Dual Eligibles

AEP Wrap Up: Humana Vies for Industry-Leading Medicare Advantage Growth Position

After a lackluster 2022 open enrollment season characterized by churn associated with its external marketing channels, Humana Inc. is touting above-industry growth after the 2023 Annual Election Period (AEP) that concluded last month. Presenting at the 41st Annual J.P. Morgan (JPM) Healthcare Conference in San Francisco, Humana Chief Financial Officer Susan Diamond said investments in the company’s products, sales channels and other aspects of its Medicare Advantage business are helping it “get back to an industry leading position” and achieve double-digit percentage enrollment gains this year.

According to the latest monthly enrollment data posted by CMS, MA now enrolls more than 30.6 million individuals, including more than 25 million in individual MA plans. That data reflects enrollment as of the Jan. 1, 2023, payment date (i.e., enrollment accepted through Dec. 2, 2022). Those figures do not reflect the full outcome of the AEP, which ran from Oct. 15 through Dec. 7, and are lower than CMS’s projection of 31.8 million for 2023, pointed out Citi’s Jason Cassorla in a Jan. 17 investor note. “[W]e expect enrollment to rise in the final 5 days of AEP and subsequently grow throughout 2023 considering both age-ins” and the Open Enrollment Period that runs from Jan. 1 through March 31, he wrote.


New Findings Show Strength of MA in Detecting, Treating Type 2 Diabetes

New research conducted by Avalere on behalf of the Better Medicare Alliance (BMA) suggests Medicare Advantage plans aid in earlier detection of type 2 diabetes and that seniors diagnosed with type 2 diabetes generally fare better than similar patients in fee-for-service (FFS) Medicare. Specifically, lower medical spending and rates of inpatient hospitalizations/emergency department visits observed by researchers may be particularly compelling for policymakers as they consider the overall value of the MA program.

With MA serving more seniors than ever before — having just reached a milestone of enrolling more than 30 million Medicare-eligible beneficiaries — and one-third of seniors estimated to have a diagnosis of type 2 diabetes, it is important to look at how these patients’ care differs in MA vs. traditional Medicare, asserted Matt Kazan, managing director with Avalere, during a Jan. 12 webinar hosted by BMA. In many cases, there are “major differences,” he noted.


SCAN Group, CareOregon Form HealthRight Group to Create ‘Formidable’ Government Partner

SCAN Group, the parent company of not-for-profit Medicare Advantage insurer SCAN Health Plan, on Dec. 14 said it will combine with another not-for-profit organization, CareOregon. For more than 25 years, CareOregon has provided health services and community benefit programs to Medicaid and the Children’s Health Insurance Program in its home state and currently serves more than 500,000 Oregonians, including individuals who are dually eligible for Medicare and Medicaid.

Under the name HealthRight Group, the combined companies will operate as a mission-driven not-for-profit health care organization and maintain their respective consumer-facing brands, according to a press release from the firms.


Insurers Eye Growing D-SNP Market, Show Modest Interest in I-SNPs

As Medicare Advantage organizations market a host of new products and benefits for the 2023 plan year, large and regional insurers alike are boosting their Dual Eligible Special Needs Plan (D-SNP) presence. And while those plans continue be the most popular type of SNP — especially as CMS phases out so-called D-SNP look-alikes and pushes states to further integrate Medicare and Medicaid programs — a smaller but growing group remains interested in pursuing the more specialized Chronic Condition SNP (C-SNP) and Institutional SNP (I-SNP) markets.

According to an analysis of CMS’s Landscape Files from Clear View Solutions, LLC, there will be 1,320 SNPs on the market in 2023, compared with 1,192 in 2022 and 1,019 in 2021. Drilling down further, Clear View observes that there will be 1,068 SNPs available next year that were offered in 2022, compared with 926 plans that carried over from 2021 to 2022. The total number of D-SNPs, which serve members who are dually eligible for Medicare and Medicaid, will rise from 723 plans in 2022 to 809 plans available in 2023.


Experts, Report Offer Ways to Supercharge Slow-to-Grow PACE Model

As the U.S. population ages and as payers and providers increasingly embrace home-based care — especially in light of the COVID-19 pandemic — a program that one expert calls the “best-kept secret in health care” seems poised to finally have its moment in the sun. However, there are a variety of barriers that need to be tackled in order for Programs of All-Inclusive Care for the Elderly to significantly grow, and recent compliance issues at the largest PACE participant raise questions about the involvement of private equity-owned, for-profit companies.

The PACE model employs comprehensive medical care and social supports to help frail, elderly Americans remain at home when they otherwise would require a nursing home level of care. Eligible enrollees — who never have to pay cost sharing — receive health care services at an adult day center, which is staffed with interdisciplinary care teams and also offers classes, games and other wraparound services.


