RADAR on Medicare Advantage

Florida Blue, Prime Post Encouraging Results of Opioid Intervention Pilot

After the Centers for Disease Control and Prevention reported alarming increases in the number of opioid-related deaths in the U.S., HHS in 2017 declared the opioid crisis a public health emergency. Insurers across the country have responded with initiatives to address opioid overuse and misuse among their member populations, including Medicare Advantage enrollees. And CMS has deployed numerous strategies to ensure the appropriate use of pain treatments among Medicare, Medicaid and CHIP beneficiaries, including requiring that all Medicare Part D sponsors adopt drug management programs by 2022. Yet opioid overuse continues to be a concern for MA and Part D organizations.

Could MA-Focused Request for Information Foreshadow Wholesale Changes to the Program?

Signaling what some say is an unusual move, CMS late last month released a request for information (RFI) in which it encouraged a variety of stakeholders to submit responses to questions related to nearly every aspect of the Medicare Advantage program, from supplemental benefits and social determinants of health (SDOH) to risk adjustment and other payment-related policies. And while that could mean CMS is looking to change multiple aspects of the program, industry experts say the agency is asking the right questions, and they are encouraged that it signals a willingness to understand the potential impact of program changes on MA organizations.

Although previous administrations have issued more general RFIs on Medicare and the Biden administration in February released an RFI specific to Medicaid and CHIP coverage and access, Avalere Senior Consultant Tom Kornfield says he can’t recall seeing one that was so explicitly focused on MA. When asked whether he thinks the request was prompted by a recent hearing on Capitol Hill regarding MA oversight and beneficiary access, Kornfield suggests it’s more likely that CMS is seeking information as it works on a proposed MA and Part D rule that would come out in the fall and contain policies for plan year 2024. “They could be using this opportunity to collect information that could then help them determine what types of policies to put into that proposed rule,” he tells AIS Health, a division of MMIT. And the RFI could generate a lot of feedback, he says.

CMS Takes Next Steps Toward Phasing Out D-SNP Look-alikes

In a new enrollment transition memo issued to Medicare Advantage organizations with a significant number of dual eligible enrollees in products that are not Dual Eligible Special Needs Plans, CMS appears to be pushing so-called D-SNP look-alike plans to the brink of extinction. But the two-year transition process, which will wrap up for the 2023 plan year, still allows traditional MA plans to enrollee a limited number of duals. And one trade organization suggests more could be done to incentivize MAOs to set up D-SNPs.

CMS in 2019 first began cracking down on D-SNP look-alikes — MA plans that are marketed to duals but are not D-SNPs or integrated products — when it released draft revisions to the Medicare Communications and Marketing Guidelines that stated look-alikes cannot imply that the plan is for dual eligibles, cannot claim or infer that they have a relationship with the state, and cannot exclusively market to duals. A year prior, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress had argued that more needed to be done to promote the development of integrated plans and raised the issue of D-SNP look-alikes. At the time, approximately 2.7 million dual eligibles were enrolled in one of four types of managed care plans available to them, yet only 8% of full-benefit duals were in a plan with a high level of Medicare and Medicaid integration. More than 4.1 million individuals are now enrolled in a SNP, of which nearly 3.7 million are in a D-SNP.

News Briefs: House Committee Advances Bill Requiring Electronic Prior Authorization in MA

CMS at press time unveiled substantive changes to its Medicare Parts C and D enrollee grievances, organization/coverage determinations and appeals guidance. Effective immediately, the Aug. 3 memo from the Medicare Enrollment and Appeals Group contained numerous redlined edits to the guidance for Medicare Advantage organizations, Prescription Drug Plans, Cost plans, Medicare-Medicaid Plans and Programs of All-Inclusive Care for the Elderly. These included guidance on ensuring that enrollees with limited English proficiency have the same level of access to plan representatives and information regarding initial determinations, appeals, and grievances as those who are proficient in English; new specifications regarding plan delivery of notifications; detailed procedures when an initial determination request is withdrawn; and a clarification that a non-contracted provider who has furnished a service to an enrollee may request that an organization determination be reconsidered by the plan.

Seniors’ Unmet Social Needs Drive Greater Acute Care Utilization

Health-related social needs (HRSNs) can increase acute care utilization among Medicare Advantage members — including avoidable hospital stays and emergency department (ED) visits — asserts a July 8 investigation published in the Journal of the American Medical Association’s Health Forum. Researchers studied a group of about 56,000 older adults enrolled in MA plans offered by Humana Inc., and found that HRSNs, such as housing, utility and food insecurity, limited access to transportation, and financial difficulties, were associated with significantly higher acute care usage. Notably, 13.6% of the selected population were Medicare-Medicaid dual eligibles, a particularly vulnerable cohort.

