Eligibility

AHIP Panelists: Medicaid Redetermination Glitches Shine Light on Clunky Processes

Nearly a year into the massive nationwide effort to reverify Medicaid eligibility after a pause in redeterminations during the COVID-19 pandemic, about 40% of renewals have yet to occur. With millions of people estimated to have lost coverage because of administrative or procedural reasons, states have an opportunity to work with managed care organizations and other health care providers to innovate and improve existing processes that aren’t working, according to panelists at a recent session of AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore.

“This is still very much in progress,” and “these next few months are going to be very important,” declared panelist Kate Honsberger, a director with NORC at the University of Chicago. States as of April 1, 2023, were allowed to begin disenrolling people from Medicaid who no longer qualify, but they have 12 months to complete eligibility redeterminations, which may have kicked off at different times depending on the state.

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As Health Equity Measurement Begins, MA Plans Must Use Precision to Close Gaps

Starting with the 2027 Star Ratings, CMS will begin rewarding Medicare Advantage plans for their efforts to assess social risk factors and address disparities in certain quality measures with the new Health Equity Index (HEI). Not all plans will qualify and only a third of top-performing plans will be rewarded, but the time is now for plans to look at how they are doing on the claims-based measures that will be impacted and how they are performing for members with one of the qualifying factors (i.e., eligible for Medicare and Medicaid, disability and/or the Part D low-income subsidy).

During a recent panel moderated by AIS Health, a division of MMIT, speakers at the 7th Annual Medicare Advantage Leadership Innovations forum discussed best practices for assessing members’ social needs and how plans can use data to address them and move the needle forward on health equity.

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© 2024 MMIT

News Briefs: House Members Urge CMS to Reform Broker Compensation in MA

One week after the Senate Finance Committee held a hearing on misleading marketing and broker compensation practices in Medicare Advantage, Reps. Frank Pallone, Jr. (D-N.J.) and Richard Neal (D-Mass.) wrote CMS Administrator Chiquita Brooks-LaSure urging the agency to increase oversight and transparency of broker participation and compensation. Specifically, they asked Brooks-LaSure to address this in the upcoming Contract Year 2025 Part C and D Policy and Technical Changes proposed rule, which was submitted to the White House Office of Management and Budget on Aug. 24 and cleared OMB on Oct. 27, with publication still pending as of AIS Health press time. “We appreciate the previous actions taken by [CMS] to prioritize the health and well-being of our nation’s seniors by ensuring that beneficiaries have access to accurate and unbiased information about Medicare coverage. These policies protect the integrity of the Medicare program and ensure that seniors are able to access affordable health coverage,” wrote Pallone, who is ranking member of the House Energy and Commerce Committee, and Neal, ranking member of Ways and Means. But they encouraged CMS to build on those policies and reform total broker payments by setting standardized limits on compensation. Ensuring such payments are set at “reasonable amounts” would eliminate “incentives that encourage enrollment in plans with the highest broker payment that may not be best suited for seniors’ health needs,” they wrote.

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© 2024 MMIT

News Briefs: CMS Says 30 States Pause Medicaid Disenrollments

CMS will reinstate coverage for approximately 500,000 Medicaid and CHIP enrollees, mainly children, after they were improperly disenrolled from the safety net insurance programs.According to CMS, on Aug. 30 the agency sent a letter to all states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands “requiring them to determine and report whether they have a systems issue that inappropriately disenrolls children and families, even when the state had information indicating that they remained eligible for Medicaid and CHIP coverage.” The agency said 30 states have reported that they are working through the “systems issue” behind the improper disenrollments and have paused procedural disenrollments for affected beneficiaries. Every state Medicaid program is working through the resumption of Medicaid eligibility redeterminations, which were paused for over two years as part of the federal response to the COVID-19 pandemic.

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© 2024 MMIT

mPulse Infuses Behavioral Science Into Text-Based Outreach to Medicaid Members

As Medicaid managed care organizations look to assist states with ensuring enrollees maintain coverage throughout the redetermination process, text messaging is often seen an effective way to reach members whose only method of communication may be a smartphone. During an Aug. 9 webinar hosted by Medicaid Health Plans of America, mPulse Mobile Chief Marketing Officer Brendan McClure said the technology company has reached out to more than 7 million members this year on behalf of its Medicaid plan clients.

