Radar on Medicare Advantage

Latest Audit Report Highlights Enforcement Activity Outside Program Audits

In CMS’s latest audit report, the agency confirms what an earlier AIS Health analysis of compliance notices indicated: the agency imposed approximately $1 million in civil money penalties (CMPs) based on 2021 referrals, and nearly half of that stemmed from one-third financial audit findings. CMS, meanwhile, cautioned the industry not to read too much into the latest audit results as they relate to 2020, when CMS audited a relatively small number of plans due to the COVID-19 public health emergency (PHE).

In the 2021 Part C and Part D Program Audit and Enforcement Report, published on June 7, CMS said it imposed 16 CMPs amounting to $1,043,953, or an average of $65,247 per CMP. Sponsors audited in 2021 covered 26% of enrollment.

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Expanded Footprints, Enhanced Benefits Aided Plans’ OEP Gains

Medicare Advantage enrollment reached nearly 28.8 million as of May, reflecting an overall increase of about 1% during the three-month Open Enrollment Period (OEP) that ended on March 31, according to the latest update to AIS’s Directory of Health Plans (DHP). That’s compared with growth of 5.3% from October 2021 to February, reflecting results from the Annual Election Period (AEP) that ran from Oct. 15 through Dec. 7. Beneficiaries who enrolled in an MA plan during the AEP have a one-time opportunity to change their coverage selection during the OEP, and insurers that made above-average membership gains during both periods attributed their successes to product enhancements, geographic expansions and strong distribution partnerships.

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UnitedHealth Dominates While Startups Make Gains in 2022 Medicare Open Enrollment Period

Medicare Advantage enrollment grew by about 232,000 lives during the 2022 Open Enrollment Period (OEP), according to CMS’s May data release and AIS’s Directory of Health Plans. As in the Annual Election Period (AEP), UnitedHealthcare dominated, holding 45.1% of the overall OEP gains, followed by CVS Health Corp.’s Aetna at 16.9% and Centene Corp at 13.5%. Among other large, publicly traded insurers, Cigna Corp. and Humana Inc. both flopped in the OEP, losing 12,600 and 4,200 members, respectively. Meanwhile, insurance startups Bright Health and Clover Health both made the top 20 despite recent financial challenges and questioned viability. See the top 25 OEP performers, plus their AEP results and current enrollment, in the chart below.

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State Medicaid Agencies Grapple With Moving PHE End Date

With the COVID-19 public health emergency presumably continuing into October, state Medicaid agencies and their partners theoretically have more time to communicate with enrollees and prepare for the inevitable resumption of eligibility redeterminations once the PHE ends. But ongoing uncertainty over the PHE’s end date presents a host of challenges for states as they handle unprecedented numbers of Medicaid enrollees and attempt to conduct other program work unrelated to redeterminations, according to officials from California, Iowa and North Carolina who spoke during a May 24 webinar hosted by the National Association of Medicaid Directors (NAMD).

Throughout the PHE, which was declared in January 2020 and first renewed that April, states have received a temporary 6.2 percentage-point increase in their Federal Medical Assistance Percentage (FMAP) in exchange for maintaining continuous enrollment of nearly all Medicaid recipients. Once the PHE ends, states have 12 months to initiate eligibility reverifications for everyone enrolled in Medicaid and CHIP and 14 months overall to complete redetermination efforts.

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Plan Finder Update Leaves Out Detail on Supplemental Benefits

As CMS continues to seek ways to improve its consumer-facing tools for comparing Medicare coverage options, the agency last month unveiled a series of tweaks to the Medicare.gov website and Medicare Plan Finder (MPF). The MPF in 2019 underwent a major makeover that reportedly cost the Trump administration $11 million but critics say fell short of fixing many of the issues highlighted in a July 2019 report from the Government Accountability Office. CMS has continued to make updates based on consumer feedback, but some industry experts suggest more detail around the supplemental benefits offered by Medicare Advantage plans would be useful.

“CMS is making Medicare.gov easier to use and more helpful for people seeking to understand their Medicare coverage, which is an essential part of staying healthy,” said CMS Administrator Chiquita Brooks-LaSure in a May 18 press release. “We are committed to listening to the people we serve as we design and deliver new, personalized online resources and expanded customer support options for people with Medicare coverage and those who support them.”

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Clover Health Hires New CFO as Firm Aims to Improve Efficiencies, Lower Costs

Medicare Advantage-focused startup Clover Health, which continues to expand its footprint and gain enrollees despite questions about its profitability, will soon have a new chief financial officer. According to a May 25 press release, Scott Leffler will join Clover in August after serving as CFO and treasurer of Sotera Health, where he oversaw the company’s global finance, procurement and IT organizations.