Humana, Elevance Realign Business Segments, Anticipate Strong 2023 AEP

After seeing improved medical cost trends and, in some cases, lower administrative costs, select insurers serving the Medicare Advantage space recently lifted their earnings projections for the full year. Conference calls to discuss second-quarter 2022 earnings were full of questions about pricing and changes related to their MA products as the 2023 Annual Election Period (AEP) approaches, but executives were more focused on touting efforts to serve members holistically, including through rebranding strategies as companies attempt to align their various business segments.

CMS-Sponsored Report Shows Medicare Advantage Members Encounter Significant Racial Disparities

Medicare Advantage members can experience markedly different outcomes in measures related to prescription drugs based on race and/or ethnicity that ultimately impact their overall quality of care, according to the CMS Office of Minority Health’s latest report on health disparities in MA. The report, “Disparities in Health Care in Medicare Advantage by Race, Ethnicity, and Sex,” was funded by CMS and conducted by RAND Health Care’s Quality Measurement and Improvement Program. The report authors studied both the 2021 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and the 2021 Healthcare Effectiveness Data and Information Set (HEDIS), highlighting disparities in several clinical areas. In addition to the prescription drug measures illustrated in the graphics below, the report also covered other clinical care measures such as cancer screening rates and patient experience measures including the ease of getting medical appointments and customer service experiences.

News Briefs: MCS Advantage Will Pay $4.2M to Settle Kickback Allegations Involving Gift Cards

Medicare Advantage plan operator MCS Advantage, Inc. agreed to pay $4.2 million to resolve False Claims Act allegations that it violated the federal Anti-Kickback Statute (AKS) by offering kickbacks to health care professionals in the form of gift cards. According to the July 1 press release from the U.S. Dept. of Justice, MCS allegedly implemented a gift card incentive program between November 2019 and December 2020, when it distributed 1,703 gift cards to administrative assistants of providers in the aggregate amount of $42,575 to induce them to refer, recommend or arrange for enrollment of 1,646 new Medicare beneficiaries into an MCS plan. The Puerto Rico insurer did not admit liability as part of the settlement agreement. The company voluntarily closed the gift card program in December 2020, which the DOJ and HHS Office of Inspector General took into consideration, according to the press release. “The Settlement highlights the breadth of the AKS, as well as the flexibility that enforcement authorities have in utilizing the AKS as a vehicle to deter behavior deemed to be problematic” and suggest that remuneration to induce referrals of beneficiaries to specific federal health care program plans, along with to specific item or service, may be within the confines of the AKS, the law firm Holland & Knight suggested in a July 11 blog post.

As Audit Season Picks Up, CMS Is Scrutinizing Rx Access Issues

As Medicare Advantage plans and their providers operate under a new normal two-and-a-half years into the COVID-19 public health emergency (PHE), CMS is resuming its regular pace of auditing MA organizations as another program audit cycle gets underway, according to compliance experts. During a June 21 session of AHIP 2022, held in Las Vegas, panelists observed that CMS continues to be focused on ensuring seniors’ smooth access to prescription drugs and emphasized the importance of audit readiness.

CMS’s audit activity was limited during the previous cycle, especially in 2020, and its latest audit report reflected that. Released in June, the 2021 Part C and Part D Program Audit and Enforcement Report said CMS imposed 16 civil monetary penalties amounting to roughly $1 million and, between 2019 and 2021, it audited about 20% of currently active sponsors representing approximately 89% of Parts C and D enrollment — which is lower than CMS’s typical goal of 95%.

New CMS Bulletin Could Mean Greater Oversight of Medicaid Network Adequacy

CMS in a recent bulletin unveiled a “suite of new resources” aimed at guiding states and CMS in their oversight of Medicaid and CHIP programs, including managed care programs. Two items of particular interest to managed care organizations in a July 6 Center for Medicaid and CHIP Services Informational Bulletin (CIB) are templates that provide a standard format for states to report managed care medical loss ratios and network adequacy to determine how well a plan actually delivers its benefits. As plans struggle to meet network adequacy standards, the new template could lead to more intense oversight of network adequacy within managed care, industry experts suggest.