Here’s What’s in Store for Medicare Advantage and Part D in 2018

Medicare Advantage and Part D

Check out these bullet points for highlights from the 2018 Medicare Advantage and Part D payment and policy updates posted by CMS.

Medicare Advantage

Medicare Advantage (MA) plans, sometimes called Medicare Part C, are private plans approved by Medicare for people enrolled in Medicare. Medicare pays a fixed amount to the MA plan company, and the company provides Medicare Part A (hospital) and Part B (medical) coverage. The plans often offer Part D (prescription drug) coverage, too.

  • The expected total change in revenue is 2.95 percent for Medicare Advantage. That’s 0.45 percent for the expected average change in revenue plus 2.5 percent for coding trends. That’s a bit above the 2.75 percent total listed in the Advance Notice. It’s also worth noting that actual amounts may vary.
  • Calculation of risk scores will use encounter data for 15 percent, and Risk Adjustment Processing System (RAPS) and Medicare Fee-for-Service (FFS) diagnoses for 85 percent. The 2018 Advance Notice had proposed to continue to use 75 percent RAPS and 25 percent encounter data, but comments played a part in deciding on the final 85/15 blend. In short, operational issues led to commenters suggesting either a more limited use of encounter data or an adjuster.

Part D

As mentioned above, Part D offers drug coverage.

  • Part D benefit parameters see some changes. For instance, the deductible for the standard benefit in 2017 is $400 and in 2018 it’s $405, and the out-of-pocket threshold will change from $4,950 to $5,000.
  • Opioid overutilization criteria change in 2018. CMS posted an analysis including these changes (bullets below are direct quotes):
    • Current Opioid Overutilization Criteria:
      • Use of opioids with cumulative daily MED [morphine equivalent dose] exceeding 120 mg for at least 90 consecutive days with more than 3 prescribers and more than 3 pharmacies contributing to their opioid claims, during the most recent 12 months, excluding beneficiaries with cancer diagnoses and beneficiaries in hospice.
    • Revised Opioid Overutilization Criteria:
      • During the most recent six months:
        • Use of opioids with an average daily MED equal to or exceeding 90 mg for any duration, and
        • Received opioids from more than 3 prescribers and more than 3 pharmacies, OR from more than 5 prescribers regardless of the number of dispensing pharmacies.
      • Beneficiaries with cancer diagnoses and beneficiaries in hospice are excluded.
      • Prescribers associated with a single TIN are counted as a single prescriber.

How About You?

What do you think of the 2018 plan?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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