Marketing

After pushing for new limits on broker compensation and other changes to ensure seniors are guided to Medicare Advantage and Part D plans that best meet their needs, the Alliance of Community Health Plans (ACHP) on April 4 celebrated a victory with the release of CMS’s final rule making policy and technical changes for the 2025 plan year. ACHP, which represents provider-aligned, not-for-profit health plans, had spelled out its hopes for these policies in its broader “MA for Tomorrow” framework and provided Senate testimony on the impact of excessive “add-on” broker fees paid by larger plans. After CMS issued its final rule containing new marketing-related policies, AIS Health, a division of MMIT, spoke with ACHP’s executive vice president of public policy, Dan Jones, to learn more about the group’s position.

Building on a sweeping set of marketing-related provisions that went into effect this year, CMS’s recently finalized 2025 Medicare Advantage and Part D rule put new restraints on agent and broker compensation, among other things. The provisions advance the Biden administration’s ongoing efforts to shield consumers from misleading marketing, but with more of a focus on activities performed by independent agents and brokers rather than the broader third-party marketing organization (TPMO) industry that was targeted in previous rulemaking. Industry experts tell AIS Health, a division of MMIT, that the finalized provisions are still open to interpretation when it comes to the role of one type of TPMO — field marketing organizations (FMO) — which often conduct lead generating and advertising on behalf of plans.

As Medicare Advantage insurers face revenue headwinds driven by changes to risk adjustment, Star Ratings and benchmark rates, one overarching question at recent conferences and webinars has been, how will MA plans do more with less? Medicare beneficiaries in recent years have flocked to MA largely because of rich benefit offerings they can’t get in fee-for-service Medicare, and they have grown accustomed to items like comprehensive dental, flex cards and fitness benefits. But as the June 3 bid deadline approaches, insurers are considering what benefits they may have to tweak and how they’ll market those benefits to consumers for 2025.

During an April 3 webinar cohosted by Deft Research and Rebellis Group, Deft Vice President of Client Services Rob Lourenço said the market is already showing signs of revenue changes trickling down to the consumer. In its latest Medicare Shopping and Switching Study, Deft observed a slight “pullback in certain benefits” and at a high level saw more removals of benefits than additions this year. Comparing plans that were offered in both 2023 and 2024, Deft saw that routine eye exam coverage remained stable, while 4% of plans removed eyewear coverage and 1% added the benefit, resulting in a net decline of -3% for eyewear access.

Each year, AIS Health does a deep dive into the enrollment shifts that took place regionally and nationally over the Medicare Annual Election Period (AEP) and explores the myriad drivers of growth (or attrition). From benefit enhancements to creative new partnerships, three AEP leaders disclose details of their winning strategies to AIS Health, a division of MMIT.

From October 2023 to February 2024 — which reflects the full capture of lives enrolled during the AEP, which ran from Oct. 15 through Dec. 7 — CVS Health Corp.’s Aetna increased its MA enrollment by 18.9% and grabbed roughly half of all new enrollment in individual plans, including Dual Eligible Special Needs Plans (D-SNPs). Aetna significantly grew its geographic footprint in both segments, maintained stable provider networks, and on average, featured lower premiums, maximum out-of-pocket costs and drug deductibles in its non-SNP plans.

Like its competitors, Humana Inc.’s evolution from a pure-play health insurer to a highly diversified health care firm came with a rebranding. To that end, Humana Pharmacy — the company’s mail-order and retail pharmacy brand — in 2022 became CenterWell Pharmacy, nestled under the company’s CenterWell health services subsidiary. Now, that division not only has a new name, but also a new app.

The app — which is available to CenterWell Pharmacy members covered by Humana’s Medicare Advantage and Part D plans — represents a “total redesign,” with increased personalization capabilities and a streamlined approach to prescription management, the firm said in a Feb. 20 press release.

