VBID – Value-Based Insurance Design Model

Value-Based Insurance Design Model

The Demonstration

Medicare Advantage Value-Based Insurance Design (VBID) Model was developed for CMS to test a broad array of Medicare Advantage (MA) health plan innovations created to minimize Medicare program expenditures, increase the quality of care for Medicare beneficiaries, and improve the coordination and effectiveness of health care service delivery. The VBID model contributes to the modernization of MA and tests if these model components improve health outcomes and lower expenditures for MA enrollees.

For the plan year 2021, out of the 19 Medicare Advantage Organizations (MAOs), 9 are participating in the Hospice Benefit Component (VBID).  There are 53 plan benefit packages (PBPs) offered by these 9 participating MAOs, which includes coverage in 206 counties throughout the nation.  It is important to remember that even if the MAO that is participating has coverage in your state, they may not be participating in PBPs that cover the entire state.

The VBID model is set to be in place from January 1, 2021, through December 31, 2024. There is currently an application process for more MAOs to be added to the VBID Model for 2022.

Six Main Elements of the Demonstration

  1. Palliative Care services
  2. Participating plans must provide the full scope of hospice benefits
  3. Transitional concurrent care services
  4. Care Transparency for Beneficiaries, Families, and Caregivers
  5. Ensuring Beneficiary Access/Network Requirements:
  • stage 1  For CY2021 and 2022 a first-year model, the participant must offer access to in-network hospices as well as out-of-network hospices. And an enrollee may secure hospice care from any allowed Medicare-certified hospice provider, except to the extent that the provider has been excluded by the plan based on concerns regarding the risk of harm to patients.
  • stage 2  For CY2022, plans to participate for their second year may have a more formal version of the consultation program. It may include a requirement that enrollees electing hospice have a consultation before electing hospice with an out-of-network provider. For enrollees taking advantage of an out-of-network provider, hospice services must be paid at the traditional Medicare rates, but enrollees must be informed of their ineligibility for hospice supplemental benefits or concurrent care.
  • stage 3  For CY2023 and future years, plans will be permitted to offer a hospice-specific point of service benefit for enrollees. But it will subject to a network acceptability requirement of having at least one Medicare-certified hospice that will provide access to services in the county and provide the full range of covered services. Relative to cost-sharing, plans may not charge higher cost-sharing than levels permitted under traditional Medicare (outpatient drugs and biologicals and inpatient respite). No other coinsurance or deductibles may be imposed for hospice services.

6. Participating MA plans cannot require prior authorization or implement other utilization management protocols that create inappropriate barriers to care. CMS will allow plans to implement program integrity safeguards in line with the plan’s policies and procedures.

MAOs could execute the following prepayment review policies:

  • Prepayment review strategy to ensure that their out-of-network hospice providers are providing drugs covered under the hospice benefit as necessary. And the cost of drugs covered under the benefit is not improperly shifted to Part D.
  • A prepayment review to address long lengths of stay like greater than 180 days, to evaluate whether recertification was appropriate.

CMS plans to impose prompt submission requirements consistent with claims processing requirements under traditional Medicare, including timely filing of Notices of Election (NOE).  CMS indicated that it would expect late submission of NOEs to be followed by payment penalties.

Participating MAOs will be paid a monthly hospice capitation payment for each month that an enrollee is treated in hospice.  For the first month of hospice care, the hospice monthly capitation rate will be balanced based on the length of time that a patient is on hospice care.

Key take-aways

  • MAOs elect to participate in this demonstration. If your patient is enrolled in a participating MAO the hospice cannot avoid providing care and getting paid by the MAO.
  • Hospices do not have to be in-network to receive a full payment equivalent to the Original Medicare payments for hospice. However, the patient may not have access to all benefits offered by the MAO if the patient chooses an out-of-network hospice.
  • No prior authorization can be required, but the MAO can need a prepayment review of documentation before paying claims.
  • While billing for services that were provided to a patient under this demonstration, the agency must bill the MAO and Original Medicare. The NOE promptness is in effect for the MAO and the hospice will be penalized if the NOE is not timely.
  • In 2022 the MAOs will be authorized to require counseling between the patient and the MAO prior to the patient selecting an out-of-network hospice.
  • More MAOs will be added for 2022 and forward.

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