Annual Election Period/AEP

If Medicare Advantage organizations and Prescription Drug Plans (PDPs) this open enrollment season have the haunting feeling they’re being watched, it’s because they are. After implementing new rules aimed at better protecting beneficiaries from confusing and misleading Medicare marketing, CMS in October issued two memos informing plans that they’ve done some digging into recent marketing activities and they don’t like what they’ve seen so far.

CMS has reported that marketing-related complaints more than doubled between 2020 and 2021 — which it largely attributed to the actions of third-party marketing organizations (TPMOs) — and has expressed particular concern with third-party marketers’ claims that some benefits are widely available to seniors when they vary by service area. To address these concerns, CMS made key changes this year, such as requiring TPMOs to use a standardized disclaimer that they do not offer every plan available in the area, clarifying that independent agents and brokers qualify as TPMOs, and stipulating that plans in their contracts with TPMOs require full recordings of sales calls with beneficiaries.

Settling a lawsuit filed by Kaiser Health News, CMS has agreed to release the results of 90 Risk Adjustment Data Validation (RADV) audits of Medicare Advantage plans for payment years 2011 through 2013, KHN reported. The news outlet in September 2019 filed the suit under the Freedom of Information Act in an effort to make public “vital information” about the estimated $600 million in overpayments the government aims to collect from plans through those completed RADV audits, said KHN. Under the settlement, CMS will share audit spreadsheets showing which medical diagnoses could not be confirmed but will redact the payment amounts. The agency has already sent the first round of records, according to KHN.

As Medicare Advantage organizations market a host of new products and benefits for the 2023 plan year, large and regional insurers alike are boosting their Dual Eligible Special Needs Plan (D-SNP) presence. And while those plans continue be the most popular type of SNP — especially as CMS phases out so-called D-SNP look-alikes and pushes states to further integrate Medicare and Medicaid programs — a smaller but growing group remains interested in pursuing the more specialized Chronic Condition SNP (C-SNP) and Institutional SNP (I-SNP) markets.

According to an analysis of CMS’s Landscape Files from Clear View Solutions, LLC, there will be 1,320 SNPs on the market in 2023, compared with 1,192 in 2022 and 1,019 in 2021. Drilling down further, Clear View observes that there will be 1,068 SNPs available next year that were offered in 2022, compared with 926 plans that carried over from 2021 to 2022. The total number of D-SNPs, which serve members who are dually eligible for Medicare and Medicaid, will rise from 723 plans in 2022 to 809 plans available in 2023.

More than 1,400 Medicare Advantage plans will offer at least one Expanded Primarily Health-Related Benefit (EPHRB) in the 2023 plan year, according to a new report from ATI Advisory. CMS in 2019 reinterpreted the definition of what constitutes as a “primary health-related” benefit, which allowed plans to offer a wider range of supplemental benefits such as adult day health services, support for caregivers of enrollees and therapeutic massage. The most commonly offered EPHRB is in-home support services, which is available in at least one plan in the majority of U.S. counties, according to ATI’s analysis. Two EPHRBs — in-home support services and support for caregivers — saw significant uptake from 2022 to 2023, growing 50% and 83%, respectively. An earlier analysis from ATI found that more than 30% of MA members are currently enrolled in a plan that offers at least one type of supplemental benefit, which includes both EPHRBs and Special Supplemental Benefits for the Chronically Ill.

As the Oct. 15 start date of the 2023 Medicare Annual Election Period (AEP) approached, insurers across the country this month unveiled new-and-improved benefits and major market expansions aimed at capturing share of the ever-growing Medicare Advantage market. And while Long Beach, Calif.-based SCAN Health Plan is offering enhanced benefits and pursuing new markets, it’s also gaining attention for launching a novel product specifically geared toward LGBTQ+ older adults. Company executives tell AIS Health, a division of MMIT, that the nonprofit insurer spent more than a year carefully shaping the product to ensure that it would meet the needs of the LGBTQ+ community, and it will continue to tweak the product as it gathers feedback from enrollees.

A little over half of Medicare Advantage Prescription Drug (MA-PD) contracts that will be offered in 2023 received an overall rating of 4 stars or higher, according to Medicare Parts C and D Star Ratings data released by CMS on Oct. 6. As expected, the new ratings reflect a return to normal after adjustments made for the COVID-19 public health emergency (PHE) resulted in a staggering 70% of MA-PD plans earning 4 stars or higher for 2022, compared with 49% of plans in 2021. But as the market becomes more saturated across the country, industry experts are watching closely to see whether recent steps taken by CMS to penalize poor performers will really level-set the market or demonstrate that more changes are needed to ensure members enroll in high-quality plans.

The average star rating for Medicare Advantage Prescription Drug (MA-PD) plans declined following the phaseout of pandemic-related flexibilities, according to CMS. While 72% of MA-PD beneficiaries are enrolled in a contract that is rated at least 4 stars for 2023, that’s down from an all-time high of 90% in 2022. These drops were anticipated however, as CMS in 2022’s ratings qualified all contracts under an “extreme and uncontrollable circumstances” policy to account for the COVID-19 public health emergency (PHE), which allowed payers to pick “best of” scores on many measures. Also, for 2023, the agency assigned a greater weight to member experience measures based largely on contracts’ Consumer Assessment of Healthcare Providers and Systems, after CMS suspended the collection of CAHPS survey data during the PHE.

Elevance Health, Inc. last month invested $35 million in GoHealth, an e-broker for Medicare Advantage plans that has struggled this year and seen its stock market value plummet. Michael Abrams, managing partner of Numerof & Associates, tells AIS Health that the investment was “equivalent to a life-saver” for GoHealth.

GoHealth received a total of $50 million, with the other $15 million coming from a company referred to as GH 22 Holdings, Inc. in an SEC filing. A GoHealth spokesperson writes in an email to AIS Health, a division of MMIT, that GH 22 is “a significant partner” of GoHealth.

Medicare beneficiaries in nearly every state will have more Medicare Advantage plans to choose from and see lower premiums this fall when shopping for coverage, according to CMS’s recently released landscape files for the 2023 plan year. And both major insurers and regional plans at press time were touting new offerings such as Part B buyback plans, flexible spending features that include allowances for utilities, and enhanced dental coverage.

“What we’re seeing is kind of a continuation of what we’ve seen in the past several years, which is expanding of not only the big five but also of the smaller insurers as well, and then increased focus on supplemental benefits and the Special Supplemental Benefits for the Chronically Ill (SSBCI), and continued expansion into the D-SNP [Dual-Eligible Special Needs Plan] market,” observes Betsy Seals, co-founder and CEO of Rebellis Group, LLC.

After observing a high volume of marketing-related complaints that the federal government believes are driven by the actions of third-party marketing organizations (TPMOs), CMS this month is implementing several new requirements aimed at protecting Medicare beneficiaries as they compare coverage options during the 2023 Annual Election Period (AEP) that starts on Oct. 15. And while one trade group is concerned that the changes may leave some independent agents and brokers out of the AEP, two marketing experts say they don’t anticipate a major shakeup and are hopeful that the changes will only weed out the bad actors.