The engagement solutions provider divides its phone-based outreach efforts into two main categories:

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Medicaid MCOs Try Multiple Touchpoints to Boost Redetermination Awareness

Effective April 1, states were allowed to begin disenrolling people from Medicaid who no longer qualify after a multiyear pause during the COVID-19 public health emergency (PHE). Yet data from the federal government suggests many people are losing coverage for procedural reasons, and surveys show a concerning lack of awareness regarding the redetermination process. Medicaid managed care organizations say they are working to supplement outreach efforts from state and federal agencies and are trying a variety of tactics to activate impacted members, including text messaging and notifications at the pharmacy. Since the start of redeterminations, CMS has clarified that states may rely on MCOs to assist enrollees with completing and submitting renewal forms and even pay them for this type of work.

KFF estimates that at least 4.77 million Medicaid beneficiaries have been disenrolled as of Aug. 15, with three quarters of disenrollments occurring for procedural reasons. HHS had previously estimated that 8.2 million people will no longer qualify for Medicaid once redeterminations resumed and find other coverage, while 6.8 million Medicaid enrollees could lose coverage despite still being eligible.

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© 2024 MMIT

Spending Bill Ends Uncertainty by Setting Start Date for Medicaid Redeterminations

While making their financial projections for 2023, health insurers have had to acknowledge that the timing of a major headwind — the resumption of Medicaid eligibility redeterminations — continued to be a question mark. Now, if a newly released draft of Congress’ year-end spending bill is passed as written, that uncertainty will be removed and replaced with a firm date: April 1.

Industry observers tell AIS Health, a division of MMIT, that it’s helpful for both state governments and managed care organizations to have a definite answer about when millions of people will start losing their Medicaid eligibility — although the event itself remains a net negative for MCOs.

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Pandemic-Transformed Medicaid Faces Looming Eligibility Challenge

At some point in the next year, it’s likely that Medicaid eligibility redeterminations will resume — a process that will be kicked off when the Biden administration declares an end to the COVID-19 public health emergency (PHE). Medicaid has hit record-high enrollment this year, meaning states and managed care organizations will have to contact more people than they ever have before in a short period of time; meanwhile, MCOs will also have to deal with looming cuts to reimbursement and rising provider rates.

Margins for MCOs seem likely to shrink. Provider rate increases are coming soon, though it’s likely that they will vary in timing and scope depending on market and contract cycles. However, the pricing effects of workforce shortages and inflation will impact every plan and provider, sources previously told AIS Health.

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Once Nonexistent, Pipeline for RSV Vaccines is Now Crowded With Contenders

For decades, a successful vaccine for respiratory syncytial virus (RSV) — which sends thousands of infants and older adults to the hospital each year — has remained elusive. Yet several heavyweight pharmaceutical companies are now poised to fill the void, as they’re nearing the finish line in the development of RSV vaccines that could ultimately comprise a multibillion-dollar market. Coverage of the new vaccines, according to an industry expert, will hinge on the all-important Advisory Committee on Immunization Practices (ACIP), which requires payers to fully reimburse any inoculation that it recommends.

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Health Policy Experts Warn of Consequences If ARPA Subsidies Expire and Medicaid Redeterminations Resume

During the past two years, the number of people enrolled in Medicaid and marketplace plans has significantly increased thanks to legislation meant to help people as the COVID-19 pandemic continues. But millions of those people may lose their health insurance coverage in the coming months if those policies end, which could lead to difficult circumstances for them and the health care industry as a whole, according to health policy experts who spoke during a July 15 webinar sponsored by Alliance for Health Policy, a Washington, D.C., nonprofit.

As of March 2022, nearly 87.9 million people were enrolled in Medicaid or the Children’s Health Insurance Program, up from just over 71.2 million in February 2020, according to the Kaiser Family Foundation (KFF). Sara Collins, Ph.D., vice president for health care coverage and access at the Commonwealth Fund, noted that much of the increase could be attributed to the Families First Coronavirus Response Act (FFCRA).

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© 2024 MMIT