Managed Medicaid

More than 710,000 people lost their Medicaid or Children’s Health Insurance Program (CHIP) coverage in April, and about 55,000 of those individuals have transitioned to Affordable Care Act marketplace coverage, according to CMS’s first data release on the restarted Medicaid eligibility redeterminations process. Starting April 1, states were permitted to start disenrolling people from Medicaid who no longer qualify after a multiyear pause during the COVID-19 public health emergency.

Of the 2.2 million enrollees due for renewal in April across 18 states, 45.5% had their coverage renewed, with more than 55% receiving automatic renewals. About one-third of the group lost their coverage, and 79% of those coverage losses were due to procedural reasons — meaning individuals didn’t return their renewal form within a specific time frame or the state was unable to reach them.

Humana Inc. on Aug. 2 said it expects to enroll approximately 825,000 members in its individual Medicare Advantage products this year, adding another 50,000 members to its initial projections and reflecting year-over-year growth of 18%. For the quarter ending June 30, the MA-focused insurer reported adjusted earnings per share (EPS) of $8.94, up from $8.76 in the second quarter of 2022, and a medical loss ratio (MLR) of 86.3%, up from 85.8% a year ago. The company raised its full-year 2023 adjusted EPS guidance to “at least $28.25,” reflecting a 25-cent increase. Humana also highlighted “stabilizing” MA utilization based on its most recent claims activity and said it continues to predict a full-year MLR of between 86.3% and 87.3%.

CVS Health Corp. on Aug. 2 reported second-quarter 2023 consolidated revenues of $88.9 billion, including $26.7 billion in revenue for the health care benefits segment, and reflecting overall growth of 10.3% from the year-ago quarter. Adjusted operating income for the health care segment declined by nearly 20% from a year ago, partly because of increased outpatient utilization in Medicare Advantage when compared with pandemic-driven utilization levels in the prior year, CVS Health explained in a detailed earnings release. For the quarter ending June 30, the company recorded an MLR of 86.2%, compared with 82.7% in the year-ago quarter, and adjusted EPS of $2.21, down from $2.53 in the second quarter of 2022. CVS Health confirmed its adjusted EPS guidance range of $8.50 to $8.70.

Government-focused publicly traded insurers reporting second-quarter 2023 earnings in July devoted a fair amount of discussion to the impact of Medicaid redeterminations on enrollment and rate adjustments, while analysts were interested in the recent trend of increased medical costs, particularly on the Medicare side. Despite these potential headwinds, the insurers appeared confident in their financial outlook for 2023, as all four raised their earnings projections for the full year.

After pausing eligibility verifications in exchange for receiving enhanced federal funding during the COVID-19 public health emergency (PHE), states were allowed to begin disenrolling people who longer qualify for Medicaid as of April 1. According to the latest update to AIS’s Directory of Health Plans, managed Medicaid enrollment as of June was nearly 73.4 million across 41 states, compared with 72.9 million a year ago — a decline that doesn’t yet fully reflect the impact of ongoing redeterminations. Nevertheless, some states have aggressively moved forward, prompting CMS to issue revised guidelines on best practices to avoid terminations driven by procedural reasons. Florida, for example, has already lost some 224,000 managed care enrollees (or close to 5%) from a year ago, according to DHP’s estimates.

Medicaid managed care organizations denied one out of every eight prior authorization requests in 2019, according to a recent report by the HHS Office of Inspector General. Among the 115 MCOs reviewed, 12 MCOs that covered about 2.7 million enrollees had denial rates higher than 25%.

The report studied seven MCO parent companies with the greatest number of Medicaid enrollees across 37 states. Molina Healthcare, Inc. had the highest overall prior authorization denial rate at 17.7%, with seven of its 12 MCOs seeing denial rates greater than 25%.

Medicaid managed care beneficiaries face “high rates of prior authorization denials” and “limited state oversight” of prior authorization, according to a notable new report from the HHS Office of Inspector General (OIG). Medicaid experts who reviewed the report say it demonstrates that Medicaid members and safety net providers may not be able to appeal denials for administrative reasons, and they add that states must do more to facilitate appeals to and prevent inappropriate denials by contracted plans.

