Catastrophic Coverage

In its annual release of the Medicare Part D bid information for the coming plan year, CMS on July 31 projected that the average total monthly Part D premium will decrease from $56.49 in 2023 to $55.50 in 2024, thanks in large part to the basic part of the premium being held down by a stabilization provision in the Inflation Reduction Act (IRA). But unlike previous years, where the national average monthly bid amount (i.e., the weighted average of the estimated cost to Part D plan sponsors of providing their benefit package) steadily dropped, CMS reported that the bid amount will rise from $34.71 for 2023 to $64.28 in 2024. That’s largely because of IRA-mandated changes and CMS’s recent rulemaking on pharmacy price concessions.

Starting in 2024, the IRA limits the annual increase in the base beneficiary premium to no more than 6%. The base beneficiary premium, which is the starting point for calculating a plan-specific basic Part D premium, is projected to rise by 5.9% to $34.70 in 2024.

There wasn’t much to be gleaned from CMS’s latest annual report on program audits of Medicare Advantage and Part D sponsors, and CMS wants it that way. According to the 2022 Part C and Part D Program Audit and Enforcement Report, published on July 18, just three MA insurers received a civil monetary penalty as the result of a program audit last year, with the average CMP around $21,000 — compared with an average of $65,247 in 2021 and $200,000 in 2019. CMS in the report said the amount of the CMP “does not automatically reflect the overall performance of a sponsor” and, similar to last year, warned against reaching “broad conclusions about the significance of deficiencies or performance across” the MA, Part D or Medicare-Medicaid Plan (MMP) programs.

As Medicare Advantage organizations prepare for the next bid cycle, each year seems to bring its own set of factors that threaten their ability to stay competitive amid potential cost increases. For the 2023 plan year, the expiration of COVID-related adjustments and expected decline in quality bonus payments had plans considering modest benefit enhancements. For the 2024 plan year, maintaining stable benefits and premiums amid anticipated rate cuts and uncertainty around Medicare Part D trends is the name of the game, according to actuaries who helped plans submit bids that were due on June 5.

After proposing substantial revisions to the CMS-Hierarchical Condition Categories (HCC) risk adjustment model that insurers argued would result in rate reductions, CMS on April 3 opted to phase in the changes starting with 2024. CMS at the time estimated that plans would, on average, see a 3.32% increase in risk adjusted revenue, although that will vary broadly by plan. CMS also estimated the combined impact of the risk model revision and fee-for-service normalization could reduce payments by 2.16%. However, given that the agency will apply a blended method to calculate risk scores next year, plans could see a 4.44% overall risk score trend.

As more employers shifted to self-funded health plans, the stop-loss insurance segment expanded to $26 billion in 2021, with a growth rate exceeding 10% in each of the past five years, according to an A.M. Best report. There has been a notable uptick in employers with fewer than 1,000 employees choosing stop-loss insurance since 2018. Although the medical loss ratio for stop-loss has been lower than for group commercial coverage over recent years, it rose from 81.5% in 2020 to 85.0% in 2021, largely due to a year-over-year increase in stop-loss claims from major insurers and several other insurers that had claims for the first time in 2021.

With premiums steadily rising and turbulence shaking up the market-share leaderboard, the stop-loss insurance segment has become integral to many health plans’ portfolios in recent years. Experts believe the level of competition will only grow as more employers transition to self-funded plans.

Net premiums earned (NPE) for stop-loss insurance, an additional layer of coverage that protects employers against extremely high-dollar claims, reached $26 billion in 2021, according to a new report from credit rating firm A.M. Best. That’s up from $24 billion in NPE in 2020 — and more than double the $11.6 billion in total NPE seven years earlier in 2014.

As the world enters the fourth year of the COVID-19 pandemic, a recent report from the IQVIA Institute for Human Data Science found — not surprisingly — that a significant shift has occurred in the outlook for global medicine spending. The report, titled The Global Use of Medicines 2023: Outlook to 2027, revealed that global spending on pharmaceuticals, including COVID vaccines and therapeutics, from 2020 to 2027 is anticipated to surpass the Institute’s pre-pandemic estimations by $497 billion.

“Here we are at the beginning of 2023, with perhaps more uncertainties still ahead of us than we might have hoped for a year ago,” observed Murray Aitken, executive director of the IQVIA Institute for Human Data Science, during a recent webinar presented by his company. “Despite the progress on the pandemic front, it’s still out there; it’s still shaping our lives to a greater or lesser extent, depending on where in the world we are. It’s also still shaping our health care systems.

In a major win for Democrats facing midterm elections in the fall, the Biden administration this month passed the Inflation Reduction Act, a $430 billion-plus spending package that contained some of the president’s key priorities for climate, drug pricing and tax reform. While the legislation made headlines for allowing Medicare to negotiate the prices of certain drugs, industry experts say it’s changes to the Medicare Part D program that have the greatest potential to save seniors money and to force plans to rethink their management of the drug benefit.

The Inflation Reduction Act of 2022 (H.R. 5376) passed along party lines in both chambers and was signed into law on Aug. 16. It includes $369 billion to fight climate change, imposes a 15% corporate minimum tax and extends enhanced Affordable Care Act subsidies for another three years. Notable among the other health care provisions, the law requires CMS to negotiate the prices of prescription drugs, starting in 2026 with 10 Part D-covered drugs (including highest cost drugs and biologic agents, excluding “small biotech drugs” and certain orphan drugs to treat only one rare disease or condition). That number will increase to 15 in 2027 and 2028 — when Part B covered drugs may be included in the list of drugs subject to negotiation — and will rise to 20 agents in 2029 and beyond.

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.

While it’s become common knowledge in the health insurance sector that employer-sponsored coverage isn’t a major growth market, stop-loss insurance is bucking that trend. And with Blue Cross Blue Shield plans in particular not taking as much market share as they could, stop-loss could present attractive opportunities to health care-focused insurance carriers, experts say.

As it applies to health coverage, stop-loss insurance is typically paired with an administrative services only (ASO) contract, in which an employer pays its workers’ health care claims and hires an insurer to process those claims and perform other administrative functions. By adding stop-loss coverage, a self-funded employer is able to have that policy cover any “high-dollar” claim above a certain threshold, called an attachment point, thus minimizing the employer’s risk.