RADAR on Medicare Advantage

Mississippi Medicaid Plays Musical Chairs With MCOs, Trades UHC for CareSource Affiliate

Despite a challenge earlier this year to its longstanding pact with Mississippi Medicaid, Centene Corp. on Aug. 10 said its Magnolia Health Plan subsidiary was selected to continue serving the Mississippi Coordinated Access Network (MississippiCAN) and the Mississippi Children’s Health Insurance Program (CHIP). Meanwhile, the state’s Division of Medicaid (DOM) unveiled its intent to award new four-year contracts to two other insurers, including new entrant and CareSource affiliate TrueCare, which will bump leading managed care organization UnitedHealthcare out of the market.

Centene over the past year has reached multiple settlements with states regarding its handling of Medicaid pharmacy benefits. In June 2021, the health care giant agreed to pay $55.5 million to Mississippi after a 2019 investigation by the Office of the State Auditor concluded Centene’s pharmacy benefit manager was overbilling the state.

Teasing 2023 Expansions, Regional MA Insurers Eye Competitive Texas Market

As Medicare Advantage insurers gear up to compete for enrollment during the 2023 Annual Election Period (AEP) that begins on Oct. 15, a handful of companies have already unveiled service area expansions that are pending CMS approval. Several of them named new territories in Texas, where some 4 million Medicare beneficiaries reside.

According to AIS's Directory of Health Plans (DHP), more than half of Medicare beneficiaries in Texas are enrolled in an MA plan. UnitedHealthcare has the biggest market share in the state, with 48.9% of enrollees, followed by Humana Inc., with 16.8%. And UnitedHealthcare has reportedly purchased the seventh-largest Texas MA plan, KelseyCare Advantage, which is operated by KS Plan Administrators and affiliated with medical group Kelsey-Seybold.

News Briefs: Individual Medicare Advantage Enrollment Surpasses 24.7 million, Up 9% Year Over Year

Individual Medicare Advantage enrollment this month surpassed 24.7 million lives, reflecting 9.3% membership growth since last August, according to a Barclays analysis of CMS’s latest monthly enrollment report. The publicly traded MCOs saw year-over-year individual MA membership grow by 10.5%, with Centene Corp. and CVS Health Corp.’s Aetna delivering double-digit enrollment gains, according to the analysis. Cigna Corp., however, underperformed with a year-over-year membership decline of 5.5%, observed Barclays. CMS’s August data release reflects enrollments accepted through July 8.

Highmark Wholecare has partnered with Posit Science to incorporate “brain fitness” into a program aimed at reducing vulnerable members’ risk of falling and improving balance. Highmark Wholecare, formerly Gateway Health, will offer BrainHQ exercises and services to approximately 7,000 qualifying members who are dually eligible for Medicare and Medicaid and identified as a high risk for falls. BrainHQ’s evidence-based brain fitness program is available via web or mobile phone and is supported by more than 200 peer-reviewed studies, according to an Aug. 15 press release from the partners.

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.