Radar on Medicare Advantage

From 2017 to 2023, the number of people enrolled in Special Needs Plans (SNPs) grew by more than 150% to about 6.3 million lives, according to the latest update to AIS’s Directory of Health Plans. Dual Eligible SNPs (D-SNPs) saw the most growth, a mammoth 170% increase to 5.6 million lives, followed by Institutional SNPS (I-SNPs) at 86% growth, then Chronic Condition SNPs (C-SNPs) at 58% growth.

Payers have grown to meet that surge, with the total number of SNP offerings expanding from 498 to 1,082 plans between 2017 and 2023, per an analysis of CMS’s Landscape files from Clear View Solutions, LLC. Clear View’s data shows that in a typical year, the number of new SNP offerings has exceeded the number of plans dropped.

Insurers are more carefully tailoring their preventive supplemental benefit offerings to support Medicare Advantage enrollees aging in place, with benefits such as home and bathroom safety modifications more than doubling between 2023 and 2024, according to a new Faegre Drinker analysis of Plan Benefit Package (PBP) data. But as CMS takes steps to gather more data on supplemental benefits, less impactful benefits could be thinned from the pack while those with greater potential to improve health outcomes are embraced by insurers.

Faegre Drinker has been tracking the growth of expanded supplemental benefits since 2020, when MA insurers were in the early days of experimenting with new offerings under CMS’s reinterpretation of “primarily health related” supplemental benefits and first began offering Special Supplemental Benefits for the Chronically Ill (SSBCI). The consulting firm's latest analysis, published on Dec. 5 and shared in advance with AIS Health, focuses on the preventive supplemental benefit market due to the large variance in uptake, with some benefits offered by fewer than 100 plans and others featured in more than 5,000 PBPs. This year, Faegre Drinker split the categories into two types: popular (i.e., offered by more than 1,000 plans) and less popular (i.e., those offered by fewer than 1,000 plans).

In a Nov. 15 rule proposing policy and technical changes for the 2025 Medicare Advantage and Part D plan year, CMS made numerous changes aimed at protecting beneficiaries from “predatory marketing” and ensuring they enroll in the MA plans that best meet their needs. And depending on how plans execute these new provisions, some have the potential to impact Star Ratings, industry experts observe. At the same time, the rule proposed several methodological enhancements, clarifications and operational updates to the 2025 Star Ratings.

For example, CMS provided an update on its plans to include the Universal Foundation of quality measures that would align across all CMS programs and to provide a “building block to which programs will add additional aligned or program-specific measures.” As part of this plan, CMS said it has submitted the Initiation and Engagement of Substance Use Disorder Treatment (IET) Part C measure to the Measures Application Partnership (MAP) for review as a measure under consideration. Additionally, CMS indicated that it will submit three other Universal Foundation measures — Adult Immunization Status, Depression Screening and Follow-Up, and Social Need Screening and Intervention, which are now reported as display measures — to MAP prior to proposing the use of those measures in future rulemaking.

In a proposed class action lawsuit filed in the U.S. District Court of Minnesota, UnitedHealth Group and its subsidiary, NaviHealth, are accused of using an artificial intelligence algorithm with a known error rate of 90% to systematically deny Medicare Advantage enrollees’ care. The lawsuit, filed by the estates of two deceased patients who were enrolled in a UnitedHealthcare MA plan and “on behalf of all others similarly situated,” alleges that the insurer continued to use its AI model to “wrongfully deny” and override physicians’ recommendations for post-acute care “because they know that only a tiny minority of policyholders (roughly 0.2%) will appeal claims, and the vast majority will either pay out-of-pocket costs or forgo the remainer of their prescribed post-acute care,” according to the complaint posted by STAT. The complaint follows and cites a STAT investigation of internal documents showing that NaviHealth employees were pressured to keep MA patients’ skilled nursing facility stays to targets developed by the nH Predict algorithm, or they would face disciplinary action. In a statement provided to STAT, UnitedHealth asserted that the NaviHealth tool is “used as a guide” but does not make coverage determinations.

Despite the program receiving continued pushback from progressive lawmakers, data from the since-renamed Global and Professional Direct Contracting (GPDC) Model suggests that it is making significant strides, with participants driving gross savings exceeding $870 million in 2022, more than seven times the $117 million in gross savings reported for performance year 2021. At least five known Medicare Advantage sponsors have subsidiaries participating in the model, which allows Accountable Care Organizations (ACOs) to share risk and receive capitated payments for serving fee-for-service (FFS) beneficiaries.

