RADAR on Medicare Advantage

Beneath High Ratings, MA-PD Stars Scores Show Shortcomings

Thanks to numerous flexibilities granted to plan sponsors during the COVID-19 public health emergency, nearly 70% of Medicare Advantage Prescription Drug (MA-PD) plans earned an overall rating of 4 stars or higher for 2022, CMS said on Oct. 8. That’s compared with just 49% of MA-PD plans in 2021. But the underlying data shows that quality improvements weren’t as impressive as the 2022 star ratings suggest, and with rising quality bonus payments (QBPs), the 2022 ratings could have major implications for MA revenue in the future, industry experts warn.

Last-Minute Memo Roils MAOs’ Third-Party Marketing Plans

Just eight days into the marketing period for the 2022 Medicare plan year, CMS issued a memo on third-party marketing that, while expected, has led to some confusion among Medicare Advantage plans and their industry partners regarding already finalized marketing materials.

Plans Seek Ways to Promote Provider Use of Z Codes

As Medicare and Medicaid plans seek ways to improve overall care quality by addressing members’ social determinants of health, an emerging source of beneficiary-level SDOH data is a subset of ICD-10 “Z Codes,” which can be attached to claims and encounters to identify causes other than a disease or injury. While there is payer enthusiasm for using these codes, new research suggests that plans have a long way to go to increase provider uptake and establish best practices in this area.

News Briefs

✦ CMS has given itself another year to finalize a proposal to begin using an extrapolation methodology in recovering overpayments from Medicare Advantage organizations. The Trump administration in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said it planned to extrapolate the results of Risk Adjustment Data Validation Audits, starting with 2011 contract-level audits, and not apply a “fee-for-service adjuster” to account for inaccurate diagnosis codes in FFS Medicare data used to calibrate the MA risk adjustment model.

Major Expansions, Rich Benefits Will Drive Competitive AEP

As the 2022 Annual Election Period (AEP) approaches, CMS expects the Medicare Advantage program to continue its upward trajectory, with enrollment climbing 10% to an estimated 29.5 million people next year while ave...

MCOs Seek Individual-Level Data to Pinpoint Disparities

Improving access to health care for underserved populations and eliminating health inequities were running themes throughout the AHIP 2021 National Conference on Medicare, Medicaid & Dual Eligibles, which was he...

States Increase MCO Demands Around Health Equity, SDOH

Given that states typically contract with just a handful of managed care organizations to serve their Medicaid enrollees, Medicaid managed care by nature has always been a competitive space. But with procurements pi...

COVID Deepened Racial, Ethnic Disparities in Medicare Mortality Rates

After years of relative stability, the COVID-19 pandemic caused mortality rates to spike in 2020, with non-white populations experiencing far greater disparities. That’s according to a September analysis of CMS da...

OIG: Chart Reviews Fueled ‘Disproportionate’ MA Pay

The HHS Office of Inspector General in prior reports has raised concerns about Medicare Advantage organizations’ heavy reliance on chart reviews and health risk assessments (HRAs) to achieve higher risk adjusted p...

News Briefs

✦ The fate of expanded Medicare benefits, drug pricing provisions and other health care measures included in Senate Democrats’ $3.5 trillion budget reconciliation package hung in the balance this week, as Pres...