriate denials it does include changes that would see CMS stepping up its oversight of MAOs. Currently, CMS conducts Risk Adjustment Data Validation audits of MAOs to confirm that diagnoses they submit for risk adjusted payments are supported by documentation. The proposed rule would strength CMS’ ability to recover overpayments identified during audits

The proposed rule also includes changes aimed at unifying the appeals process and integrating benefits for dual-eligible beneficiaries participating in dual-eligible special needs plans. Other proposed changes include an update to the methodology for calculating Star Ratings.

Comments on the proposed rule may be sent via mail or submitted electronically. Comments are due December 31.