The OIG found, in a review of 2019 claims data from seven multistate carriers, that the studied MCOs “fully or partially denied approximately 2.2 million requests for the prior authorization of services,” amounting to one out of every eight requests, or 12.5% of all prior authorization requests. That rate was more than double the Medicare Advantage prior authorization denial rate of 5.7% in 2019, according to the OIG report published July 17.

UnitedHealth Group saw higher-than-expected utilization in the second quarter, driven by seniors and those seeking behavioral health care. However, the company kept its full-year adjusted earnings per share (EPS) guidance intact, indicating that it expects that it can offset the higher costs associated with increased utilization.

For the quarter, UnitedHealth had a medical loss ratio (MLR) of 83.2%, up from 81.5% in last year’s second quarter and from 82.2% in this year’s first quarter. That was due primarily to an increase in the number of members who sought care during the quarter, particularly in seniors who had delayed outpatient orthopedic and cardiac surgeries during the coronavirus pandemic.

John Rex, UnitedHealth’s Chief Financial Officer, told analysts during a July 14 conference call that the company filed its 2024 Medicare Advantage offerings with the assumption the elevated level of seniors seeking care will persist into next year.

Elevance Health, Inc. reported positive second-quarter 2023 results, powered by solid commercial performance and promising returns from its Carelon health services division, which was launched last year.

The firm, which is the parent company of the Anthem and Wellpoint insurance brands, took in $43.4 billion of operating revenue in the quarter, up $4.9 billion or 12.7% year-over-year. Adjusted earnings per share (EPS) in the quarter were $9.04, beating the Wall Street consensus of $8.78 and representing a year-over-year increase of $1.07, or slightly more than 13%. The firm’s medical loss ratio (MLR) was 86.4%, down 70 basis points from the prior-year quarter — but it increased from the 85.8% figure.

An Elevance press release said the strong top-line revenue result was “primarily driven by premium rate increases in our Health Benefits business and higher premium revenue due to membership growth in Medicaid and Medicare. The increase in operating revenue was further attributable to growth in pharmacy product revenue within CarelonRx driven by growth in external pharmacy members served and the acquisition of BioPlus” — a specialty pharmacy firm — “in the first quarter of 2023.”

Enrollment in both commercial health coverage and public health insurance slightly increased over the past six months, according to AIS’s Directory of Health Plans. Managed Medicaid membership continued to grow, from 74.0 million in 2022 to 76.5 million in 2023, while a record high 16.7 million people enrolled in Affordable Care Act marketplace coverage. Commercial (employer-based) health coverage grew by nearly 1 million lives, with several major national health plans reporting double-digit growth.

The return of Medicaid redeterminations, which the managed care sector expected to be a daunting challenge, has proven even more difficult to handle than anticipated. States have begun to seek more time and resources from CMS to manage staggering amounts of beneficiary outreach and other administrative chores. Now, thanks to recent regulatory guidance, states can also pay managed care organizations to take on some of that work.

Several states — which are ultimately responsible for handling the income checks and disenrollments necessary for what many have called the “unwinding” of COVID-19 pandemic-related continuous enrollment — have paused redeterminations or extended their deadlines for enrollees to complete their redetermination paperwork, and others may follow. The pauses are clear evidence of the scale and complexity of the task at hand.

CMS on July 7 unveiled a long-awaited regulation that would crack down on short-term, limited-duration insurance (STLDI), which some consumer advocates — and the Biden administration — refer to as “junk plans.” Designed to fill a temporary gap in insurance coverage, STLDI plans are exempt from the Affordable Care Act’s rules for comprehensive coverage, allowing them, for example, to deny coverage for preexisting conditions and set lifetime and annual dollar limits on coverage. The Obama administration capped the duration of such plans at three months and limited their renewability, but a 2018 rule from the Trump administration allowed STLDI plans to cover individuals for up to 364 days and be renewed for up to 36 months. If finalized, the Biden administration’s notice of proposed rulemaking would return to the Obama-era three-month limit for SLTDI plans’ initial contract period, and it would set the maximum coverage period at four months, taking into account any renewals or extensions.