January 2, 2018
Seema Verma, Administrator
Centers for Medicare and Medicaid Services
United States Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
Sent via http://www.regulations.gov.
Re: ACAP Comments on Quality Payment Program Final Rule with Comments (CMS-5522-FC)
Dear Ms. Verma,
The Association for Community Affiliated Plans (ACAP), is pleased to submit comments in response to CMS’ final rule for comment on the Quality Payment Program. ACAP represents 61 not-for-profit, community-based Safety Net Health Plans located in 29 states. Our member plans provide coverage to about seventeen million individuals enrolled in Medicaid, Children’s Health Insurance Program (CHIP) and Medicare Advantage Dual-Eligible SNPs. Nationally, ACAP plans serve almost half of all Medicaid managed care enrollees. Twenty-four of our plans operate managed long-term services and supports (MLTSS) products, 24 are D-SNPs, and 14 of participate in the Financial Alignment Demonstration, accounting for approximately 30 percent of all enrollment in the Demonstration.
The rule includes a requirement that advance payment models under the Medicaid component of the all-payer combination option must be submitted through the Medicaid state agency rather than directly from the plan to CMS. States vary in their knowledge base as it relates to value-based payment and alternative payment models. In addition, state staff could vary in their interpretation of the submission requirements in a manner that would not occur if Medicaid managed care organizations were dealing directly with CMS. Finally, state staff are often overworked and may not have the bandwidth to deal with an issue not directly related to their Medicaid roles.
ACAP does not support the requirement that the Medicaid state agency must submit the Advanced APM on behalf of a Medicaid MCO. ACAP believes this requirement is ill-advised, could result in unnecessary confusion and delay, and ultimately make it harder for plan network providers that are serving the Medicaid population to receive credit for their participation in the health plan advanced APM initiatives as part of the CMS Quality Payment Program.
The rule also sets a deadline of April 1st for submission of Medicaid and Medicaid MCO models for the 2019 performance year. Moreover, CMS will only make one determination per year on the whether submitted models meet the CMS specified- requirements. This fails to provide an adequate timeline for the development and submission of the advanced APM though the state entity.
ACAP does not support the artificial April 1st deadline for the performance year 2019. In addition, ACAP does not support the use of a single annual determination by CMS. At a minimum, ACAP believes that the June 1, 2018 deadline in place for Medicare Advantage Health Plans should also apply to Medicaid Managed Care Organizations and that CMS should utilize rolling determinations that include a period for corrective action as necessary to allow for a positive final determination.
In addition, providers that serve Medicaid beneficiaries, including dual-eligible beneficiaries, differ in the degree of risk they are prepared and financially able to undertake. CMS’ definitions of nominal and financial risk should be more flexible to account for the amount of risk providers are able to assume. In particular, there is concern that safety net providers, such as FQHCs, do not have the financial reserves to assume downside risk. The important role of these providers in caring for Medicaid beneficiaries and dual eligible beneficiaries should be acknowledged and strengthened, rather than jeopardized, by the move towards inflexible Advanced APMs.
ACAP requests that CMS exclude or create an exception for safety net providers from the criteria of assuming significant downside risk as currently defined.
Finally, as we noted in our previous comments, many states have been working with CMS to implement system delivery reform that include the creation of Medicaid Medical Homes. Existing state Medicaid Medical Homes should be deemed acceptable as Other Payer Advanced APMs as they currently exist. CMS should not expect states, plans, and providers to change the criteria of Medicaid Medical Homes after those programs have already been developed and approved by CMS.
ACAP supports grandfathering Medicaid Medical Homes that have been previously approved by CMS under the CMS Quality Payment Program.
ACAP thanks you for the opportunity to comment and is prepared to assist with additional information, if needed. If you have any additional questions, please do not hesitate to contact Deborah Kilstein at (202) 341-4101.
Margaret A. Murray
Chief Executive Officer