After an administrative law judge (ALJ) agreed with protesters that the Arizona Health Care Cost Containment System (AHCCCS) used an “arbitrary and flawed procurement process” that involved the use of undisclosed scoring criteria when awarding new contracts for the Arizona Long Term Care System (ALTCS), the implementation of the new pacts is on hold. AHCCCS on Aug. 13 said it is “pausing member transition activities” related to the new contracts that were scheduled to begin Oct. 1 and initially awarded to subsidiaries of Centene Corp. and UnitedHealthcare (UHC).

AHCCCS has 30 days to accept, modify or reject the ALJ’s decision, which was issued Aug. 9. The agency said it is “currently in the process of reviewing” the decision.

Medicare Advantage membership growth during both the 2024 Annual Election Period (AEP) and the Open Enrollment Period (OEP) was largely driven by major insurers (namely, CVS Health Corp.’s Aetna) and some of the insurtechs, according to a recent AIS Health analysis. But many of the regional and provider-led insurers that performed well during the AEP also continued their growth through the OEP. One such plan is VNS Health, which has long catered to underserved New Yorkers with complex needs and recently relaunched MA plans designed for Medicare-Medicaid dual eligibles and “near duals.”

As part of an annual series on the growth stories of AEP/OEP “winners,” AIS Health, a division of MMIT, spoke with leaders at VNS Health about their successful reentry into MA.

Outside of serving seniors through a Special Needs Plan geared toward institutional/institutional equivalent enrollees, Medicare Advantage plans are not fundamentally designed to support seniors’ long-term care needs. But with their inherent focus on care coordination and recent innovations in nonmedical benefits that can support aging in place, MA plans are uniquely positioned to address gaps in the continuum between Medicare and Medicaid, which is the primary payer of long-term services and supports (LTSS).

Speaking during a prerecorded session of the upcoming Virtual Fifth National Medicare Advantage Summit, panelists agreed that while nonmedical benefits were initially perceived as marketing tools to differentiate plans from their competitors, there is great potential for them to serve enrollees in the long term. Participants in the panel discussion, “The Opportunity for Medicare Advantage Plans to Address Long-Term Care Needs,” which will be livestreamed and archived on July 10, discussed a variety of benefit innovations and the mounting evidence around their impact to costs, outcomes and quality of life.

After interest among long-term care providers and Medicare Advantage insurers to partner on Institutional Special Needs Plans plateaued during the COVID-19 pandemic, a somewhat ambiguous provision in a recent CMS final rule has the potential to significantly increase the I-SNP market. By expanding the definition of qualifying facilities that serve institutionalized members, SNP experts say it could reduce current barriers to enrollment and garner interest from assisted living facilities (ALFs), which have largely been shut out of the I-SNP opportunity.

I-SNPs, which were permanently authorized in the Bipartisan Budget Act of 2018, currently restrict enrollment to MA-eligible individuals who meet the definitions of “institutionalized” (i.e., they continuously reside for 90 days or longer in one of several types of long-term care facilities or are expected to need the level of services provided in such a facility) or “institutionalized-equivalent,” meaning they reside in an ALF and get the same level of care they’d receive in a qualifying long-term care facility. Such facilities that currently qualify (as defined by Medicaid or Medicare statute) are skilled nursing facilities, nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric hospitals, rehabilitation hospitals or units, long-term care facilities and “swing-bed” (e.g., critical access) hospitals.

When it comes to aging in place, seniors in the U.S. have a hodgepodge of programs and services available to them, and health plans can be a connector to and integrator of those services in their respective markets. Speakers at AHIP’s 2024 Medicare, Medicaid, Duals & Commercial Markets Forum, held March 12 to 14 in Baltimore, agreed that health plans can also play a valuable role in driving innovations across the Medicare and Medicaid programs, such as providing emergency and acute care in the home, supporting family caregivers, and advocating for policy solutions.

Before CMS in 2020 introduced the Hospital Without Walls program enabling health systems to provide acute hospital care in the home, integrated insurer-provider Kaiser Permanente (KP) launched the Advanced Care at Home (ACAH) model. One of several KP initiatives that support aging in place, ACAH leverages expert care teams and technology to provide 24/7 physician-led acute care and coordinate patients’ recovery in the familiar setting of the home. Eligible patients are identified in urgent care, emergency and/or inpatient settings but must also meet certain social and clinical criteria, explained Rachna Pandya, regional strategic implementation leader of Medicare operations and strategy, during the session, “Best Practices to Support Aging in Place.”

As the CMS Center for Medicare and Medicaid Innovation works toward its goal of having all fee-for-service (FFS) Medicare beneficiaries and most Medicaid beneficiaries in accountable care relationships by 2030, CMMI this year has unveiled three models aimed at advancing value-based care. One of them is the Guiding an Improved Dementia Experience (GUIDE) Model, which combines care coordination, caregiver support and respite services to improve the quality of life for people with dementia and their caregivers while delaying avoidable long-term nursing facility placement. Although the model does not serve Medicare Advantage beneficiaries, its mission appears to parallel specialized MA plans that offer supplemental benefits aimed at helping people age in place, deploy interdisciplinary care teams and empower caregivers to play an active role in their loved ones’ care.

An estimated 6.7 million people in the U.S. are currently living with Alzheimer’s or another form of dementia, and that number is expected to grow to nearly 14 million by 2060. Medicare will cover most of those Americans at some point, but the program as it exists today does not have a standardized care delivery approach for dementia, observed Tonya Saffer, director of the division for health care payment models at CMMI, during a Sept. 13 webinar on the model hosted by Manatt, Phelps & Phillips, LLP.

After issuing a request for information (RFI) and reviewing feedback from stakeholders, Sen. Bill Cassidy, M.D. (R-La.), is circulating discussion draft legislation to improve coverage for Medicare-Medicaid dual eligibles. While several industry experts agree that the legislation is moving integration in the right direction, they also say certain elements of it may be overly ambitious and raise many questions, such as whether states that have limited the number of Medicaid managed care organizations will inhibit the ability of Medicare Advantage plans to participate in the new model.

Cassidy, who frequently tackles health care issues as a member of several Senate committees, led a bipartisan group of senators in drafting the proposal, which was informed by more than 125 responses to the November RFI. According to a Cassidy aide, the senators will collect feedback through July 1 and hope to formally introduce legislation after Labor Day.

As Programs of All-Inclusive Care for the Elderly (PACE) grow across the U.S., sponsoring entities can expect CMS to put additional scrutiny on their operations. New PACE organizations are subject to audits in their first three years of operation, and updated audit protocols for 2023 include expanded collection of data around both the clinical services provided to participants as well as the non-clinical program features such as transportation, according to BluePeak Advisors, a division of Gallagher Benefit Services, Inc. This will require significantly more man hours and readiness on the part of the sponsoring PACE organization, adds BluePeak, which helps PACE organizations and Medicare Advantage organizations prepare for audits.

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.

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.