Medicare Advantage Value-Based Insurance Design Model

FOR INFORMATION ON THE HOSPICE BENEFIT COMPONENT, PLEASE CLICK HERE

FOR INFORMATION ON THE 2023 VBID MODEL, PLEASE CLICK HERE

Through the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, CMS is testing a broad array of complementary MA health plan innovations designed to reduce Medicare program expenditures, enhance the quality of care for Medicare beneficiaries, including those with low incomes such as dual-eligibles, and improve the coordination and efficiency of health care service delivery. Overall, the VBID Model contributes to the modernization of MA and tests whether these model components improve health outcomes and lower costs for MA enrollees.

For plan year 2023, the VBID Model has 52 participating Medicare Advantage Organizations (MAOs) with a total of 9.3 million enrollees projected to be enrolled in participating plan benefit packages (PBPs). Over 6.0 million of these enrollees are projected to receive additional Model benefits and/or rewards and incentives as part of the Model test in 2023.

  • Alignment Healthcare USA, LLC
  • AllCare Health, Inc.
  • AlohaCare
  • Athena Healthcare Holdings, LLC
  • Banner Health
  • Blue Cross & Blue Shield of Rhode Island
  • Blue Cross and Blue Shield of North Carolina
  • Blue Cross Blue Shield of Arizona
  • BlueCross BlueShield of Tennessee
  • Bright Health Group, Inc.
  • Cambia Health Solutions, Inc.*
  • Capital District Physicians' Health Plan, Inc.
  • CareOregon, Inc.
  • Catholic Health Care System*
  • Centene Corporation
  • Chinese Hospital Association
  • CIGNA
  • Commonwealth Care Alliance, Inc.
  • Community Health Group
  • Community Health Plan of Washington
  • CVS Health Corporation*
  • Devoted Health, Inc.
  • DOCTORS HEALTHCARE PLANS, INC.
  • Elevance Health, Inc.*
  • EmblemHealth, Inc.
  • Geisinger Health
  • Guidewell Mutual Holding Corporation*
  • Hawaii Medical Service Association*
  • Healthfirst, Inc.
  • HealthPartners, Inc.
  • Henry Ford Health System
  • Highmark Health*
  • Humana Inc.*
  • INLAND EMPIRE HEALTH PLAN
  • Kaiser Foundation Health Plan, Inc.*
  • Louisiana Health Service & Indemnity Company*
  • Marquis Companies I, Inc.*
  • MHH Healthcare, L.P.
  • New York City Health and Hospitals Corporation
  • Presbyterian Healthcare Services*
  • SANTA CLARA COUNTY HEALTH AUTHORITY
  • SCAN Group*
  • Sentara Health Care (SHC)
  • The Health Plan of West Virginia, Inc.
  • Thomas Jefferson University
  • Triton Health Systems, L.L.C.
  • Troy Holdings, Inc.
  • Ultimate Healthcare Holdings, LLC
  • UnitedHealth Group, Inc.*
  • Universal Health Services, Inc.
  • UPMC Health System
  • Visiting Nurse Service of New York*

*Indicates participation in the Hospice Benefit Component of the VBID Model for Calendar Year 2023

 

Background

MA plans offer Medicare beneficiaries an alternative to Original Medicare, also referred to as “Fee-for-Service.” In addition to covering all Medicare services, some MA plans also offer Medicare beneficiaries extra coverage through supplemental benefits, such as vision, hearing, and dental services. Additionally, some MA Plans also offer prescription drug coverage (Part D) as part of their plan.

MA plans can charge different out-of-pocket costs for certain services within guidelines defined by Medicare. VBID generally refers to health insurers’ efforts to structure cost-sharing and other health plan design elements to encourage enrollees to use the services that can benefit them the most.

