I am writing to urge that the Center for Medicare use discretion in implementing the authority it has to terminate Medicare Plans which have earned a “low performing indicator” in each of the last three years. The Association for Community Affiliated Plans (ACAP) represents 58 not for profit community based plans in 24 states. Over half of our plans operate Dual Special Needs Plans or are involved in the Financial Alignment Demonstrations; some are in both or are transitioning from D-SNPS to MedicareMedicaid (MMP) plans.

As plans which serve a highly specialized category of primarily full-benefit duals, we have ongoing concerns about how the risk adjustment and the Star rating systems inadequately serve the needs of full benefit duals and the D-SNPs in which they are enrolled. If you read through our comments to previous CMS guidance, you will find we have long advocated that CMS require all plans to report (and be reported on) at the “benefit package level” so that fair comparisons can be made of D-SNP to D-SNPs and of D-SNPs to fee-for service.

Recent rules give CMS the authority to terminate plans which have earned less than three Stars in either Part C and/or Part D for three consecutive years. We understand that a disproportionate number of plans at risk of termination are D-SNPs and wonder if that is an indication of the challenges in measuring equitably and comparing D-SNP performance. On page 92 of the 2015 Call letter, CMS shares its own concerns about the precision of the Stars system. “In constructing Star Ratings, a key concern is the potential for generating Star Ratings that do not reflect a contract’s “true” performance, otherwise referred to as the risk of “misclassifying” a contract’s performance (e.g., scoring a “true” 4-star contract as a 3-star contract, or vice versa).” That same system could also misclassify a 3-star contract as a 2.5 Star performer.

We urge CMS to focus terminations on MA-PD plans failing essential operations tests and postpone action on D-SNP plan terminations related to Star rankings.

Before terminating a plan that has crossed the three year LPI threshold, CMS should look at recent plan improvement and other factors of plan strength before removing these options for beneficiaries. Examples include recent Model of Care approvals, successful program audits and other oversight such as demonstrated readiness for participation as an MMP plan in the duals demonstration. But most importantly, before terminating a plan, CMS must be confident that they have identified plans that truly are not adding value to their enrollees.

We and our plans would be happy to meet and discuss our concerns about Stars, risk adjustment and other ways CMS could use to support plans that are focusing on some of the most vulnerable people served in Medicare. Questions and comments may be addressed to: Mary Kennedy, Vice President of Duals and MLTC at 202-701-4749 or at: mkennedy@communityplans.net.

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