Managed Medicaid

Three quarters into 2023, Moody’s Investors Service says the predictions it made at the start of the year for the health insurance sector — namely, earnings growth in the mid-to-high single digits — have largely proven accurate. However, while financial results were consistent with the credit rating firm’s expectations, analysts said in a new report that the reasons for those results were not exactly what they predicted.

“Our outlook was premised on reduced membership as a result of Medicaid redeterminations and the impact of a possible recession on commercial membership,” the analysts wrote in a report released on Nov. 20. “However, with no recession this year, commercial membership has been better than expected, but its growth has been offset by higher-than-expected MA [Medicare Advantage] utilization.” Additionally, “although Medicaid redeterminations are underway, their impact so far has been relatively small.”

Most employer-sponsored plans that have stop-loss insurance coverage should be able to pay for expensive gene therapies that have proven to be cost-effective, according to a recent paper from Health Affairs Scholar. However, a separate Health Affairs analysis published this month argues that payers must assess alternative payment models to afford the medications, which can cost more than $1 million per dose.

Aaron S. Kesselheim, M.D., one of the authors of the latter Health Affairs paper says that plans have taken varied approaches to paying for gene therapies ranging from “extremely permissive to extremely tight coverage.”

In 2024, managed care organizations will have to manage more complex care coordination requirements and compliance with ambitious equity goals in many states — even as Medicaid programs have been forced to step up reimbursement rates across many care categories. That’s according to the 2023 edition of KFF's annual survey of state Medicaid officials, which was released on Nov. 14.

The overwhelming majority of states are increasing Medicaid reimbursement rates across many care categories. Forty-eight states increased rates for at least one care category in 2023, and 47 will do the same in 2024. Only 21 states implemented at least one rate restriction in 2023, and 19 expect to do so in 2024.

That means total state spending for the safety net health insurance program is likely to increase, despite the ongoing reduction in total enrollment due to the return of eligibility redeterminations. Medicaid spending per enrollee is likely to increase in 2024, KFF found, while total Medicaid spending growth in the surveyed states will likely be 8.3% in 2023, down from 9.8% in 2022.

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.  

The Cigna Group could be fielding offers for its Medicare Advantage book, according to a Nov. 6 Reuters report. Experts say that a spinoff is plausible given the small size of Cigna’s MA book and Cigna’s heavy focus on commercial insurance — and Wall Street analysts say the move could be a first step toward a megamerger with a government-focused insurer.

Wells Fargo and RBC analysts say that the move could be an effort to preempt the intense antitrust scrutiny Cigna might face if it sought to merge with a government insurance-focused firm such as Humana Inc. or Centene Corp., because Cigna would have only commercial and Affordable Care Act marketplace books after an MA spinoff.

The Cigna Group could be fielding offers for its Medicare Advantage book, according to a Nov. 6 Reuters report. Experts say that a spinoff is plausible given the small size of Cigna’s MA book and Cigna’s heavy focus on commercial insurance — and Wall Street analysts say the move could be a first step towards a megamerger with a government-focused insurer.

Wells Fargo and RBC analysts say that the move could be an effort to preempt the intense antitrust scrutiny Cigna might face if it sought to merge with a government insurance-focused firm such as Humana Inc. or Centene Corp., because Cigna would have only commercial and Affordable Care Act marketplace books after an MA spinoff.

As of Nov. 1, nearly 10.1 million people had been disenrolled from Medicare during the resumed eligibility redetermination process, according to KFF’s Medicaid Enrollment and Unwinding Tracker. KFF, which compiles data from CMS and state websites, noted that 35% of people with a completed renewal application were disenrolled from Medicaid, while the remaining 65% had their coverage renewed. The disenrollment rates range from 10% in Illinois to 65% in Texas. During most of the COVID-19 public health emergency, states have been banned from conducting routine eligibility checks on Medicaid beneficiaries, but that process restarted on April 1.

Medica, which offers health insurance coverage in 12 states, has promoted Lisa Erickson to president and CEO, replacing John Naylor, who announced his resignation in July. Erickson joined Medica as chief financial officer in April after spending three and a half years as senior vice president of industry and network relations at Optum, UnitedHealth Group’s health services subsidiary. Medica is based in Minnetonka, Minnesota, a Minneapolis suburb.

Humana Inc.’s stock dipped after its third-quarter 2023 earnings report, with analysts largely blaming the firm’s revised estimate of its full-year medical loss ratio (MLR). The Medicare Advantage-focused insurer said that while it had been expecting health care utilization to stabilize, instead it continued at the elevated level that Humana first started noticing earlier in the year.

“This morning, we reported that our insurance segment benefit ratio exceeded expectations by 40 basis points due to higher medical costs in our Medicare Advantage business,” Chief Financial Officer Susan Diamond said during the company’s Nov. 1 earnings call. “We continue to experience an increase in COVID admissions in the third quarter, whereas our forecast previously assumed that this would occur in the fourth quarter.”

Centene Corp. reported sterling results in the third quarter of 2023, with the firm exceeding its quarterly earnings target and executing $773 million in share repurchases in that time. Executives promised further improvement on Medicare Advantage Star Ratings and touted notable individual marketplace enrollment growth during the quarter.

Centene executives credited the strong results to membership growth and low utilization in the firm’s Affordable Care Act marketplace book of business. Executives also said that the firm, which mainly has members who are enrolled in managed Medicaid plans, has capably weathered the return of eligibility redeterminations, which were suspended during the bulk of the COVID-19 public health emergency and resumed in the spring. The firm’s total Medicaid enrollment during the third quarter declined by only 2.9% year over year to 15.24 million members.

Enrollment in managed Medicaid dropped by more than 2.1 million from the first quarter of 2023 to the second quarter, as the Medicaid eligibility redeterminations process resumed after a multi-year pause, according to AIS’s Directory of Health Plans.

Seven of the major national Medicaid insurers saw membership losses, with Centene Corp. losing more than 602,000 HMO members. Its membership declined by more than 100,000 in three states: Florida, Iowa and Texas. At the 2023 Wells Fargo Healthcare Conference on Sept. 6, Centene’s executives said that they expected the number of disenrolled former members to be in the range of 2.3 million to 2.4 million. Elevance Health, Inc. also reported significant membership loss in the second quarter, as nearly 475,000 members left its Medicaid HMO plans.