NHPCO NewsLine Fall 2021 - 17

(Part A and Part B), some MA plans also offer extra
coverage through supplemental benefits such as
vision, dental and hearing services, as well as nontraditional
health-related benefits such as
transportation, gym memberships and food support.
Some MA plans also offer prescription drug coverage
(Part D). Beneficiaries voluntarily sign up for MA plans
to access these additional services. MA plans are
incentivized through increased administrative flexibility
and value-based contracts that allow for shared
savings. Until VBID, the Medicare Hospice Benefit has
been " carved out " for MA plans. This means that even
MA plan beneficiaries had their hospice covered
through traditional, FFS Medicare (Part A).
VBID is often referred to as the " Medicare Carve-in. "
Through VBID, CMS is testing an array of valuebased
health plan innovations for Medicare
Advantage (MA) plans. Currently, 9 of the 19 MA
plans participating in VBID are also participating in
the Hospice Benefit Component, with applications
open for greater participation in 2022. Under the
Hospice Benefit Component of VBID, the MA plan
retains financial responsibility for hospice (no
Medicare " carve out " ) and can contract directly with
hospices to offer a more flexible benefit and must
include coverage for palliative care and concurrent
treatment while on hospice. While all VBID providers
must cover all hospices at this time, this requirement
will change by 2023, giving hospices that have
contracted as networked providers with the MA plan
an advantage. More information on VBID is found on
the CMS innovation page.
PCF/SIP - Primary Care First/
Seriously Ill Population
This 5-year payment pilot out of CMS' Center for
Medicare and Medicaid Innovation (CMMI) is an
effort to support the delivery of advanced primary
care. It is offered in 26 regions in the country. PCF
includes 3 models:
▌ PCF-Only which focuses on transitioning primary
care practices to a value-based payment model for
all traditional Medicare patients in their practice;
▌ SIP which focuses increasing care coordination for
traditional Medicare patients who are both
seriously ill and receiving fragmented care; and
▌ Hybrid model for practices that want to provide
both PCF and SIP.
Hospices can apply for SIP and the Hybrid models,
though the applications are currently closed.
Hospices also have the opportunity to coordinate
with PCF providers which are incentivized to limit
acute utilization and maximize care coordination.
More information on PCF is available from CMS.
DCE - Direct Contracting Entities
A DCE is an Accountable Care Organization (ACO)-like
organization which includes Medicare providers and
suppliers. Through CMS, DCEs accept overall
accountability for quality and cost of the medical care
provided to Medicare patients assigned to the entity. A
DCE will receive capitated payments and assume both
upside and downside risk, which means that they get
to keep at least some of the savings they create, but
also may have to pay CMS back if their spending goes
over the benchmark. This is an innovation model that is
just being launched by CMMI and currently has 53
participants. There are currently three DCE models:
▌ Global Direct Contracting model offers 100%
savings/losses sharing and offers either full or
partial capitation payments.
▌ Professional Direct Contracting model offers 50%
savings/losses sharing and offers partial
capitation payments.
▌ Geographic Direct Contracting model is currently
on hold by CMS and under review.
For the Global and Professional Direct Contracting
models, often referred to collectively as GPDC, there
are four types:
▌ Standards DCEs are providers that have
experience serving Medicare FFS beneficiaries,
such as through an ACO or Medicare Shared
Savings Program (MSSP) and have at least 5,000
Medicare FFS beneficiaries assigned to them.
Newsline / Fall 2021 17
https://innovation.cms.gov/innovation-models/primary-care-first-model-options https://innovation.cms.gov/innovation-models/vbid https://innovation.cms.gov/innovation-models/vbid
NHPCO NewsLine Fall 2021

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