Medicare Advantage plans next year can expect to receive, on average, a 3.70% increase in risk adjusted revenue, according to the 2025 Advance Notice of payment changes for MA and Part D plans, released on Jan. 31. That’s when taking into account a 2.45% revenue decline stemming from CMS’s phased-in risk model revision and fee-for-service (FFS) normalization, an effective growth rate of 2.44% and an average increase in risk scores of 3.86%, according to a CMS fact sheet. CMS this time last year estimated that plans would see a modest rate increase of 1.03%, but revised that projection to 3.32% for 2024 after deciding to phase in changes to the CMS-Hierarchical Condition Categories risk adjustment model starting this year. CMS said it plans to proceed with the phase-in as described in last year’s rate notice and is “proposing updates to the Part D risk adjustment model to reflect the redesign of the Part D benefit as required by the IRA [Inflation Reduction Act].” CMS requested comments on the proposals by March 1; the final rate notice is expected to be released no later than April 1.

Although new policies proposed by CMS aim to protect Medicare beneficiaries by clamping down on fees that promote anticompetitive sales practices, critics of the proposed rule say CMS’s actions inappropriately target agents and brokers who sell Medicare Advantage plans and the field marketing organizations (FMOs) that support them. Further, they warn that CMS’s proposed changes to agent and broker reimbursement could lead to significant industry disruption that would trickle down to beneficiaries.

The proposed rule was issued on Nov. 6 and published in the Nov. 15 Federal Register and contained provisions aimed at improving access to behavioral health, enhancing transparency around supplemental benefits, streamlining enrollment options for dual eligibles, encouraging biosimilar product substitution, and assessing the impact of prior authorization policies on health equity. CMS accepted comments through Jan. 5, and it received hundreds of comment letters addressing the rule’s more controversial proposals seeking to place new limits on agent and broker compensation.

For years, health plans have turned to the prior authorization (PA) process to help prevent the use of unnecessary medications or medical procedures, improve patient outcomes and reduce costs. But as their use has exploded, physicians have pushed back, calling the restrictions onerous and accusing them of hampering their ability to provide care. Now, following years of complaints about PA, several health plans are cutting back on their use of the tactic, potentially spurring others to do the same.

Payers have used PA for decades to help reduce low-value or unsafe care, in turn protecting patients from ineffective or even harmful care and cutting down on waste and unnecessary costs for patients and plans alike. A Milliman report commissioned by the Blue Cross Blue Shield Association and published March 30, 2023, found that if PA were eliminated in the commercial market, increases in premiums could be between $43 billion and $63 billion annually.

Continuing a theme of protecting consumers and ensuring appropriate use of Medicare dollars, the Biden administration on Nov. 6 released its annual rule proposing policy and technical changes for the Medicare Advantage and Part D program. The 2025 MA and Part D proposed rule contains provisions aimed at improving access to behavioral health, streamlining enrollment options for dual eligibles, encouraging biosimilar product substitution, and assessing the impact of prior authorization policies on health equity. But some of the rule’s most detailed proposals centered on two hot-button program areas: supplemental benefits in MA and misleading marketing practices.  

Plans participating in the Medicare Advantage Value-Based Insurance Design (VBID) Model next year must begin reporting beneficiary-level utilization data on three key supplemental benefit categories: food, transportation, and general supports for living (e.g., utilities assistance). That requirement was included in a 2024 request for applications released late last year, and CMS officials have since hinted that the agency is interested in gathering additional information about supplemental benefit usage from the MA industry at large. But in a move that flew largely under the radar, the agency in September issued a proposal to begin requiring all MA organizations to submit information about supplemental benefits at a greater level of detail than some plans may be able to provide at this time, industry experts tell AIS Health, a division of MMIT.

Supplemental benefits have been on the rise since plan year 2019, when CMS’s reinterpreted definition of “primary health-related” enabled MAOs to include benefits like adult day health services, support for caregivers of enrollees and therapeutic massage in their plan benefit packages (PBPs). And with the passage of the CHRONIC Care Act of 2018, MA plans in 2020 began offering Special Supplemental Benefits for the Chronically Ill (SSBCI), a category of “non-primarily health related” items and services that can be made available to certain beneficiaries.