CCA Encourages Comments on the Proposed Rule about Medical Loss Ratios in Medicare Advantage

On Friday February 20^th, the US Department of Health and Human Services issued a proposed rule outlining medical loss ratio (MLR) requirements for the Medicare Advantage Program and the Medicare Prescription Drug Benefit Program. Read the rule.

Population health management services are impacted by this regulation as it discusses how wellness and health services are viewed as “activities that improves health care quality” and not “administrative expenses”. This aligns with commercial MLR regulations.

Under this proposed rule, wellness and health services include: wellness assessments; wellness/lifestyle coaching programs designed to achieve specific and measurable improvements; coaching programs designed to educate individuals on clinically effective methods for dealing with a specific chronic disease or condition; public health education campaigns that are performed in conjunction with state or local health departments; actual rewards, incentives, bonuses, reductions in copayments (excluding administration of such programs), that are not already reflected in premiums or claims; any quality reporting and related documentation in non-electronic form for wellness and health promotion activities; coaching or education programs and health promotion activities designed to change member behavior and conditions (for example, smoking or obesity); and health information technology (HIT) to support these activities.

Specific to the HIT category, the proposed rule goes on to state that, “[a]ny HIT expenditure that is attributable to improving health care, preventing hospital readmissions, improving safety and reducing errors, or promoting health activities and wellness to an individual or an identified segment of the population, would under our proposal be classified as a quality improving activity.” Public comments will be accepted until April 16^th.

Comment and Read the Rule

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