Managed Medicaid

News Briefs: CMS Projects Average Rate Increase of 1.03% for MA Plans in 2024

CMS in its 2024 Advance Notice projected that Medicare Advantage organizations can expect an average estimated change in revenue of 1.03%, when taking into account an average increase in risk scores of 3.3%. Even though analysts expected that rate to fall well below the robust 8% CMS predicted in its preliminary rate notice for 2023, they characterized it as low when excluding the risk scoring trend. The 2024 projection is also based on an effective growth rate of 2.09%, which CMS this time last year estimated would be 4.75%. Additionally, CMS will continue to apply the statutory minimum coding intensity adjustment of 5.9% to offset the effects of higher levels of coding intensity in MA relative to fee-for-service (FFS) Medicare. That coding intensity adjustment generated much discussion in comment letters on the Advance Notice last year. When asked during a Feb. 1 call with reporters why CMS again opted for the minimum adjustment, CMS Deputy Administrator and Center for Medicare Director Meena Seshamani, M.D., Ph.D., told AIS Health: “We continue to analyze and evaluate MA coding patterns, and 5.9% we feel is adequate at this time, and we continue to look at coding pattern differences, how we set that pattern adjustment [and] how that’s applied…in future years as well.” The preliminary rate notice also included technical updates to the risk adjustment model, including a reliance on condition categories from the ICD-10 classification system (instead of the ICD-9 system) and a shift to more recent underlying FFS data years to reflect 2018 diagnoses and 2019 expenditures.

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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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Even With Split Congress, Some Experts Predict Heightened Health Care Oversight

Although there’s a divided Congress this year — with Republicans controlling the House and Democrats in charge of the Senate — there are still a variety of health care policy issues that federal and state legislators alike have in their crosshairs, experts said during a recent webinar hosted by the Alliance for Health Policy. And some of those agenda items could be of considerable interest to health insurance companies.

Paul Edattel, principal of Todd Strategy Group, LLC, a federal government affairs firm, said he expects the newly Republican-controlled House to zero in on budgetary issues. “Budgetary issues are top-of-mind for House Republicans and some Senate Republicans,” he remarked during the Jan. 25 webinar. “Things like the operating budget for the Department of Health and Human Services...will be under really heightened scrutiny relative to prior Congresses.”

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Medicaid Faces Behavioral Health Provider Shortage, but MCOs Can Help

Amid heightened demand for mental health care, Medicaid managed care plans are struggling to connect their members with behavioral health care services. New research from the Kaiser Family Foundation (KFF) reveals that low payment rates, along with administrative burden and slow revenue cycles, are key reasons why Medicaid beneficiaries can’t access mental health care despite high need.

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News Briefs: UnitedHealth Group Reported Full-Year Revenue Growth of 13%, Maintained ’23 Guidance

Reporting financial results for the quarter and year ending Dec. 31, 2022, UnitedHealth Group on Jan. 13 said full-year revenues grew 13% year over year to $324.2 billion, and earnings from operations rose 19% to $28.4 billion. The company ended the year with an 82.0% medical loss ratio, which was consistent with projections provided at its annual Investor Day. The UnitedHealthcare segment reported full-year revenues of $249.7 billion, up 12% from the prior year, and operating earnings of $14.4 billion, up 20% from 2021. Those results were largely driven by growth in the number of people served, including an additional 615,000 in Medicare Advantage; overall MA enrollment exceeded 7.1 million at the end of 2022. UnitedHealth also reported adjusted earnings per share of $22.19 for full-year 2022 and maintained guidance of adjusted EPS between $24.40 and $24.90 for 2023.

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Federal Funding Law Introduces New Compliance Challenges in Telehealth, Mental Health, Medicaid

The Consolidated Appropriations Act, 2023 (2023 CAA) — the latest edition of the annual bill that funds the federal government — includes notable new policies that will touch on telehealth, behavioral health and Medicaid enrollment, among other areas. According to policy experts, because of the law, health plans have a great deal of new compliance requirements to manage in plan year 2023 and beyond.

Congress discussed notable reforms to telehealth and mental health care over the course of 2022, and the 2023 CAA includes permanent changes to the latter — and temporary extensions of pandemic-era policies for the former. Meanwhile, the law sets out requirements for states and managed care organizations disenrolling Medicaid members as part of the return of Medicaid eligibility redeterminations.

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2023 Outlook: Analysts Predict Another ‘Stable’ Year for Health Insurers

This year, a variety of headwinds and tailwinds are likely to buffet the health insurance industry, including inflation, a possible recession, the return of Medicaid eligibility checks, potential policy changes in Medicare Advantage, a split Congress, easing COVID costs and more. But the net effect of all those factors is likely to leave the sector on stable footing, analysts tell AIS Health.

“The tailwinds and headwinds change every year — that’s the case again for ’23. Overall, we think it’s balanced; that’s why we have a stable view,” says James Sung, associate director of insurance at S&P Global Ratings.

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News Briefs: Blues Plans Roll Out Contracting Org for Medical Benefit Drugs

A group of Blue Cross and Blue Shield affiliates has founded the Synergie Medication Collective, a medication contracting organization focused on improving affordability of clinically administered drugs that are covered under patients’ medical benefit. The goal of the organization is to establish “a more efficient contracting model” for things like multimillion-dollar gene therapies and infusible cancer drugs while “utilizing a transparent business model in collaboration with industry stakeholders.” The independent entity will go to market “in January of 2023,” according to a Jan. 5 press release, and is owned by the Blue Cross Blue Shield Association (BCBSA), Elevance Health, Blues-affiliate-owned Evio Pharmacy Solutions and Prime Therapeutics, and nine regional Blues plans. Pharmaceutical industry veteran Jarrod Henshaw will serve as Synergie’s CEO, and BCBSA President and CEO Kim Keck will be the organization’s initial board chair.

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By the Numbers: National Health Insurance Market in December 2022

Three years into the COVID-19 pandemic, enrollment in both commercial health coverage and public health insurance continued its growth. Managed Medicaid membership jumped from 61.4 million in December 2020 to 74.0 million in 2022, while Medicare Advantage (MA) enrollment reached 29.9 million this year, compared with 25.2 million in 2020, according to AIS’s Directory of Health Plans. Commercial health coverage gained 300,000 enrollees over the past year, yet several major health plans reported slight decreases in commercial enrollment, including Centene Corp. and CVS Health Corp.’s Aetna.

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© 2024 MMIT

By the Numbers: National Health Insurance Market in December 2022

Three years into the COVID-19 pandemic, enrollment in both commercial health coverage and public health insurance continued its growth. Managed Medicaid membership jumped from 61.4 million in December 2020 to 74.0 million in 2022, while Medicare Advantage (MA) enrollment reached 29.9 million this year, compared with 25.2 million in 2020, according to AIS’s Directory of Health Plans. Commercial health coverage gained 300,000 enrollees over the past year, yet several major health plans reported slight decreases in commercial enrollment, including Centene Corp. and CVS Health Corp.’s Aetna.

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© 2024 MMIT