Leffler’s hiring follows several key additions to the company’s management team this year. During the first quarter, Clover Health appointed Conrad Wai as chief technology officer and Joseph Martin as general counsel. And in May, the company hired Aric Sharp as CEO of value-based care. The news of Leffler’s appointment comes after Clover Health spent more than 10 months seeking a replacement for Joe Wagner, who left the company in August 2021 for personal reasons.

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News Briefs: Aetna Wins Group Medicare Advantage Contract to Connecticut State Retirees

CVS Health Corp.’s Aetna won a new group Medicare Advantage contract to serve retirees covered by Connecticut’s state health plan. Connecticut Comptroller Natalie Braswell on June 1 said the state selected Aetna after a competitive bidding process and that the new contract will save an estimated $400 million over the next three years. Beginning Jan. 1, 2023, Aetna will serve some 57,000 Medicare-eligible retirees and dependents enrolled in the state’s MA plan. Connecticut first adopted an MA plan for retirees in 2018.

After CMS imposed a historic increase to Medicare Part B premiums partly due to cost considerations around Alzheimer’s disease treatment Aduhelm, the agency on May 27 said it will not make a midyear change but will likely lower the Part B premium in 2023. Upon raising the standard monthly premium by $21.60 to $170.10 for 2022, the agency in November said it considered “[a]dditional contingency reserves due to the uncertainty regarding the potential use” of Aduhelm, which was approved in July 2021 and priced at $56,000 per year. After Aduhelm makers Biogen and Eisai, Co., Ltd., cut that price in half starting Jan. 1, HHS Secretary Xavier Becerra instructed CMS to reassess the Part B premium. Meanwhile, the FDA issued a National Coverage Determination stating that Medicare will cover Aduhelm only for patients enrolled in randomized, controlled clinical trials conducted either through the FDA or the National Institutes of Health. CMS recommended incorporating the savings realized from this year’s lower-than-anticipated spending into the 2023 Part B premium determination.

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PHE Unwinding Delay Gives States, MCOs Time to Ease Transitions

With radio silence from HHS on May 16 — when states at the very latest had expected to hear whether the COVID-19 public health emergency would end in July — HHS at press time appeared to be gearing up for another extension of the PHE. This will give states, insurers and other stakeholders more time to prepare for the inevitable resumption of Medicaid eligibility redeterminations, which could cause millions of adults and children to lose health insurance coverage.

The PHE has been extended multiple times since the start of the pandemic and remains a moving target. As a condition of receiving enhanced federal funds during the PHE, states have been required to ensure continuous Medicaid and CHIP coverage for most enrollees by pausing eligibility redeterminations. And the Biden administration has promised to provide states 60 days’ notice before any possible termination or expiration. But without such notification, sources estimate the next end date could be Oct. 13. Bloomberg on May 16 reported that the PHE would be extended past mid-July, “according to a person familiar with the matter.”

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Medicaid Rolls Soar to Nearly 89 Million Beneficiaries as Redeterminations Loom

Nationwide Medicaid enrollment has grown more than 22% since the outset of the COVID-19 pandemic, topping 88.7 million lives, according to the latest update to AIS’s Directory of Health Plans. But the end of the Public Health Emergency (PHE) — which at press time was likely to be extended beyond mid-July — could leave between 5.3 million and 14.2 million people without coverage when redeterminations resume, asserted a May 10 analysis from the Kaiser Family Foundation. A separate study from the Georgetown University Heath Policy Institute found that 6.7 million children stand to lose CHIP coverage at the end of the PHE. See a state-by-state overview of three years of pandemic-fueled Medicaid enrollment changes in the chart below.

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Segmented, Personalized Outreach Drives MAO Retention Efforts

Medicare consumers are facing an overwhelming variety of resources and plan choices and are showing signs of increased movement during the Open Enrollment Period (OEP). As a result, effective member engagement during the OEP and throughout the year is becoming increasingly important and can be achieved through using data to segment membership and deliver targeted, personalized messaging to ensure that a member is in the right plan from the start, industry experts advised during the 13th Annual Medicare Market Innovations Forum, hosted by Strategic Solutions Network, LLC (SSN).

After the Medicare Annual Election Period (AEP) that typically runs from Oct. 15 through Dec. 7, the three-month Medicare OEP starts on Jan. 1 and allows beneficiaries who selected a Medicare Advantage plan to make a onetime coverage change. This year was the fourth OEP since it was reinstated by the Trump administration after a hiatus, and seniors’ utilization of the renewed opportunity is growing.

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