Radar on Medicare Advantage

A newly formed retiree advocacy group called RISE Delaware has filed a lawsuit to stop the “unilateral implementation” of a private Medicare Advantage plan that will replace state retirees’ current health care coverage in Delaware. Highmark Blue Cross Blue Shield of Delaware in February was awarded a three-year contract to serve some 30,000 retired state employees and has reportedly made accommodations to address retirees’ concerns, but the plan’s opponents maintain that it was established by the State Employee Benefits Committee (SEBC) in a clandestine manner without proper input from stakeholders and without consideration for a suitable alternative proposed by a separate committee. And, like a lawsuit in New York City, the group is concerned about the extent to which beneficiary care will be subject to prior authorization under MA.

A New York District Court judge denied Anthem, Inc.’s request to transfer a False Claims Act lawsuit to another district and to strike allegations contained in an amended complaint. The suit in question was filed by the U.S. Attorney for the Southern District of New York in 2020 and alleges that while conducting chart reviews aimed at identifying additional diagnosis codes for obtaining risk adjusted payment through the Medicare Advantage program from 2014 to 2018, Anthem neglected “its duty to delete thousands of inaccurate diagnoses” and “often generated $100 million or more a year in additional revenue” as a result. According to an opinion filed by U.S. District Judge Andrew Carter on Sept. 30, the company now known as Elevance Health filed a motion to transfer this action to the Southern District of Ohio (or dismiss the suit altogether) and to strike portions of the complaint referencing the government’s settlements with other MA organizations or health care providers.

Medicare beneficiaries in nearly every state will have more Medicare Advantage plans to choose from and see lower premiums this fall when shopping for coverage, according to CMS’s recently released landscape files for the 2023 plan year. And both major insurers and regional plans at press time were touting new offerings such as Part B buyback plans, flexible spending features that include allowances for utilities, and enhanced dental coverage.

“What we’re seeing is kind of a continuation of what we’ve seen in the past several years, which is expanding of not only the big five but also of the smaller insurers as well, and then increased focus on supplemental benefits and the Special Supplemental Benefits for the Chronically Ill (SSBCI), and continued expansion into the D-SNP [Dual-Eligible Special Needs Plan] market,” observes Betsy Seals, co-founder and CEO of Rebellis Group, LLC.

There is limited evidence to suggest any major differences exist between Medicare Advantage and traditional, fee-for-service (FFS) Medicare when measuring beneficiary satisfaction, according to the Kaiser Family Foundation’s (KFF) recent literature review of 62 studies comparing the two programs. Nor did either program consistently stand out across quality measures. There were also few differences in length of hospital stays for common ailments or aggregate days spent in inpatient care between the two groups.

With a focus on Medicare Advantage beneficiaries, UnitedHealth Group and Walmart Inc. have struck a 10-year “wide-ranging collaboration” with value-based care elements that could ultimately extend into Medicaid and commercial plans. In addition to launching a co-branded MA plan, the partnership will connect Walmart Health clinicians with Optum’s analytics and decision support tools for value-based care delivery, and it represents the latest example of a major retailer seeking out a partner to grow its health care business.

Walmart already has a Medicare Part D partnership with Humana Inc. and in October 2020 introduced a co-branded MA offering with Clover Health. The Bentonville, Ark.-based retail giant at the time also launched an insurance brokerage called Walmart Insurance Services. According to walmartinsurance.com, it sells plans from Anthem (Elevance Health), Arkansas Blue Cross Blue Shield, Humana, UnitedHealthcare and Centene Corp.’s WellCare. The site does not, however, list Clover Health, and a spokesperson for Walmart confirms that the collaboration ended in 2021.

Bowing to CMS’s request after another public comment period, Tennessee is reluctantly pursuing a series of changes to the pending TennCare III demonstration that had been approved by the Trump administration for a start date of Jan. 8, 2021. In what one source says is an unusual back-and-forth on public display, the state will abandon its notorious plans to implement a closed Medicaid formulary and adopt a fixed funding mechanism.

Shortly before President Joe Biden took office, the Trump administration in January 2021 approved Tennessee’s request to use an “aggregate cap” for Medicaid funding that many industry observers had likened to a block grant. Through that approach, Tennessee would have received federal Medicaid funds based on a fixed budget target that is determined by CMS and the state using historical enrollment and costs data. If spending fell below that target cap but certain quality goals were met, the state would earn up to 55% of annual savings to reinvest back into other state health programs.

A new study published in JAMA Network Open raises questions about whether health systems can actually achieve significant savings through the Medicare Shared Savings Program (MSSP), or if Medicare Advantage could be a better bet. To identify spending patterns in MA and MSSP’s Accountable Care Organizations (ACOs), researchers studied the characteristics and claims data of about 16,000 Medicare patients at Ochsner Health System (OHS), a large, academic system in Louisiana, from 2014 to 2018. Ochsner joined MSSP in 2013, and its ACO hosts more than 2,200 providers. It also offers MA plans via a partnership with Humana Inc.

CMS’s Center for Medicare and Medicaid Innovation last year declared a goal of having all traditional Medicare enrollees in an accountable care arrangement by 2030. America’s Physician Groups (APG), which represents more than 300 physician groups that accept various degrees of risk with all payer types, including Medicare Advantage plans, wants CMS to apply that same goal to MA. In a recent comment letter on CMS’s request for information on the MA program, APG President and CEO Susan Dentzer urged the administration to incentivize the delegation of full risk to providers in MA.

After giving stakeholders a month to formulate their thoughts on how best to address a variety of aspects of the Medicare Advantage program, CMS received nearly 4,000 comments on its request for information (RFI). An AIS Health review of select letters reveals comments on a multitude of hot-button topics including beneficiary decision-making, marketing practices and plan oversight, and MA reimbursement.

CMS published the MA-focused RFI on Aug. 1 and asked for input by Aug. 31. The sprawling request asked commenters to consider dozens of questions on key topics such as health equity, risk adjustment, social determinants of health (SDOH), supplemental benefits and value-based care.

The number of Medicare Advantage marketing-related complaints submitted to CMS more than doubled between 2020 and 2021, according to a recent report from Axios. Referencing CMS data, the news outlet reported that CMS received approximately 39,600 complaints about the marketing of MA and Part D plans in 2021, compared with about 15,500 in 2020 and an average of 6,000 to 7,000 in prior years. Consumers complained about things like being enrolled without contact from a health plan and misleading information about provider networks. Senate Finance Committee Chair Ron Ryden (D-Ore.) last month wrote to 15 states asking for detailed information about such complaints, while CMS has taken steps to tighten oversight of third-party marketing organizations. “While actions to reign in marketing constructs could affect competitive dynamics within MA, we should continue to see robust growth in this end market in totality, with an emphasis on consumer choice, branding, and benefit constructs affecting the competitive landscape moving forward,” observed Citi Research analyst Jason Cassorla.