Biden Admin Aims to Stymie MLR Inflation Among ACA Plans

In its annual omnibus regulation for the Affordable Care Act exchanges, CMS revealed that it aims to crack down on some questionable behavior used by health plans when calculating their medical loss ratios (MLRs) — a move that will likely result in insurers paying even higher rebate amounts to consumers than they already are.

The ACA requires individual and small-group market insurers to spend at least 80% of their premium income on medical care and quality improvement. For the large-group market, that threshold is 85%. If insurers’ MLRs dip below those percentages, they’re required to return the difference to plan members. MLR rebates, which are calculated using a three-year average, have risen considerably in recent years and totaled $2 billion for the 2020 plan year.


CMS Rule Seeks More Oversight of TPMOs, ‘Chain of Enrollment’

Following up on its October 2021 “Third Party Marketing” memorandum warning of misleading tactics by some organizations, CMS in its latest Medicare Advantage and Part D proposed rule said it believes “additional regulatory oversight” is needed to protect beneficiaries from “bad actors” in this space. The agency observed that an increase in third-party marketing activities in recent years has been accompanied by a rise in marketing-related complaints from beneficiaries, such as those who do not understand how an agent or broker obtained their information.

While previous guidance and rules have focused more on MA organizations’ relationships with agents and brokers, the new proposed rule serves to address the prevalence of lead-generating entities that may not directly contract with MAOs but qualify as first tier, downstream or related entities (FDRs), explains Helaine Fingold, a partner in the Health Care and Life Sciences practice at the law firm Epstein, Becker & Green, P.C.

InnovAge Replaces CEO After CMS Imposes Second Enrollment Freeze on the PACE Organization

Shortly after Denver-based InnovAge learned that CMS suspended enrollment in the company’s Colorado programs due to noncompliance, the leading Programs of All-Inclusive Care for the Elderly (PACE) provider unveiled the resignation of its longtime CEO, Maureen Hewitt. InnovAge serves more than 6,300 PACE participants, or 12% of PACE enrollees overall, and is in the midst of a major expansion. The company on Jan. 3 said Hewitt was leaving to “pursue other opportunities” and it promoted Patrick Blair, the current president, to president and CEO.

InnovAge in March 2021 began trading on the Nasdaq Global Select under the ticker symbol “INNV,” and at the time said it planned to expand its footprint of 16 centers in five states. The company in November said it expected to open three centers in fiscal year 2023 and was looking at additional locations and eyeing acquisitions in new markets.

Payer Execs Answer Question: ‘How’s Interoperability Going?’

The road to complying with new data interoperability regulations has not been an easy one for health insurers, but the process has offered valuable insights to an industry that’s continually striving to modernize and better meet consumers’ needs.

Those are some of the main takeaways from a virtual “Health Insurance Provider Interoperability Town Hall” that AHIP convened as part of its 2021 Consumer Experience & Digital Health Forum. The Dec. 8 panel discussion featured speakers from a diverse array of payers, yet many of their experiences complying with interoperability mandates had common themes.


Rewards and Incentives Rule Has Compliance, Stars Implications

Although it may have gone largely unnoticed by Medicare Advantage plans this year, a clarification regarding rewards and incentives (R&I) programs embedded in an 894-page final rule issued in January 2021 could have significant implications for plans’ star ratings strategy in addition to posing compliance risks and added costs in 2022. Industry experts say now is the time for plans to get compliant with the provision, which goes into effect on Jan. 1, 2022, and to begin rethinking their R&I programs to incentivize healthy behavior across the broader MA population and not just those members who are falling behind in their star measures.

Latest OIG Risk Adjustment Audit Seeks $6.4 Million From UPMC

Continuing a series of audits in which the HHS Office of Inspector General is reviewing the accuracy of diagnosis codes submitted to CMS by Medicare Advantage organizations, OIG last month said most of the codes it reviewed for UPMC Health Plan, Inc. could not be validated by medical records. The agency used its own extrapolation methodology to estimate that the Pittsburgh-based insurer owes $6.4 million for the 2015 and 2016 payment years, prompting a detailed rebuttal from UPMC and adding to the ongoing debate over the use of sampling to approximate a plan’s true payment error rate.