Description: Traditional Medicare [TM] has many coverage gaps and no out-of-pocket maximum. Most members must purchase a Medicare Supplement Plan and a Part D plan for pharmacy coverage. Over 50% of members have opted for a Medicare Advantage [MA] plan that replaces TM and the need to purchase a Supplement and (in most cases) a Part D plan. All this for less cost to the member, but at a greater overall cost to the federal government even though MA plans provide TM benefits for less than it costs the government. The attendee will learn why this occurs. However, given these facts, the focus of the session will be on the future of Medicare: namely, should the parameters regarding MA bids and payments be limited to what is paid for TM, or can we take the best administrative techniques of MA and TM to provide more robust benefits for all Medicare members at a cost no greater than the government is currently paying? Or is there an even better idea?

Description: State Medicaid agencies have been implementing value-based payment (VBP) models for the last decade and are increasingly exploring advanced population-based payment (PBP) models that increase flexibility, predictability, and accountability for participating provider organizations. PBP models show promise in advancing Medicaid priorities, but are still in the early stages of development, and model design and implementation challenges remain. This article from the Center for Health Care Strategies explores the fundamentals of VBP and how PBP - a particular type of payment model - can help Medicaid agencies achieve goals related to care transformation and quality improvement, revenue stability, and controlling cost of care.

Description: "Risk adjustment (RA) is a key component for CMS Medicare Advantage program and California Medicaid Managed Care program. While both RA programs follow generally accepted basic principles at a high level, their underlying methodologies and assumptions are also quite different. Due to recent events such as COVID-19 Public Health Emergency and Medicaid redetermination delay and restart, it adds complexity to Risk Adjustment. This is a hot topic in the industry and has significant impact to health plans. Keeping current with risk adjustment program changes and understanding the commonalities and differences of these two government risk adjustment programs is important to our health actuaries. Compare these two risk adjustment programs so you can learn key elements of a risk adjustment program, similarities and differences in methodology and assumptions , as well as special considerations due to serving different populations."