CMS, in a fact sheet highlighting the performance year 2022 data, observed that the total financial savings increased year over year because of “growth in model participation, a longer performance period in PY2022 (12 months vs. 9 months in PY2021), and performance improvements by model participants as they gained experience.” Last year, 99 Direct Contracting Entities participated in the model, up from 53 DCEs in 2021, with 21 million beneficiary months, compared with 3 million beneficiary months in 2021.

Continuing a theme of protecting consumers and ensuring appropriate use of Medicare dollars, the Biden administration on Nov. 6 released its annual rule proposing policy and technical changes for the Medicare Advantage and Part D program. The 2025 MA and Part D proposed rule contains provisions aimed at improving access to behavioral health, streamlining enrollment options for dual eligibles, encouraging biosimilar product substitution, and assessing the impact of prior authorization policies on health equity. But some of the rule’s most detailed proposals centered on two hot-button program areas: supplemental benefits in MA and misleading marketing practices.  

With more than 78% of Medicaid beneficiaries enrolled in managed care plans as of the latest update to AIS’s Directory of Health Plans (DHP), winning and maintaining state contracts is crucial to MCOs that serve the Medicaid population. Six states have pending requests for proposals (RFPs) that serve about 11 million lives combined, while four states recently awarded new contracts. 

In recent years, new Medicaid RFPs have emphasized population health, asking payers to focus on health equity and social determinants of health while integrating services such as behavioral health, managed long-term services and supports (MLTSS), and pharmacy services into acute care. For example, Georgia will shift its aged, blind and disabled Medicaid population from fee-for-service care delivery to managed care when its new contracts begin, and Virginia plans to combine its MLTSS and managed Medicaid plans into one program. States also want improved analytics capabilities to track member outcomes and simplify claims and appeals processes.  

Rising utilization in Medicare Advantage caught the attention of investors earlier this year after UnitedHealth Group disclosed an increase in outpatient care utilization in June, followed by Humana Inc.’s revelation that it was also seeing elevated medical costs due to an increased use of services. When reporting second-quarter 2023 earnings this summer, several insurers indicated that they were able to factor such trends into their bids for the 2024 plan year. Now, it appears that insurers’ rich supplemental benefit offerings continue to drive costs, as both CVS Health Corp. and Humana attributed elevated medical loss ratios (MLRs) in the third quarter to higher-than-normal uptake of benefits such as dental and flexible spending cards.

The Cigna Group could be fielding offers for its Medicare Advantage book, according to a Nov. 6 Reuters report. Experts say that a spinoff is plausible given the small size of Cigna’s MA book and Cigna’s heavy focus on commercial insurance — and Wall Street analysts say the move could be a first step toward a megamerger with a government-focused insurer.

Wells Fargo and RBC analysts say that the move could be an effort to preempt the intense antitrust scrutiny Cigna might face if it sought to merge with a government insurance-focused firm such as Humana Inc. or Centene Corp., because Cigna would have only commercial and Affordable Care Act marketplace books after an MA spinoff.

One week after the Senate Finance Committee held a hearing on misleading marketing and broker compensation practices in Medicare Advantage, Reps. Frank Pallone, Jr. (D-N.J.) and Richard Neal (D-Mass.) wrote CMS Administrator Chiquita Brooks-LaSure urging the agency to increase oversight and transparency of broker participation and compensation. Specifically, they asked Brooks-LaSure to address this in the upcoming Contract Year 2025 Part C and D Policy and Technical Changes proposed rule, which was submitted to the White House Office of Management and Budget on Aug. 24 and cleared OMB on Oct. 27, with publication still pending as of AIS Health press time. “We appreciate the previous actions taken by [CMS] to prioritize the health and well-being of our nation’s seniors by ensuring that beneficiaries have access to accurate and unbiased information about Medicare coverage. These policies protect the integrity of the Medicare program and ensure that seniors are able to access affordable health coverage,” wrote Pallone, who is ranking member of the House Energy and Commerce Committee, and Neal, ranking member of Ways and Means. But they encouraged CMS to build on those policies and reform total broker payments by setting standardized limits on compensation. Ensuring such payments are set at “reasonable amounts” would eliminate “incentives that encourage enrollment in plans with the highest broker payment that may not be best suited for seniors’ health needs,” they wrote.