Additionally, currently, Medicare Beneficiaries may enroll into MA and have access to all original Medicare benefits plus additional supplemental benefits beyond what original Medicare covers. Historically, when an MA enrollee elects hospice, Fee-For-Service (FFS) Medicare becomes responsible for most services while the MA organization retains responsibility for certain services (e.g., supplemental benefits). This hospice “carve-out” from MA results in a convoluted set of coverage rules for MA enrollees who elect hospice and fragments accountability for care and financial responsibility across the care continuum.

Initiative Details

The VBID Model tests a broad array of MA service delivery and/or payment approaches and contributes to the modernization of MA through increasing choice, lowering cost, and improving the quality of care for Medicare beneficiaries.

The VBID Model allows MAOs to further target benefit design to enrollees based on chronic condition and/or socioeconomic characteristics (as defined as being eligible for the Low Income Subsidy (LIS) or, in US territories, being dually eligible) and/or incentivize the use of Part D prescription drug benefits through rewards and incentives. MAOs may also offer the Medicare hospice benefit to its enrollees (as described below) as part of the VBID Model. Additionally, the VBID model requires that all participating plans engage their enrollees through structured and timely wellness and health care planning, including advanced care planning.

In Calendar Year (CY) 2023, the VBID Model will test the following Model Components. All participating MAOs must participate in the mandatory Wellness and Health Care Planning component of the VBID Model in 2023. Participating MAOs may also test one or more of the other interventions in CY 2023.

  1. Wellness and Health Care Planning (WHP)
  2. VBID Flexibilities, for Model PBPs’ select enrollees targeted by condition, socioeconomic status or a combination of both, for offering: 
    1. Primarily and non-primarily health related supplemental benefits, which may include new and existing technologies or FDA-approved medical devices as a mandatory supplemental benefit
    2. Use of high-value providers and/or participation in care management program(s)/ disease state management program(s)
    3. Reductions in cost-sharing for Part C items and services and covered Part D drugs
  3. Part C and Part D Rewards and Incentives (RI) Programs
  4. Hospice Benefit Component

For more details on these Model Components please see the links to the VBID and VBID Hospice Benefit Components Requests for Applications (RFA) below.

Hospice Benefit Component

The Centers for Medicare & Medicaid Services announced in January 2019 that beginning in CY 2021, through the VBID Model, participating MAOs could include the Medicare hospice benefit in their Part A benefits package.

Under the Model in CY 2023, fifeen MA organizations, through 119 PBPs, will participate in the Hospice Benefit Component of the VBID Model. These PBPs will test the Hospice Benefit Component in service areas that cover 806 counties.

A downloadable list of PBPs with service area and contact information can be found here: VBID CY2023 Hospice Benefit Contact Information (XLS)

By including the Medicare hospice benefit in the MA benefits package, CMS will test the impact on service delivery and quality of MA plans providing all original Parts A and B Medicare items and services required by statute. Additionally, CMS is testing how the hospice benefit component can improve beneficiary care through greater care coordination, reduced fragmentation, and transparency in line with recommendations by the Office of Inspector General (OIG), the Medicare Payment Advisory Commission (MedPAC) and others. CMS will require that MAOs provide beneficiaries with broad access to the complete original Medicare hospice benefit. MAOs participating in the hospice benefit component will be required to outline how they will provide palliative care to eligible enrollees, irrespective of the election of hospice, and may make transitional, concurrent care services as well as hospice-specific supplemental benefits available to enrollees who elect hospice through network hospice providers.

For technical and operational guidance, please reference the Hospice Benefit Component Technical and Operational Guidance. Visit the Hospice Benefit Component overview page for further information.

CY 2023 Materials

CY 2022 Materials

Additional Information

The separate, OIG-issued, fraud and abuse waivers applicable to Medicare Advantage Organizations in the VBID Model are available at https://www.cms.gov/medicare/physician-self-referral/fraud-and-abuse-waivers

CMMI has released a memorandum providing guidance on Model treatment of reductions in Part D cost-sharing.

Webinars

CY 2023 Webinars & Recordings

 

Evaluation Reports

Latest Evaluation Reports

Prior Evaluation Reports

Last updated on:
11/16/2022