MMAPA is a non-for-profit association comprised of the leading Medicaid and Medicare Advantage organizations in Puerto Rico: Humana, MCS, MMM/PMC and Triple-S Advantage. This association was born in 2009 to evaluate and act about the implications of new government policy on funding for Puerto Rico’s healthcare system.

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Administrative Proposal  

Specific actionable items MMAPA and the Health Care Community are working with HHS/CMS in the short term at the administrative level

1. MMAPA Proposal: During 2015 and 2016, MMAPA submitted specific proposals to CMS on the STARs program, the Risk Score model, as well as other recommendations under the Medicare Advantage (MA) program to HHS and CMS leadership. In addition MMAPA, as a charter member of the Puerto Rico Healthcare Crisis Coalition, worked with CMS all year on the “data issues” regarding the base rate of the MA payment formula, which led to some of the proposals in the 2017 Advance Notice and Draft Call Letter. 

2. What was the 2017 Final Announcement and Call Letter and when was it released? The 2017 Advance Notice is the final announcement, which determines the MA funding for 2017 and it was released on April 4, 2016.

Key Positives Changes done by CMS for PR:

a. Impact in 2017 funding: total estimated mitigation of potential 7.7% incremental cuts is       
    approximately $260-$300 million.

  • Zero-claim adjustment of 4.4%

  • Incorporation of Part A rate increase estimated at 0.8%

       b. Impact in 2018 Funding

  • Estimation of an LIS proportion in PR to apply the socio-economic status (SES) adjustment in STARs.

  • Medication adherence weighted at 0, but still used for improvement measure.

  • Estimated that several plans/contracts could increase ½ STAR for 2017 STARs, 2018 impact.

        c. National policies and trends that helped PR

  • National growth rate

  • Changes to risk scores for duals, resulting in an average 2% increase for PR.


3. Other proposals that MMAPA is working with HHS and CMS:       

       a. Medicare FFS does not Work in PR

  • Get correct FFS data and continue detailed analysis

  • Maintain current fixes, increase adjustment

    • General MA proxy

           b. CMS to Finalize SSI Proxy proposal for Part A UC

    • CMS finalizes proposal in 2017 draft rule

      • CMS uses proxy also for old 25% DSH

      • CMS makes corresponding adjustment in MA rates

              c. Exempt Territories from Health Insurance Providers Fee

      • Legitimate legal theory presented to Treasury, and to the WH General Counsel

      • Can mitigate Governments deficit

              d. MS to correct GPCI for Part B physician fees

      • MS to correct GPCI for Part B physician fees

      We are thankful that CMS moved, tentatively, in the right direction with the language used in the Advance Notice, but PR will still be at the lowest funding level when compared to the rest of the MA programs in the US. We need the support from the PR government to continue urging CMS to act on their proposals, so CMS can FINALIZE the necessary changes to mitigate payment disparities in Puerto Rico.

      Thank you for your interest in MMAPA’s Call to Action.

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