Radar on Medicare Advantage

News Briefs: SCAN Wins Lawsuit Over 2024 Star Ratings Calculations

SCAN Health Plan won a legal challenge to CMS’s calculation of the 2024 Star Ratings that could have major implications for quality bonus payment (QBP) outlays and 2025 cut point generation. According to a June 3 memorandum opinion filed in the U.S. District Court for the District of Columbia, Judge Carl Nichols agreed with the not-for-profit Medicare Advantage insurer that CMS “failed to follow its own regulation,” which resulted in SCAN receiving an incorrect Star Rating. In a lawsuit filed against HHS in December, SCAN argued that CMS was “arbitrary and capricious” when it applied new guardrails (i.e., restricting the movement of cut points by no more than 5% in either direction) to hypothetical cut points for the previous year rather than actual cut points, yet did not amend its regulations to reflect that decision. Nichols agreed that the “best and most natural reading” of CMS’s so-called Guardrail Rule was that it referred to actual cut points in both the initial year and the following year, and he granted the plaintiff’s motion for summary judgment. SCAN, which serves roughly 277,000 MA enrollees in five states, had a 4.5 Star Rating for six consecutive years until 2024, when it received a 3.5 Star Rating, costing it nearly $250 million in lost quality bonus payments. Elevance Health, Inc. in December filed a similar lawsuit; the insurer in March disclosed that CMS “updated” its original ratings, which will lead to an additional $190 million in revenue for plan year 2025. MA insurers Hometown Health Plan and Zing Health also have similar suits pending, reported Modern Healthcare.

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2025 MA Bid Cycle Was ‘Wild Ride’ That Could Lead to Market Exits, Actuaries Say

Compounded by known challenges in estimating Medicare Part D costs stemming from the Inflation Reduction Act (IRA), the process of finalizing Medicare Advantage insurers’ bids for the 2025 plan year was an “extra wild ride” due to a variety of unknowns, according to Matt Kranovich, principal and consulting actuary with Milliman. And while national insurers in recent months have publicly disclosed their intent to skinny down their MA offerings through things like benefit adjustments and strategic exits, similar reactions to revenue headwinds may play out across the country and lead to more market consolidation than CMS would care to see, warns Tim Murray, principal with Wakely, an HMA company.

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Fast-Growing NY Insurer Credits MA Benefit Stability, Behavioral Health Focus

CDPHP, a not-for-profit managed care organization serving Medicare Advantage members primarily in Upstate New York and the Hudson Valley, is one of several provider-led insurers that carried a strong growth trajectory from the Medicare Annual Election Period (AEP) through the Open Enrollment Period (OEP) in the first quarter of 2024, according to a recent AIS Health analysis.

The Albany-based insurer added more than 5,000 MA members during the AEP and another 5,400 between February and May, for overall growth of 20% since October, per AIS’s Directory of Health Plans. According to CDPHP’s senior vice president and chief growth officer, Nicholas Kraft, the plan nabbed 66% of new enrollment in its market and is now the third-fastest growing MA plan in the U.S. CDPHP was also ranked No. 1 in member satisfaction among commercial insurers in New York State by J.D. Power & Co.

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More States Offer Health Benefits to Retirees Exclusively Through MA Plans

As of this year, a dozen states provide health coverage to their Medicare-eligible retirees only through Medicare Advantage plans, according to a recent KFF review.

Employer-sponsored health care coverage for retirees was generally designed to coordinate with or wrap around traditional Medicare. Yet over the past few years, many states have shifted to contracts with private insurers to provide all Medicare-covered benefits and extra benefits for their retirees. These moves may help states reduce spending on retiree health costs and simplify administration.

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Amount of Medicaid Funds Flowing to MCOs Is Poised to Rise, KFF Predicts

Taking a look at the overall state of Medicaid managed care, KFF earlier this month compiled data from prior years of its surveys and analyses to identify notable trends. About 75% of all Medicaid beneficiaries are enrolled in risk-based managed care — with that percentage set to grow as Oklahoma transitions away from fee-for-service (FFS) Medicaid — and most states spend at least 40% of total Medicaid dollars on payments to MCOs. KFF noted that spending could increase as states shift higher-cost, higher-need beneficiaries, such as disabled individuals and adults aged 65 and older, into managed care. Moreover, most states (32 states including Washington, D.C.) with managed care carve in their pharmacy benefits to MCO contracts, observed KFF.

