Consumer Engagement

As Medicaid Redeterminations Loom, MCOs Can Help States Ease the Process

Three years after states’ annual efforts to verify enrollees’ Medicaid eligibility were paused because of the COVID-19 public health emergency (PHE), states as of April 1 may begin terminating Medicaid coverage for individuals who no longer qualify. States and their managed care partners have been working to update beneficiary contact information for the inevitable return of redeterminations, and Medicaid managed care organizations can play a big role in raising awareness about the process, according to industry experts.

“I think that many members, probably 60% to 70% of folks, are just completely unaware that this is happening, and a lot of other folks just don’t realize the rigmarole they have to go through in order to maintain eligibility,” remarks Jerry Vitti, founder and CEO of Healthcare Financial, Inc., a firm that connects low-income, elderly, and disabled populations with Medicaid and other public benefit programs. “But plans can do mailings, do outreach, and be a connection point to Medicaid agencies where they can get enrolled.” Unfortunately, “they have uneven demographic information on these folks since the population is so transient, but they can reach out to members…and I think plans can do a really good job to build awareness of what’s happening and the implications.”

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2023 Outlook: Redeterminations, Social Needs Will Keep Medicaid Plans Busy

Medicaid managed care organizations this year will have their hands full as they support state efforts to resume eligibility redeterminations and try to help members avoid gaps in coverage, or “churn” historically associated with failing to meet cumbersome paperwork requirements. At the same time, MCOs may have more opportunities to address health-related social needs (HRSNs) as CMS encourages states to pursue new funding flexibilities around items like food and housing, industry experts tell AIS Health, a division of MMIT.

As a condition of receiving enhanced federal matching funds during the COVID-19 public health emergency —which will end on May 11 — states had to maintain continuous coverage for Medicaid enrollees. But the Consolidated Appropriations Act of 2023 (CAA) decoupled that requirement from the expiration of the PHE. Per the CAA, the temporary 6.2 percentage-point increase in the Federal Medical Assistance Percentage will phase down over three quarters starting on April 1, when states may begin terminating Medicaid coverage for individuals who no longer qualify. States have up to 12 months to begin — and 14 months to complete — eligibility redeterminations for all individuals enrolled in Medicaid.

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MedPAC Mulls Concept of Standardizing Common Supplemental Benefits in MA

As Medicare Advantage insurers continue to grow their supplemental benefits offerings and CMS maintains a focus on improving the consumer experience, the Medicare Payment Advisory Commission (MedPAC) has begun work on the nascent concept of standardizing certain benefits in MA. During its Nov. 4 public meeting, the commission seemed mostly interested in standardizing a limited number of common supplemental benefits in the name of helping beneficiaries make better plan comparisons, but several commissioners expressed concern about potentially hampering MA plan innovation.

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Top Stars Performers Credit Careful Messaging, Provider Collaboration

As CMS resumed normal Star Ratings calculations and gave greater weight to patient experience measures for 2023, the proportion of Medicare Advantage Prescription Drug (MA-PD) plans earning 4 stars or higher saw a dramatic drop from 2022, according to newly released CMS data. In Part 2 of an AIS Health series on successful Star Ratings strategies, top performers say maintaining a company-wide focus on quality and member experience is key to their approach. And while member outreach is a critical part of those initiatives, successful plans are careful to avoid overcommunicating with members and creating message fatigue, sources tell AIS Health, a division of MMIT.

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Mark Cuban Cost Plus Drugs Strikes First Deals with Insurer, Outside PBM

Mark Cuban Cost Plus Pharmacy, the online pharmacy and generic manufacturing startup backed by the eponymous billionaire investor, recently struck its first deals with a health plan, Pennsylvania’s Capital Blue Cross, and a PBM, Rightway Healthcare Inc. The direct contracting deal represents a major step for the startup, which has done most of its business so far as a direct-to-consumer retailer — and one drug pricing expert tells AIS Health, a division of MMIT, that the deals help Cost Plus moves toward its ambitious, disruptive goals.

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Top Stars Performers Credit Coordinated Messaging, Targeted Outreach

As CMS resumed normal Star Ratings calculations and gave greater weight to patient experience measures, the proportion of Medicare Advantage Prescription Drug (MA-PD) plans earning 4 stars or higher for 2023 saw a dramatic drop from 2022, according to newly released CMS data. In an AIS Health series on successful Star Ratings strategies, top performers highlight connecting the dots around medication adherence, maintaining a year-round focus on member experience, and helping members navigate and utilize their benefits as key priorities. And while member outreach is a critical part of those initiatives, successful plans are careful to avoid overcommunicating with members and creating message fatigue, sources tell AIS Health, a division of MMIT.

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Mark Cuban Cost Plus Drugs Strikes First Deals with Insurer, Outside PBM

Mark Cuban Cost Plus Pharmacy, the online pharmacy and generic manufacturing startup backed by the eponymous billionaire investor, recently struck its first deals with a health plan, Pennsylvania’s Capital Blue Cross, and a PBM, Rightway Healthcare Inc. The direct contracting deal represents a major step for the startup, which has done most of its business so far as a direct-to-consumer retailer — and one drug pricing expert tells AIS Health, a division of MMIT, that the deals help Cost Plus moves toward its ambitious, disruptive goals.

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A Large Share of American Households Still Struggle With Paying Medical Bills

About 42% of working-age adults said they had problems paying medical bills or were paying off medical debt, according to findings from the 2022 Commonwealth Fund Biennial Health Insurance Survey. With 43% of the respondents inadequately insured, medical costs and debt remained a major concern for many Americans. Almost one-third of adults who were underinsured — whose coverage did not provide them with affordable access to health care — reported they were contacted by a collection agency regarding unpaid medical bills. Of those with medical debt, 56% said the amount reached $2,000 or more.

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Companies Should Focus on Patients for Successful Digital Strategies

While the pharmaceutical industry has accepted the importance of digital, implementing it in patient solutions remains a challenge. Manufacturers should prioritize patients’ needs and understand how they can evolve over the course of their treatment journey to offer them accessible and useful solutions, according to industry experts at a recent webinar sponsored by Reuters Events.

One trend within the digital space is tied to the change within the health care landscape and its digital support methods. Most would agree that this is a positive development. But according to Paul Fu, M.D., chief medical information officer at City of Hope, a cancer research and treatment organization, as well as a research center for diabetes and life-threatening diseases, “I think that one of the challenges of being a health care system is that the technology is moving faster than our ability to handle that rate of change. We see that with our patients.”

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Study: Pharma Companies Often Profit From Donations to Patient Assistance Charities

Pharmaceutical companies often profit from their donations to non-profit patient assistance charities that are intended to help people afford high-cost medications, according to a study published in this month’s edition of the journal Health Affairs.

HHS’s Office of Inspector General (OIG) has provided guidance on the charities and cracked down in recent years on several charities and drug manufacturers. However, the authors noted that “the current regulations or enforcement permit donations that violate the spirit of Medicare’s Anti-Kickback Statute,” which prohibits pharma companies from covering Medicare Advantage enrollees’ out-of-pocket drug spending for the drugs they manufacture.

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