Consumer Engagement

With nearly all states having completed the Medicaid “unwinding process” that shed millions of people from the rolls, a new analysis notes that total Medicaid and Children’s Health Insurance Program (CHIP) enrollment is actually higher than it was before the COVID-19 pandemic. One expert tells AIS Health that private insurers helped conduct crucial outreach to ensure people losing coverage could get insured elsewhere — although Medicaid managed care organizations (MCOs) still are grappling with the financial consequences of the unwinding.

The unwinding process began in April 2023 after the end of the continuous enrollment provision in the Families First Coronavirus Response Act. This provision was enacted due to the COVID-19 public health emergency to ensure that no one covered by Medicaid lost their insurance — even if a change in income rendered individuals ineligible. Enrollment had reached an all-time high of 94 million when unwinding began, up from 71 million in February 2020.

Employers and health plans are less satisfied with the “Big Three” PBMs — CVS Health Corp.’s Caremark, UnitedHealth Group’s Optum Rx and The Cigna Group’s Express Scripts — compared with their smaller peers in the pharmacy benefits industry, according to a Pharmaceutical Strategies Group (PSG) survey published this month. While the Big Three have taken steps in recent months to offer more transparent models, Michael Lonergan, PSG’s president, tells AIS Health those companies have faced numerous challenges to their businesses that have made them more unpopular among clients.

For instance, he mentions the Federal Trade Commission (FTC) lawsuit filed on Sept. 20 against the Big Three PBMs and their affiliated group purchasing organizations (GPOs), accusing them of inflating the list price of insulin medications and restricting access to those drugs. The FTC also issued an interim report in July that was highly critical of the Big Three, which together account for about 80% of the U.S. prescription drug claim processing market.

Five insurers received the highest scores in the latest National Committee for Quality Assurance (NCQA) Health Plan Ratings, which assess plans based on patient experience and clinical quality. Two of those health plans tell AIS Health that their early adoption of value-based care models and buy-in from physicians and members are the keys to achieving their highly rated status.

The results of the annual NCQA report were published on Sept. 16 and included 1,019 commercial, Medicare and Medicaid health plans that reported Healthcare Effectiveness Data and Information Set (HEDIS) data to the NCQA, representing about 227 million people.

In August, Highmark Inc. launched a new Medicaid managed care organization in West Virginia, becoming the Mountain State’s first Blue Cross Blue Shield-branded MCO. In doing so, the insurer will confront challenges that MCOs of all stripes are facing, such as building a comprehensive provider network and grappling with the financial pressures related to states resuming their routine eligibility checks after a multiyear pause.

The West Virginia Dept. of Human Services approved Highmark Health Options’ application to be the state’s newest MCO in January, giving the not-for-profit organization a statewide contract that runs for four years. Highmark Health Options will compete against a trio of MCOs in West Virginia that include Elevance Health, Inc.’s Unicare Health Plan of West Virginia, Aetna Better Health of West Virginia, and The Health Plan’s Mountain Health Trust. As of September, Highmark Health Options West Virginia had attained roughly 1,800 members, according to AIS’s Directory of Health Plans (DHP).

Health Care Service Corp. (HCSC), which owns Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, recently rolled out an “alternative health plan” that combines what essentially is a tiered provider network, price transparency and streamlined medical billing.

Industry experts who spoke to AIS Health, a division of MMIT, say HCSC’s new benefit design has a variety of intriguing elements that could prove attractive to employers. Indeed, UnitedHealthcare has in recent earnings calls been touting the rising popularity of a similar offering.

While plenty of telehealth and online drug dispensing companies have rolled out direct-to-consumer (DTC) offerings, two pharma manufacturers have unveiled their own digital platforms this year in a bid to streamline and simplify consumers’ experience with the U.S. health care system. Other drugmakers are likely to launch similar offerings, say industry experts, as they offer benefits to various stakeholders. Still, certain challenges exist for those stakeholders, and manufacturers will need to ensure that they take certain steps — both pre- and post-launch — to set themselves up for success while remaining compliant with various regulations.

On Aug. 27, Pfizer Inc. launched PfizerForAll, a “user-friendly digital platform designed to make access to healthcare and managing health and wellness more seamless for people across the U.S.” It is aimed at Americans with migraine, COVID-19 or flu and offers adult vaccinations for conditions such as COVID-19, flu, respiratory syncytial virus (RSV) and pneumococcal pneumonia.

As part of CMS and the Biden administration’s overall framework for health equity, Medicare Advantage organizations’ ability to assess social risk factors (SRFs) and address care disparities has taken on new importance this year, thanks to the introduction of the Health Equity Index (HEI) to the Star Ratings. Starting in 2027, insurers won’t be penalized for failing to close gaps in care on certain quality measures, but qualifying Parts C and D sponsors will be rewarded if they perform well on the HEI, which CMS has described as a “methodological enhancement” to a subset of existing measures. Quality experts say readiness varies across the industry, and plans need to better understand where to target interventions and where they stack up against other plans that may qualify for the HEI.

And not all plans will qualify: Contracts that enroll a minimum threshold percentage of enrollees with social risk factors (SRFs) will be assessed and divided into three tiers of performance. Plans that perform in the top tier will receive 1 point, the middle tier will receive 0 points, and the bottom tier is assigned -1 point for each measure. After a series of calculations, the points translate to an HEI score that ultimately determines whether plans receive a reward that is applied to quality bonus payments for the 2027 Star Ratings.

In an email to contracted brokers on Aug. 23 that has now stirred considerable controversy, Centene Corp. said it would no longer pay new and renewal commissions for enrollments in its stand-alone Prescription Drug Plan (PDP) products.

For insurance agents who previously enrolled clients in a Centene/Wellcare product and anticipated putting time and resources into continuing to serve that client, the rug was effectively pulled out from under them. Fearing that the move could set a dangerous precedent, the broker community over the last week has rallied to voice its objections and demand answers from the leading PDP carrier.

Even after health plans were given the option to expand pre-deductible coverage in certain health plans, medication adherence didn’t significantly improve, according to a recent issue brief from the Employee Benefit Research Institute (EBRI).

Yet while the impact was minimal for most medications, Paul Fronstin, Ph.D., one of the report’s authors, says adherence was already high for the members evaluated, and the majority of insurers introduced copayments and/or coinsurance when expanding pre-deductible coverage.

Along with other major changes to the Medicare Part D benefit, beneficiaries starting next year will have a $2,000 limit on their annual out-of-pocket (OOP) prescription drug costs, thanks to the Inflation Reduction Act (IRA). If seniors find themselves uncomfortably close to that threshold, they also can smooth those OOP costs over the course of the 2025 plan year through the IRA-established Medicare Payment Prescription Plan (M3P) program. While sources agree the program has the potential to improve access to prescription drugs, they say its success is also largely dependent on how well plans inform patients that the option is available.