Radar on Medicare Advantage

Centene Will Join Delaware in Value-Based, Person-Centered Medicaid Revamp

With a focus on value-based care, health equity and social determinants of health, Delaware this month selected three managed care organizations to serve some 280,000 Medicaid and CHIP recipients through the statewide Diamond State Health Plan and DSHP Plus managed care programs. Incumbents AmeriHealth Caritas and Highmark Health Options Blue Cross Blue Shield were both selected for the new pacts, while Centene Corp.’s Delaware First Health will round out the trio of plans, the state’s Dept. of Health and Social Services (DHSS) said on July 12.

Delaware’s Medicaid managed care program, comprised of DSHP and DSHP Plus, is currently operating under the authority of a Section 1115 demonstration waiver that was most recently extended through Dec. 31, 2023. It provides integrated physical health, behavioral health and long-term services and supports (LTSS) to eligible Medicaid and CHIP enrollees.

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IEHP, Mom’s Meals Hope to Replicate Successful CHF Pilot With Other Populations

Using a “tapered” meal delivery approach supported by plan-appointed navigators, Mom’s Meals and Inland Empire Health Plan (IEHP) last year cut both emergency room visits and hospitalizations in half for patients with congestive heart failure who participated in a six-month pilot. The program resulted in significant medical cost savings and positive outcomes for patients, boding well for future applications in the IEHP population and in California’s recently launched CalAIM Community Supports program.

Patients with congestive heart failure (CHF) tend to have significantly high rates of recurring emergency department visits and hospitalizations, and upon discharge, many lack social supports to pursue the dietary and lifestyle changes that are needed to improve chronic care, according to Mom’s Meals, which provides fully prepared, refrigerated meals across the U.S. and serves the Medicaid, Medicare and individual markets. Since one of the key components of heart failure treatment is reducing sodium in the diet, Mom’s Meals provided lower-sodium (i.e., 600 mg less of sodium) fully prepared meals to members throughout the six-month pilot.

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On SCOTUS Refusal to Review UHC Case, MAOs Must Tighten Chart Review and Coding Practices

Amid mounting attention to Medicare Advantage organizations’ risk adjustment and prior authorization practices — which were the subjects of intense discussion during a recent House Energy & Commerce Committee hearing — the U.S. Supreme Court last month declined to take up a case brought by UnitedHealthcare (UHC) challenging CMS’s 2014 Overpayment Rule. Industry experts tell AIS Health, a division of MMIT, that this decision means CMS can begin enforcing its rule and may soon finalize its long-awaited extrapolation methodology for conducting Risk Adjustment Data Validation (RADV) audits.

“I think given the makeup of the court, on the one hand it was a bit surprising that they declined to take the case and that the denial of cert was issued without a comment. But on the other hand, given the general political landscape and issues that the court is considering, this is fundamentally an issue of administrative law and they’ve considered some other administrative law cases this term and I can understand why they decided not to take this case,” remarks Lindsey Brown Fetzer, member with Bass Berry & Sims and chair of the firm’s managed care practice.

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News Briefs: CMS’s Enhanced MTM Model Still Isn’t Showing Savings to the Medicare Parts A and B Programs

After four years, the Enhanced Medication Therapy Management (MTM) Model still has not generated any net savings to the Medicare program. Through the five-year model that started in January 2017, model participants tested a variety of interventions to improve Part D beneficiaries’ medication use. Despite efforts by some sponsors to alter their interventions, there continued to be no statistically significant impacts on Medicare Parts A and B expenditures for the overall enrollee population in model-participating plans, observed the Fourth Evaluation Report released by the CMS Innovation Center last month. Findings from subgroup analyses suggested that enrollees eligible for the low-income subsidy and enrollees with medically complex profiles did not benefit more from the model compared to the overall enrollee population, while the program saw decreases in inpatient expenditures and admissions related to the Ambulatory Care Sensitive Conditions for both the medically complex subgroup and the all-enrollee cohort, according to the report prepared by Acumen.

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As PBMs Are Under Microscope, New Suit Accuses CVS of Generics-Blocking Scheme

At a time when the federal government is clamping down on pharmacy benefit managers and seeking ways to lower prescription drug prices, a recently unsealed whistleblower complaint details how one of the three largest PBMs allegedly drove up costs for Medicare Part D beneficiaries and the federal government. In a lawsuit that CVS Health Corp. intends to fight, the False Claims Act complaint accuses the parent company of colluding with its “supposedly firewalled” entities — the SilverScript Part D subsidiary, PBM CVS Caremark and CVS pharmacies — of striking secret rebate agreements with the drug makers that required SilverScript to block substitution on its formularies of generic drugs in favor of costlier brand-name alternatives.

