Health Market Science

In February, the Centers for Medicare and Medicaid Services provided Medicare Advantage organizations, prescription drug plan sponsors and others with advance notice of upcoming methodological changes for Medicare Advantage capitation rates, Part C and Part D payment policies in Calendar Year 2012.

The 153-page advance notice and call letter outlined several key changes. Specifically, the growth percentage change for the national per capita Medicare Advantage health plan will be 0.7 percent, but is likely to increase the average actual Medicare Advantage per-capita payment to 1.6 percent due to quality rating bonuses.

CMS will be offering a special enrollment period next year to allow individuals who have enrolled in Medicare Advantage to switch to a five-star rated plan at any time during 2012. It is also worth noting that four- and five-star plans will get higher payments, and payment amounts are likely to vary between counties.

As part of a streamlining effort, CMS may eliminate ordinary plans with fewer than 500 enrollees that have been in existence for three or more years. Additionally, some special needs plans that have fewer than 100 members may be discontinued. Low-enrollment plans looking to be extended must either provide justification for their low numbers or confirm they will be consolidating with another plan for 2012. Justifying factors such as geographic location will be considered favorably by CMS, according to officials.

With regard to Part D claims for Schedule II drugs, Part D sponsors will be required to validate prescriber data - specifically Drug Enforcement Administration numbers on Schedule II drug claims or map NPIs on the claims to the prescriber's DEA - as well as confirm that prescribing the controlled substance is within the prescriber's scope of practice.

Scope of practice refers to the regulation of prescribers at the state level, based on their credential type. The specifics of these regulations vary from state to state and are partially regulated by DEA guidelines pertaining to mid-level practitioners' authorization, although these do not cover other practitioner types.

There are several variables affecting scope of practice in 2012, including the presence of an active status on the authoritative DEA file, the federal DEA schedule listing controlled substance rights, the aforementioned state regulations and specialty mapping to NDC code permissions.