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Major payer coverage policies across select categories often met fair access criteria for cost sharing, clinical eligibility, step therapy and provider restrictions, according to the third annual “Barriers to Fair Access” assessment published by the Institute for Clinical and Economic Review (ICER).

The analysis examined coverage policies for 18 drugs across 10 commercial formularies, eight Affordable Care Act exchange plans and the Veterans Health Administration national formulary, representing 42 million enrollees in total. ICER asked the payers for coverage policy information and leveraged the MMIT Analytics Market Access Database for additional information. (MMIT is the parent company of AIS Health, which maintains journalistic independence and did not play a role in producing the report.)

Despite the program receiving continued pushback from progressive lawmakers, data from the since-renamed Global and Professional Direct Contracting (GPDC) Model suggests that it is making significant strides, with participants driving gross savings exceeding $870 million in 2022, more than seven times the $117 million in gross savings reported for performance year 2021. At least five known Medicare Advantage sponsors have subsidiaries participating in the model, which allows Accountable Care Organizations (ACOs) to share risk and receive capitated payments for serving fee-for-service (FFS) beneficiaries.

CMS, in a fact sheet highlighting the performance year 2022 data, observed that the total financial savings increased year over year because of “growth in model participation, a longer performance period in PY2022 (12 months vs. 9 months in PY2021), and performance improvements by model participants as they gained experience.” Last year, 99 Direct Contracting Entities participated in the model, up from 53 DCEs in 2021, with 21 million beneficiary months, compared with 3 million beneficiary months in 2021.

With more than 78% of Medicaid beneficiaries enrolled in managed care plans as of the latest update to AIS’s Directory of Health Plans (DHP), winning and maintaining state contracts is crucial to MCOs that serve the Medicaid population. Six states have pending requests for proposals (RFPs) that serve about 11 million lives combined, while four states recently awarded new contracts. 

In recent years, new Medicaid RFPs have emphasized population health, asking payers to focus on health equity and social determinants of health while integrating services such as behavioral health, managed long-term services and supports (MLTSS), and pharmacy services into acute care. For example, Georgia will shift its aged, blind and disabled Medicaid population from fee-for-service care delivery to managed care when its new contracts begin, and Virginia plans to combine its MLTSS and managed Medicaid plans into one program. States also want improved analytics capabilities to track member outcomes and simplify claims and appeals processes.  

Here’s how major health insurers’ stock performed in October 2023. UnitedHealth Group had the highest closing stock price among major commercial insurers as of October 31, 2023, at $535.56. Humana Inc. had the highest closing stock price among major Medicare insurers at $523.69.

The Cigna Group may be considering the sale of its Medicare Advantage business, according to Reuters. The insurer is working with an investment bank to evaluate its options and the potential sale could bring in several billions of dollars, the sources told Reuters.

Cigna’s MA plans cover more than 580,000 lives in 35 states and the District of Columbia, according to the latest data from AIS’s Directory of Health Plans (DHP). The insurer is better known for its administrative services only employer-based health plans, and only 3.4% of its enrollees are in MA plans.

Major payer coverage policies across select categories often met fair access criteria for cost sharing, clinical eligibility, step therapy and provider restrictions, according to the third annual “Barriers to Fair Access” assessment published by the Institute for Clinical and Economic Review (ICER).

The analysis examined coverage policies for 18 drugs across 10 commercial formularies, eight Affordable Care Act exchange plans and the Veterans Health Administration national formulary, representing 42 million enrollees in total. ICER asked the payers for coverage policy information and leveraged the MMIT Analytics Market Access Database for additional information. (MMIT is the parent company of AIS Health, which maintains journalistic independence and did not play a role in producing the report.)

Only 2% of Medicare beneficiaries who enrolled in a stand-alone Prescription Drug Plan (PDP) in 2024 will be in contracts with 4 or more stars, compared to 42% in the 2022 plan year and 9% in 2023, according to CMS’s recently released estimates. The average Star Rating for PDPs dropped to 3.11 in 2024 from 3.70 in 2022, with two contracts receiving 1.5 stars.

The distribution change is largely fueled by methodology changes in how many of the Star Ratings are calculated. Known as Tukey outlier deletion, the changes center on removing outlier contract scores when determining the cut points for all non-Consumer Assessment of Healthcare Providers and Systems measures.

Fewer Medicare Advantage plans are using Special Supplemental Benefits for the Chronically Ill (SSBCI) to offer non-primarily health-related benefits (NPHRB) in 2024, according to an Oct. 30 report on 2024 non-medical supplemental benefits from ATI Advisory, funded by the SCAN Foundation. The health care research and advisory services firm observed some significant changes across supplemental benefit categories, and one social determinants of health (SDOH) expert expressed disappointment in MA organizations’ uptake of these benefits.

About 30% of MA plans are offering any NPHRB for 2024, just a 2.4% increase from the current plan year. And while fewer plans are using SSBCI to offer these benefits, the Center for Medicare and Medicaid Innovation’s Value-Based Insurance Design (VBID) model got a boost, with 10.4% of MA plans offering NPHRBs through the VBID model in 2024 vs. 5.5% of plans in 2023. (Plans participating in the newly extended VBID model are required to start offering supplemental benefits that address key SDOH in 2025, and ATI suggested some payers may be getting a jump on this.)

The average annual premium for employer-sponsored health insurance in 2023 was $8,435 for single coverage and $23,968 for family coverage, a 7% increase from 2022, according to the Kaiser Family Foundation 2023 Employer Health Benefits Survey. On average, premiums for single and family coverage grew 22% since 2018. Over the past 10 years, the growth seen in the average premium for family coverage outpaced the rate of inflation (47% vs. 30%), whereas the average family premium and average wages grew at comparable rates (47% vs. 42%).

Only 2% of Medicare beneficiaries who enrolled in a stand-alone Prescription Drug Plan (PDP) in 2024 will be in contracts with 4 or more stars, compared to 42% in the 2022 plan year and 9% in 2023, according to CMS’s recently released estimates. The average Star Rating for PDPs dropped to 3.11 in 2024 from 3.70 in 2022, with two contracts receiving 1.5 stars.

The distribution change is largely fueled by methodology changes in how many of the Star Ratings are calculated. Known as Tukey outlier deletion, the changes center on removing outlier contract scores when determining the cut points for all non-Consumer Assessment of Healthcare Providers and Systems measures.