Monday, April 7, 2014

Announcement of Calendar Year (CY) 2015 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

Key Changes from the Advance Notice: 

Growth Percentages: Attachment I provides the final estimates of the National MA Growth
Percentage and the FFS Growth Percentage and information on deductibles for MSAs.

CMS-HCC Risk Adjustment Models for CY2015: For reasons discussed in Attachment II,
for the 2015 payment year we will blend the risk scores calculated using the 2013 CMS-HCC
and 2014 CMS-HCC models by 67 percent and 33 percent, respectively.

Medicare Advantage Enrollee Risk Assessments: CMS is not implementing, for 2015, the
proposed policy to exclude, for payment purposes, diagnoses identified during a home visit
that are not confirmed by a subsequent clinical encounter.

Normalization Factors: 

The final 2015 normalization factors are:

  • CMS-HCC model implemented in 2013: 0.992 
  • Clinically Revised CMS-HCC model implemented in 2014: 0.978 
  • CMS-HCC model for PACE plans: 1.028 
  • ESRD Dialysis/Transplant model: 1.004 
  • ESRD Functioning Graft model: 1.028 
  • RxHCC model: 0.961 
  • RxHCC Risk Adjustment Model: CMS will not implement the updated RxHCC model in 2015. 
  • We will continue to use the RxHCC model used in 2014, as published in the 2014 Rate Announcement (Attachment VII, Tables, 6-10). 

International Classification of Diseases-10 (ICD-10) Code Sets and Diagnosis Data Sources for 
2015 Risk Scores:

As proposed in the Advance Notice, CMS will use the prior calendar year as
the data collection year for 2015 risk scores (specifically, we will use CY 2014 diagnoses to
calculate the risk scores used in 2015 payment).

In addition, as proposed in the Advance Notice, CMS will use diagnoses from the Encounter Data System submissions for the calculation of 2015 risk scores (2014 dates of service), in addition to diagnoses submitted to the Risk Adjustment Processing System.

In the Advance Notice, we anticipated that data from both of these data sources would include diagnoses from ICD-10 code sets beginning with October 1, 2014 dates of service. Section 212 of the “Protecting Access to Medicare Act of 2014” delayed the adoption of ICD-10 standard code sets to no earlier than October 1, 2015.

Therefore, only ICD-9 standard code sets will be used for diagnoses for 2014 dates of service and, therefore, for 2015 risk scores.

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