Choosing the Right Medicare Advantage Plans: What to Consider?

Selecting the right Medicare Plan is crucial as always. As you navigate the options available, it's essential to consider factors that can impact your healthcare coverage and costs. Medicare Advantage Plans, often referred to as Medicare Part C, are an alternative to Original Medicare (Part A and Part B). These plans are offered by private insurance companies approved by Medicare. They provide all the benefits of Original Medicare and often include additional services, such as prescription drug coverage and wellness programs.

Benefits of Medicare Advantage Plans

 

• Comprehensive Coverage: Medicare Plans typically cover hospital services, medical services, and prescription drugs, all under one plan.
• Additional Benefits: Many plans offer extra benefits like dental, vision, and fitness programs that Original Medicare does not cover.
• Network Options: These plans may have networks of preferred providers, which can save you money.
• Out-of-Pocket Maximum: There's a cap on your annual out-of-pocket spending, providing financial protection.

Importance of V24 to V28 for Medicare Advantage Transition

The switch from V24 to V28 for Medicare Advantage is a significant change in Medicare Advantage reimbursement. Healthcare providers must effectively manage this three-year transition while dealing with two model versions. This shift is crucial for ensuring accurate reimbursement and requires a strategic approach to coding, data management, and financial planning. Successfully adapting to Version 28 is essential for healthcare organizations to maintain financial stability and deliver quality care to Medicare Advantage beneficiaries.

The Significance of HCC Coding 

It is a system used by Medicare to assess the health status of beneficiaries. It helps determine the expected costs of healthcare for each individual and is instrumental in shaping Medicare Plans.

How It Works

HCC Coding assigns scores to the diagnoses of beneficiaries. The scores are used to predict the expected healthcare costs. The higher the score, the more resources a patient is expected to require.

Impact on Plan Selection

 

• Risk Adjustment: As mentioned earlier, HCC coding affects risk adjustment and funding for plans.
• Plan Tailoring: Plans may customize their benefits based on the HCC scores of their enrollees.
• Accuracy of Diagnosis: It is crucial for healthcare providers to accurately code and document diagnoses for beneficiaries, as this directly impacts their risk scores.

Making the Right Choice

That’s the right way to choose! 

• Consider Your Health Needs

• Compare Plans

• Consult a Medicare Expert 

Learn more about it Persivia. Check out our Medicare Advantage Plans and healthcare platforms. 

Helpful Tips for Bridging HCC Care Gaps in Medicare Advantage (MA) Plans

 The Centers for Medicare and Medicaid Services (CMS) pays MedicareAdvantage (MA) Plans for each insured participant, giving preference to older and disabled adults who meet the criteria. Apart from hospice care, the MA coverage is the same as Part A hospital, Part B medical, and Part D prescription medication coverage.

Instead of being provided by the federal government, the Medicare Advantage Plans, often known as Part C or MA Plans, are provided by Medicare-approved private organizations that must adhere to Medicare's regulations. They often include hospitalization, medical care, and prescription medication coverage. Healthcare companies get a predetermined monthly premium for insurance coverage and charge enrollees for out-of-pocket expenditures.

MA Plans and Hierarchical Condition Categories (HCC Coding)

CMS-HCC Coding system compensates Medicare Advantage Organizations (MAOs) differently depending on condition prevalence and demography. Approximately 9,000 ICD-10 codes are classified with a risk factor. Weighting or a stratification assigns higher scores to more severe issues. Must report conditions annually under the HCC Coding framework.

Bridging HCC Care Gaps and Ensuring Effective Code Tracking

It is critical to document all HCC codes for the ascribed members to provide correct risk adjustment scores and total payer allocations.

Healthcare organizations can close HCC Care Gaps by following these helpful tips: 

1)      Check Patients once a year

Diagnoses must be obtained through face-to-face consultations and reported on an annual basis. Plan ahead of time and develop comprehensive outreach strategies.

2)       Plan ahead of time for patient visits

Assist physicians in identifying HCC patients ahead of time so that activities like chart prep, issue list reviews, and morning huddles can be more impactful and focused.

 3)     Use Appropriate Forms

Use Patient Assessment Forms (PAFS) or Comprehensive Health Assessments (CHAs) to collect comprehensive and accurate diagnoses at the point of care.

 

4)      Automated chart review process 

Utilize techniques to monitor high-value interactions that require coder review, optimize your workflow, and guarantee that HCC coding is completed before claim submission.

 

5)      Determine Performance Indicators

Evaluate the Key performance indicators and data that the team should monitor to operate successfully, and then develop timely, consistent reports on important reimbursement drivers like:

 a. Recapture rate of HCC (by location and provider)

 b. Patient risk adjustment score trending

 c. Patients with severe illnesses that must be scheduled

  

6)      Assemble the Correct Team

Healthcare providers must receive assistance to finish the documentation and HCC data analysis. If required, consider hiring additional support personnel.

 

Medicare Advantage Risk Adjustment Recommendations For 2022

 A Risk adjustment Solution estimates healthcare costs that compare a person's health to a number known as a risk score. The "risk" to a health insurance plan covering members with high projected healthcare usage is "adjusted" by covering those with low estimated healthcare costs.

Risk adjustment is a program in which health insurance providers participate and are reimbursed for managing individuals' healthcare requirements depending on their diagnosis.

Since Risk Adjustment programs are devised and maintained by government organizations that exist to serve all entitled members of the general public, a health insurance provider cannot prejudice or cover just the members of a specific demographic with a restricted range of predicted healthcare expenditures. The case mix of both healthy and critical patients and the cost-sharing of spending shared by all members is intended to enable access to quality care regardless of medical condition or history.

Medicare Advantage Plans

Apart from the government's regular Medicare and Medicaid programs, Medicare enrollees have the option of getting services through a variety of private insurance plans. These private insurance alternatives are known as Medicare Advantage (MA) Plans. They are a component of Medicare Part C. MA is a method of obtaining medical services and Medicare coverage.

Recommendation for Medicare Advantage Risk Adjustment in 2022

Considering the critical stay-at-home instructions and regulations throughout 2020, Medicare Advantage providers are now confronted with the issue of insufficient prospects to accumulate encounter data to do comprehensive risk adjustment equations. Concerned about the impact of risk adjustment scores on consumer premiums, benefits packages, and patient out-of-pocket costs, the Alliance of Community Health Plans (ACHP) has requested that CMS amend the MA risk adjustment criteria for the year 2022.

ACHP recommends CMS to permit MA entities to use a 24-month look-back timeframe to enhance 2020 statistics for the assessment of 2021 risk scores. ACHP argues that it allows Medicare Advantage Plans to avoid the detrimental impact of under-risk-adjusting. 

ACHP suggests that CMS create a replicable strategy for 2022 since recent increases in COVID-19 show that the healthcare industry will be under pressure long beyond 2021.

ACHP anticipates that even though COVID-19 vaccination is now available in 2021, there will be a time lag between its supply and the return to regular activities. Considering the fact that vaccine distribution efforts are regulated on a state-by-state basis, it is quite probable that recipients, particularly the most vulnerable, will be unwilling to shift to pre-pandemic standards of care instantly.