News Briefs: Individual Medicare Advantage Enrollment Surpasses 24.7 million, Up 9% Year Over Year

Individual Medicare Advantage enrollment this month surpassed 24.7 million lives, reflecting 9.3% membership growth since last August, according to a Barclays analysis of CMS’s latest monthly enrollment report. The publicly traded MCOs saw year-over-year individual MA membership grow by 10.5%, with Centene Corp. and CVS Health Corp.’s Aetna delivering double-digit enrollment gains, according to the analysis. Cigna Corp., however, underperformed with a year-over-year membership decline of 5.5%, observed Barclays. CMS’s August data release reflects enrollments accepted through July 8.

Highmark Wholecare has partnered with Posit Science to incorporate “brain fitness” into a program aimed at reducing vulnerable members’ risk of falling and improving balance. Highmark Wholecare, formerly Gateway Health, will offer BrainHQ exercises and services to approximately 7,000 qualifying members who are dually eligible for Medicare and Medicaid and identified as a high risk for falls. BrainHQ’s evidence-based brain fitness program is available via web or mobile phone and is supported by more than 200 peer-reviewed studies, according to an Aug. 15 press release from the partners.


CMS Takes Next Steps Toward Phasing Out D-SNP Look-alikes

In a new enrollment transition memo issued to Medicare Advantage organizations with a significant number of dual eligible enrollees in products that are not Dual Eligible Special Needs Plans, CMS appears to be pushing so-called D-SNP look-alike plans to the brink of extinction. But the two-year transition process, which will wrap up for the 2023 plan year, still allows traditional MA plans to enrollee a limited number of duals. And one trade organization suggests more could be done to incentivize MAOs to set up D-SNPs.

CMS in 2019 first began cracking down on D-SNP look-alikes — MA plans that are marketed to duals but are not D-SNPs or integrated products — when it released draft revisions to the Medicare Communications and Marketing Guidelines that stated look-alikes cannot imply that the plan is for dual eligibles, cannot claim or infer that they have a relationship with the state, and cannot exclusively market to duals. A year prior, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress had argued that more needed to be done to promote the development of integrated plans and raised the issue of D-SNP look-alikes. At the time, approximately 2.7 million dual eligibles were enrolled in one of four types of managed care plans available to them, yet only 8% of full-benefit duals were in a plan with a high level of Medicare and Medicaid integration. More than 4.1 million individuals are now enrolled in a SNP, of which nearly 3.7 million are in a D-SNP.


Payers, Government Are Increasing Focus on Health Inequities

Health insurers, states and the federal government are beginning to take more seriously health inequities, according to experts who spoke with AIS Health, a division of MMIT, as the issue becomes a hot topic due to the health and financial costs caused by disparities in health care access and outcomes.

Health inequities related to race, socioeconomic status and sex/gender account for $320 billion in annual health care spending for five high-cost diseases, according to a Deloitte report released on June 22. Deloitte actuaries project that could increase to $1 trillion by 2040 and lead to an average $2,000 increase in health spending per person in the U.S. if those issues are not addressed. The researchers examined the costs of health inequities related to the treatment — or lack thereof — of breast cancer, diabetes, colorectal cancer, asthma and coronary heart disease.


SCAN, CCA Team Up to Support PACE Enrollees Through myPlace

As the pandemic underscores the importance of enhanced support for community-dwelling seniors with complex care needs, two not-for-profit Medicare Advantage organizations have teamed up to sponsor an “integrated care delivery organization” designed to serve enrollees who qualify for Programs of All-Inclusive Care for the Elderly (PACE). Long Beach, Calif.-based SCAN Health Plan and Boston-based Commonwealth Care Alliance (CCA) last month unveiled the launch of myPlace Health as part of their shared mission of keeping seniors healthy and independent.

Robbie Pottharst, CEO of the newly launched company, confirms that myPlace is seeking to become a PACE organization and align with local health plans that may already serve dual eligibles who qualify for PACE and that, in his words, “can lend capability, expertise and a lot of accelerators to build this business.” Pottharst previously held leadership roles with Cityblock Health, Kaiser Permanente and CareMore Health, where Sachin Jain, M.D., served as president and CEO before taking over the reins at SCAN.


News Briefs: CMS Is Seeking Applicants for the 2023 MA VBID and Part D Senior Savings Models

CMS on March 1 issued a request for applications (RFA) for the 2023 Medicare Advantage Value-Based Insurance Design Model, which will include new elements such as a Health Equity Incubation Program that will encourage testing of interventions in “the most promising focus areas” (e.g., food insecurity) and designing best practices for such interventions. Thirty-four MA organizations are currently offering benefit packages that feature tailored VBID model benefits and rewards and incentives to more than 3.7 million enrollees, according to the model’s website. CMS on Feb. 28 also released an RFA from Medicare Part D sponsors and pharmaceutical manufacturers interested in participating in the 2023 Part D Senior Savings Model. Now in its third year, the insulin-focused model is intended to lower out-of-pocket costs for seniors by featuring “predictable” copayments of no more than $35 for a broad set of insulins. The voluntary model has 106 participants, including five manufacturers. CMS is accepting applications for the VBID model through April 15 and for the SSM through April 8.