CMS tests Medicare Advantage plan benefit designs

September 3, 2015
Innovative plan benefit design model could cut costs, improve care for enrollees.

High-quality, cost-efficient care is the goal of a proposed value-based insurance model that grants health plans flexibility to offer new supplemental benefits tailored to enrollees' clinical needs.

The Centers for Medicare and Medicaid Services (CMS) announced select testing of this Medicare Advantage Value-Based Insurance Design (MA-VBID) model that could reduce out-of-pocket costs and premiums, and promote better benefits for Medicare Advantage plan enrollees, according to a CMS statement released on September 1.

The MA-VBID model will test the utility of structuring patient cost-sharing and other health plan design elements to encourage patients with chronic conditions—such as diabetes or certain cardiovascular diseases—to seek out high-value clinical services. CMS specifically mentions the idea of eliminating co-payment on eye exams for Medicare Advantage enrollees with diabetes.

AOA supports removing cost barriers to eye exams for patients with diabetes

The AOA supports Medicare Advantage plans eliminating cost barriers for patients with diabetes to get eye exams—as specifically mentioned in the CMS statement—and will offer feedback to the CMS Center for Medicare and Medicaid Innovation in support of the MA-VBID model.

"We think CMS has a good idea here, to remove cost barriers to eye exams for older Americans with diabetes," says AOA President Steven A. Loomis, O.D. "Other experts agree with us that eye exams are crucial for patients with diabetes, because the disease is the leading cause of adult-onset blindness and the risk of vision impairment for a patient increases the more time passes without an eye exam. Ultimately, the best way to prevent developing eye complications from diabetes is to have your eyes examined annually, and to control blood glucose levels and blood pressure.

"We hope Medicare Advantage plans will implement this innovative benefit design that will not only save sight but also lead to long-term cost savings for patients and the Medicare program."

The AOA frequently advocates with federal and other policymakers about the importance of regular, in-person eye exams for patients with diabetes. For example, accountable care organizations (ACOs) participating in the Medicare Shared Savings Program and large group practices participating in the Physician Quality Reporting System are now expected to ensure that the fee-for-service Medicare beneficiaries with diabetes receive eye exams.

CMS testing benefit design in select states

A 5-year trial run of the MA-VBID is scheduled to begin Jan. 1, 2017, in seven states, including: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania and Tennessee. The AOA has notified optometry leaders in these states of the opportunity to encourage their plans' participation in this innovative model.

With CMS approval, eligible plans in these states may implement plan benefit changes among four categories:

  1. Reduced cost-sharing for high-value services.
  2. Reduced cost-sharing for high-value providers.
  3. Reduced cost-sharing for enrollees participating in disease management or related programs.
  4. Clinically targeted additional supplemental benefits.

Find more information on the CMS' MA-VBID model Web page.

Read more about AOA weighing in on the diabetes debate and access the AOA's milestone evidence-based clinical practice guideline, Eye Care of the Patient with Diabetes Mellitus—Second Edition.

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