Medicare Advantage Value-Based Insurance Design Model

FOR INFORMATION ON THE HOSPICE BENEFIT COMPONENT, PLEASE CLICK HERE

FOR INFORMATION ON THE 2022 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 2022, 34 Medicare Advantage Organizations (MAOs) offering MA benefits to plan benefit packages (PBPs) with 7.4 million projected enrollees will provide tailored Model benefits and rewards and incentives to over 3.7 million projected enrollees in 49 states, the District of Columbia and Puerto Rico. Out of the 34 MAOs, thirteen are participating in the Hospice Benefit Component.

  • Alignment Healthcare USA, LLC
  • Anthem, Inc.
  • Athena Healthcare Holdings, LLC
  • AvMed, Inc.*
  • Banner Health
  • Blue Cross Blue Shield of Michigan Mutual Ins. Co.
  • Blue Cross Blue Shield of Rhode Island
  • Cambia Health Solutions, Inc.*
  • CareOregon, Inc.
  • Capital District Physicians' Health Plan, Inc.
  • Catholic Health Care System*
  • CIGNA
  • CVS Health Cooperation*
  • DevotedHealth, Inc.
  • EmblemHealth
  • Geisinger Health
  • Hawaii Medical Service Association*
  • Health Partners Plans, Inc.
  • HealthFirst, Inc.
  • Highmark Health
  • Humana, Inc.*
  • Intermountain Health Care, Inc.*
  • Kaiser Foundation Health Plan, Inc.*
  • Medical Card System, Inc.
  • New York City Health and Hospitals Corporation
  • Presbyterian Healthcare Services*
  • Reliance HMO, Inc.
  • Sentara Health Care (SHC)
  • Summit Master Company, LLC*
  • Triple-S Management Corporation*
  • Troy Holdings, Inc.
  • Ultimate Healthcare Holdings, LLC
  • UnitedHealth Group, Inc.*
  • Visiting Nurse Service of New York*

    *Indicates participation in the Hospice Benefit Component of the VBID Model for Calendar Year 2022

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 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) 2022, 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 2022. Participating MAOs may also test one or more of the other interventions in CY 2022.

  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. Cash or Monetary Rebates, a flexibility to share beneficiary rebates savings more directly with enrollees in the form of cash or monetary rebates
  4. Part C and Part D Rewards and Incentives (RI) Programs
  5. 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 2022, thirteen MA organizations, through 115 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 461 counties.

A downloadable list of PBPs with service area and contact information can be found here: VBID CY2022 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 2022 Materials

CY 2021 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

Webinars

CY 2023 Webinars & Recordings

CY 2022 Webinars & Recordings

CY 2021 Webinars & Recordings

Evaluation Reports

Latest Evaluation Reports

Prior Evaluation Reports

Last updated on:
10/06/2021