Consumer Engagement

Digital Therapeutic Helps Kentucky WellCare Members With PTSD

Amid an ongoing mental health crisis that has seen a near 40% increase in patients grappling with mental health conditions since 2020, Centene Corp.’s WellCare of Kentucky launched a pilot program to address two conditions — panic attacks and post-traumatic stress disorder (PTSD) — that are often overlooked.

Working with digital therapeutics company Freespira Inc., the pilot program takes an innovative approach to managing conditions at home with supportive technology and personalized coaching. AIS Health, a division of MMIT, connected with leaders of the two organizations, Timothy Houchin, M.D., a board-certified adult, child and forensic psychiatrist and senior medical director for WellCare Kentucky, and Joseph Perekupka, CEO of Freespira, to discuss the collaboration and learn about the early outcomes.

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© 2024 MMIT

News Briefs: Wyden Urges CMS to Penalize Unscrupulous Brokers

Sen. Ron Wyden (D-Ore.), Chair of the Senate Finance Committee, wrote a letter on May 20 to CMS Administrator Chiquita Brooks-LaSure urging the agency to fine unscrupulous health insurance brokers. Wyden sent his letter following a CMS statement earlier this month that the agency had received about 40,000 complaints that people had been switched from one Affordable Care Act marketplace plan to another without their consent during the first three months of this year. CMS also said it had received about 50,000 complaints of unauthorized enrollments in plans in January, February and March. Wyden noted that the Affordable Care Act contains a provision that allows for penalties of up to $250,000 for “individuals who submit fraudulent information for a qualified health plan” in a “knowing and willful” manner. He wrote that “I am disappointed these penalties have not yet been used to hold bad actors accountable.” Wyden added in his letter that “the brokers, agencies and lead generators participating in fraudulent enrollment schemes should be held criminally responsible. While CMS does not have this authority today, I intend to introduce legislation shortly to give you this authority.”

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© 2024 MMIT

CMS Extends Regs Allowing Medicaid Plans to Assist Renewals

CMS on May 9 extended through June 2025 waivers meant to help states and Medicaid managed care organizations navigate the unwinding of COVID-19 pandemic-related eligibility rules. The waivers, which include provisions allowing MCOs to reach out to members about redeterminations and help members complete eligibility paperwork, were originally set to expire in January 2025.

The extension of the waivers — specifically, 1902 (e)(14) waivers — could help MCOs leave behind the upheaval caused by the return of eligibility redeterminations, which resumed in spring 2023 after a multiyear pause tied to the COVID-19 public health emergency. The crush load of eligibility checks has been difficult for states to manage. Many states disenrolled eligible Medicaid beneficiaries for administrative reasons, typically because the beneficiary made an error in their eligibility check or didn’t return paperwork in time to meet a redetermination deadline. The chaos, which was the subject of mutual recrimination between states and CMS, has caused no shortage of headaches for MCOs.

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© 2024 MMIT

Balancing Technology, Human Touch Can Improve Therapy Access, Adherence

Emerging technologies such as artificial intelligence (AI) are being incorporated into numerous processes within the health care system with an eye on improving a wide range of results. But rather than applying them across the board, a balance must be struck between what tasks are best suited for automation and what work best when provided with a human touch.

When it comes to patient onboarding, for instance, automated solutions may help fulfill certain requirements quickly, allowing patients to start needed therapies soon. But adherence to those treatments may be better achieved with a human touch that can help personalize approaches.

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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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Part D Plans Get Ready for Potentially ‘Messy’ Rollout of M3P Program

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month.

Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full.

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© 2024 MMIT

Insurers, Retailers Rethink Clinics After ‘Exuberant’ Spending Spree

Some insurers and retailers are backing away from their investments in provider verticals, especially retail health brands. Cigna's stake in VillageMD, a joint venture with Walgreens Boots Alliance Inc., has lost money, and VillageMD will soon close many locations instead of pursuing aggressive growth. Walmart Inc. also said it will close its health care venture.

In recent years, diversified insurers have seen clinics in which they own a stake as a place where they can control cost of care and, ideally, improve member satisfaction by reducing the friction required to access basic care services — in addition to growing revenue in a segment that isn’t capped by medical loss ratio (MLR) rules. But that premise hasn’t always amounted to much more than a compelling story in practice.

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ACHP: Final Rule Checks ‘Untethered’ Agent, Broker Fees Impacting Competition

After pushing for new limits on broker compensation and other changes to ensure seniors are guided to Medicare Advantage and Part D plans that best meet their needs, the Alliance of Community Health Plans (ACHP) on April 4 celebrated a victory with the release of CMS’s final rule making policy and technical changes for the 2025 plan year. ACHP, which represents provider-aligned, not-for-profit health plans, had spelled out its hopes for these policies in its broader “MA for Tomorrow” framework and provided Senate testimony on the impact of excessive “add-on” broker fees paid by larger plans. After CMS issued its final rule containing new marketing-related policies, AIS Health, a division of MMIT, spoke with ACHP’s executive vice president of public policy, Dan Jones, to learn more about the group’s position.

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Finalized Broker Pay Cap Appears to Exclude FMOs, But Impact Remains Unclear

Building on a sweeping set of marketing-related provisions that went into effect this year, CMS’s recently finalized 2025 Medicare Advantage and Part D rule put new restraints on agent and broker compensation, among other things. The provisions advance the Biden administration’s ongoing efforts to shield consumers from misleading marketing, but with more of a focus on activities performed by independent agents and brokers rather than the broader third-party marketing organization (TPMO) industry that was targeted in previous rulemaking. Industry experts tell AIS Health, a division of MMIT, that the finalized provisions are still open to interpretation when it comes to the role of one type of TPMO — field marketing organizations (FMO) — which often conduct lead generating and advertising on behalf of plans.

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Email ‘Nudges’ Spur Small Increase in Switching to Superior ACA Exchange Plans

Sending informational emails helped lead to some California residents switching to superior Affordable Care Act exchange plans, according to a study published on March 29 in JAMA Health Forum. However, Marina Lovchikova, Ph.D., the trial’s lead author, points out that the vast majority of households remained in their original plans and the impact on health care utilization was minimal. This suggests that more can be done to make sure enrollees are fully aware of their options and eligibility for more generous plans, she tells AIS Health, a division of MMIT.

Lovchikova, a senior researcher at Covered California, says the state’s exchange is “trying to get people to the coverage that could be most affordable for them and increase the access for their coverage. Some methods the state employs are sending emails or doing other low-cost, so-called nudges, which attempt to inform residents of their options but not automatically enroll them in another plan without their consent.

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© 2024 MMIT