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News Briefs: KFF Poll Finds Voter Awareness of IRA Drug Pricing Is Low but Improving

Most U.S. voters are unaware of the Medicare drug pricing provisions resulting from the Inflation Reduction Act, although awareness among older voters has improved since November. That’s according to a new KFF poll tracking voters’ perceptions of major health and entitlement programs and how they align with presidential candidates’ views. Of voters aged 65 and older, nearly half (48%) indicated awareness of drug price negotiation — compared with 36% in November — and 40% knew about the annual limit on Part D out-of-pocket prescription drug costs, up from 27% in November. Meanwhile, large shares of voters indicated support for extending some of the prescription drug provisions to all adults with private insurance, which President Joe Biden has proposed, reported KFF.

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Not in Kansas Anymore: Aetna Gets Left Out of Medicaid Awards

Ousting CVS Health Corp.’s Aetna from the current roster of Medicaid managed care organizations serving the Kansas Medicaid program, Elevance Health, Inc.’s Healthy Blue was chosen as the third insurer for new KanCare contracts starting Jan. 1, 2025. Incumbents Sunflower Health Plan (Centene Corp.) and UnitedHealthcare Community Plan held onto their spots. The awards mark the latest in a string of wins for Centene and Elevance and another disappointment for Aetna.

According to results posted by the Kansas Dept. of Health and Environment on May 14, seven MCOs responded to the request for proposals (RFP) process that began in October 2023 after a delay. Serving nearly 154,000 enrollees, UnitedHealthcare currently has the biggest share of the Kansas Medicaid market, per AIS’s Directory of Health Plans. Aetna, meanwhile, serves nearly 133,000, or about 31% of KanCare enrollees.

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CMS Minority Health Report Suggests Similar Patient Experiences, Varied Outcomes

As CMS continues efforts to advance health equity, the agency on May 2 released its annual report on disparities in the Medicare Advantage program based on race, ethnicity and sex. Racial and ethnic minorities are consistently more likely to enroll in Medicare Advantage versus the traditional, fee-for-service Medicare program. The 2024 report, released by the CMS Office of Minority Health in partnership with The RAND Corp., examined patient experience measures based on responses to the 2023 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, as well as clinical care measures based on the Healthcare Effectiveness Data and Information Set (HEDIS) that is collected from administrative data and patients’ medical records, reflecting care received in 2022.

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M3P Stakeholders Warn of Potential Beneficiary Confusion, Star Ratings Impact

As Medicare Part D sponsors consider critical steps to setting up the new Medicare Prescription Payment Plan (M3P), CMS is weighing feedback from stakeholders on various aspects of the program, from beneficiary communications to pharmacy interactions. And some warned that potential beneficiary confusion may lead to increased complaints that impact plans’ Star Ratings.

The M3P, which takes effect on Jan. 1, 2025, requires both stand-alone Prescription Drug Plan and Medicare Advantage Prescription Drug carriers to give beneficiaries the option to spread their pharmacy costs over the plan year via a capped monthly payment. CMS in February issued its second draft guidance on the M3P and asked for comments no later than March 16. CMS plans to release the final guidance this summer. The agency sought comment on model materials issued through an Information Collection Request (ICR), including a standardized notice that plans would be required to use for targeted outreach to enrollees who are likely to benefit from the M3P. The initial 60-day comment period on the model materials ended April 29; CMS said it expects to issue a second, 30-day comment period in Spring 2024.

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SCAN CEO Challenges Industry to Take Stock of Mission-Driven Work

In recent years, publicly traded managed care organizations have jumped on a growing corporate trend of publishing annual environmental, social and governance (ESG) reports designed to spotlight the larger impact their company is having on society. Alignment Healthcare Inc., for one, in 2022 released its inaugural ESG report highlighting efforts from the previous year that focused on delivering high-quality care at a lower cost compared to fee-for-service Medicare and addressing social determinants of health (SDOH). In 2023, The Cigna Group’s 98-page ESG report categorized similar efforts into four “pillars” — healthy society, healthy workforce, healthy company and healthy environment — and included efforts to reduce greenhouse gas emissions in the latter category.

In a 2022 podcast hosted by law firm K&L Gates LLP, speakers suggested that the health care industry by nature is “mission-driven…focused on the improvement of the human condition” and “is particularly well suited to address ESG issues.” And insurers’ efforts in recent years to address health inequities mirror the increased focus from the Biden administration and CMS on tying health equity to reimbursement, such as the CMS Innovation Center incorporating health equity into models that drive value-based care.

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