The U.S. Dept. of Justice chose not to intervene in the second amended complaint, which was filed in the U.S. District Court for the Eastern District of Pennsylvania in March and recently obtained by Stat. The suit was filed by relator Alexandra Miller, who worked for CVS Health for 19 years. According to Miller’s LinkedIn profile, she most recently served as senior director of Medicare Part D operations and is now senior director of member and provider experiences for Oscar Health.

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Watchdog Agencies Put CMS in Hot Seat, Stress Ways to Improve MA During Hearing

During a recent hearing held by the House Energy and Commerce (E&C) Committee’s Subcommittee on Oversight and Investigations, lawmakers heard testimony from three federal watchdog agencies on ways CMS can achieve efficiencies in the Medicare Advantage program and improve oversight of MA organizations. But while CMS’s actions were the subject of intense discussion, the agency itself wasn’t present — a point that several lawmakers felt worth repeating, even though CMS claims it was not properly invited.

E&C Chairman Frank Pallone, Jr. (D-N.J.) on June 28 convened the hearing, “Protecting America’s Seniors: Oversight of Private Sector Medicare Advantage Plans,” to “examine the quality of care that America’s seniors are receiving through Medicare Advantage plans and the fiscal sustainability of the Medicare Advantage program,” according to a June 24 memorandum issued to the subcommittee.

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Medicare Advantage Organizations Chase ‘Signature Trend’ of Offering Extra Benefits for 2023

Judicious enhancements to supplemental benefits was the common theme as Medicare Advantage organizations prepared their bids for 2023, according to actuaries who recently helped sponsors submit bids that were due on June 6. The benefit changes come as plans considered potential bonus payment losses in 2024 and other possible drivers of increased costs next year.

“The signature trend of this year was carrying forward a lot of the innovative benefits that we’ve seen take hold over the past few years,” remarks Tim Murray, principal with Wakely, an HMA company. These include “wallet” benefits such as over-the-counter card allowances and flexible “choose your own adventure” benefits often involving healthy food and/or groceries, he observes.

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News Briefs: Centene Settles New Mexico Medicaid Pharmacy Investigation for $13.7 Million

In the latest settlement with a state Medicaid program over its pharmacy benefit practices, Centene Corp. has agreed to pay $13.7 million to the state of New Mexico. Upon referral from the Office of the State Auditor in collaboration with the New Mexico Health Services Dept. — which oversees the Centennial Care Medicaid program — Attorney General Hector Balderas (D) conducted an investigation focused on “concerns that Centene was layering fees and not passing on retail discounts” to the program, according to a June 13 press release from the AG’s office. Centene has spent millions to settle claims by state Medicaid programs that it overcharged them for prescription drugs and is in the process of restructuring its pharmacy benefit management platform.

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Trustees Report Underscores Need for Wholesale Medicare Reform

While the headline takeaway from the latest Medicare Trustees report was that the Hospital Insurance (HI) trust fund will be exhausted two years later than previously projected, industry experts suggest that the report should light a fire under Congress to take swift legislative action to sustain Medicare financing. During a recent webinar hosted by the Bipartisan Policy Center, a panel of seasoned policy experts agreed that the report underscored the need for comprehensive structural reform to the Medicare program, including potential changes to the way Medicare Advantage plans are paid.

Published on June 2, the Medicare Board of Trustees’ annual report provides previous and projected costs for the Medicare program’s two separate trust funds: the Hospital Insurance trust fund (HI), which helps pay for inpatient hospital and other services covered by Medicare Part A; and the Supplemental Medicare Insurance trust fund (SMI), which helps pay for physician, outpatient hospital, home health and other services covered by Parts B and D.

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MedPAC Mulls Method of Reducing High-Cost Outlier Impact on Risk Scores

After its last two reports suggested comprehensive reforms to Medicare Advantage plan reimbursement, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress shifted its MA focus to one area in particular: the potential for high-cost patient outlier data to skew the calculation of risk scores that determine MA plans’ risk-adjusted pay.

Although the Hierarchical Condition Category (HCC) risk adjustment model is intended to produce scores that reflect the relative health status of a plan’s enrollees, fee-for-service (FFS) Medicare spending data that is used to calculate risk scores can include a small group of outliers whose annual costs are much higher than the average costs of patients with a given condition, explained MedPAC Executive Director Jim Mathews during a June 15 web briefing with members of the press.

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