Membership Growth

The Biden administration on Jan. 25 released a Request for Information to seek feedback about the best way to enhance Medicare Advantage data capabilities and increase public transparency. In a press release, HHS pointedly noted that “transparency is especially important now that MA has grown to over 50% of Medicare enrollment, and the government is expected to pay MA health insurance companies over $7 trillion over the next decade.” To that end, the agency said it’s seeking data-related input on aspects of the MA program including access to care, prior authorization, provider directories and networks, supplemental benefits, marketing; care quality and outcomes, value-based care arrangements and equity, and “healthy competition in the market, including the effects of vertical integration and how that affects payment.”

A recent status report on the Medicare Advantage program presented by analysts with the Medicare Payment Advisory Commission led one MedPAC member to accuse leadership of producing a negative report for partisan political purposes. According to a MedPage Today writeup of a recent MedPAC public meeting, Brian Miller, M.D., of Johns Hopkins University said the report “appears to be slanted to arrive at a foregone conclusion in order to set up and provide political cover” before CMS issues its annual rate notice and “reads like attack journalism.” The report, which was presented on Jan. 12, showed that national market concentration in MA is nearing the Herfindahl-Hirschman Index (HHI) “highly concentrated” threshold, which the Dept. of Justice and the Federal Trade Commission use to review mergers. According to the presentation, the three largest MA insurers combined enroll 58% of MA members and in a typical market enroll roughly 80% of beneficiaries. That report also suggested that MA coding continues to generate excess payments relative to fee-for-service Medicare. Specifically, the MedPAC analysis of CMS enrollment and risk score files estimated that coding intensity will drive payments to MA organizations of $54 billion this year, up from $47 billion in 2023. “It is not lost on me that this discussion is occurring immediately prior to the CMS Medicare Advantage rate notice,” stated Miller, according to a transcript of the meeting. “The Chair has noted that he is in regular communication with CMS leadership. This gives the appearance that MedPAC as an independent and thoughtful policy organization is being hijacked for partisan political aims.” CMS’s annual preliminary rate notice is due out by Feb. 1.

The Cigna Group may sell its Medicare Advantage business to Health Care Service Corp. for between $3 billion and $4 billion, according to the Wall Street Journal. After Cigna and Humana Inc. reportedly abandoned their rumored talks of combining, Bloomberg last month reported that HCSC and Elevance Health, Inc. were competing to buy Cigna’s MA segment. Sources close to the matter said Cigna is in “exclusive talks” with HCSC, which operates Blue Cross and Blue Shield plans in five states, the Wall Street Journal reported on Jan. 3.

After securing an amended credit agreement with JP Morgan, Bright Health Group, Inc. on Jan 1. finalized the previously announced sale of its Medicare Advantage assets to Molina Healthcare, Inc. The technology-driven startup on Dec. 29 said an amendment to its credit facility with JP Morgan would reduce the final repayment amount by roughly $30 million to approximately $298 million. With the close of the MA sale — which involves the California plans Brand New Day and Central Health Plan — the company has eliminated its secured debt and will use the remaining proceeds of the sale to “provide a solid foundation” for advancing its NeueHealth accountable care organization business, according to a Jan. 2 press release. Molina in December said it would buy the MA plans for approximately $425 million, down from the originally announced $510 million; analysts speculated the discount had to do with underperformance in Bright’s MA business due to heightened Medicare utilization trends in 2023.The deal nets Molina 121,863 MA members, boosting its membership by 115%, according to AIS’s Directory of Health Plans.

Nearly 32 million people were enrolled in Medicare Advantage plans as of December 2023, up from about 29.5 million in December 2022, according to AIS’s Directory of Health Plans. And while the six national carriers led by UnitedHealthcare currently enroll 69.8% of the market, regional Blues affiliates, provider-sponsored payers and other locally focused insurers have largely continued to grow alongside them. Tech-enabled startup insurers, meanwhile, saw some of the most explosive gains — and losses — in 2023. See the year-end enrollment wrap-up in the graphics below.

While major Medicare Advantage insurers are bracing for potential revenue reductions stemming from upcoming changes to the risk adjustment model, three insurers presenting at their recent investor conferences appeared bullish on the prospect of continued growth in MA, and in particular, the sizable opportunity to serve people who are dually eligible for Medicare and Medicaid. According to a recent analysis from AIS’s Directory of Health Plans, roughly 5.6 million out of an estimated 13 million dual eligibles in the U.S. are enrolled in a Dual Eligible Special Needs Plan (D-SNP).

Although managed Medicaid and the exchanges remain its No. 1 and 2 revenue drivers, Centene Corp.’s MA business — which has a large concentration of D-SNP members — will be an “important growth driver for Centene long term,” CEO Sarah London told investors on Dec. 12.

Just a few weeks after reports surfaced that The Cigna Group was looking to offload its Medicare Advantage business, reports emerged of a possible transaction with Humana Inc. that would create a diversified health insurance giant in the same weight class as CVS Health Corp. and UnitedHealth Group. Wall Street analysts agreed such a deal would invite scrutiny from regulators, partly because of Cigna’s substantial MA overlap with Humana, although multistate Blues insurer Health Care Service Corp. (HCSC) is reportedly interested in picking up Cigna’s MA book. To complete the square dance, rumors have also resurfaced of Walmart’s interest in purchasing Humana.

Reuters on Nov. 6 first reported that Cigna was exploring a sale of its MA business, which represents about 3% of its overall medical membership. Sources told the news outlet that the insurer was working with an investment bank to evaluate its options and that the potential sale could bring in several billions of dollars. Analysts at the time suspected that the move was an effort to preempt the intense antitrust scrutiny Cigna might face if it sought to merge with a government-focused firm such as Humana or Centene Corp.

Leading up to the 2024 Annual Election Period (AEP) that started on Oct. 15 and concluded on Dec. 7, major Medicare Advantage insurers unveiling geographic expansions signaled their continued pursuit of dually eligible Medicare-Medicaid beneficiaries. A new analysis of the 2024 Special Needs Plan landscape confirms that more SNPs designed specifically for dual eligibles will be available next year, while interest in Institutional SNPs (I-SNPs) appears to be waning after experiencing a short burst of growth. The Chronic Condition SNP (C-SNP) market, meanwhile, will remain relatively stable.

There will be 1,368 SNPs on the market in 2024, up from 1,320 in 2023 — a modest increase compared with the 10% jump between 2022 and 2023, according to the analysis from Clear View Solutions, LLC. Within the total, however, Clear View observed a notable increase in the number of D-SNPs. In 2024, there will be 874 D-SNPs available — including 698 plans that were available in 2023 and 176 new plans — compared with 809 in 2023 and 401 in 2018, before the Bipartisan Budget Act (BBA) of that same year granted permanent authorization to all SNP types. There are also more D-SNPs being added than dropped next year, which could be due to some plan consolidation, observes Clear View.

From 2017 to 2023, the number of people enrolled in Special Needs Plans (SNPs) grew by more than 150% to about 6.3 million lives, according to the latest update to AIS’s Directory of Health Plans. Dual Eligible SNPs (D-SNPs) saw the most growth, a mammoth 170% increase to 5.6 million lives, followed by Institutional SNPS (I-SNPs) at 86% growth, then Chronic Condition SNPs (C-SNPs) at 58% growth.

Payers have grown to meet that surge, with the total number of SNP offerings expanding from 498 to 1,082 plans between 2017 and 2023, per an analysis of CMS’s Landscape files from Clear View Solutions, LLC. Clear View’s data shows that in a typical year, the number of new SNP offerings has exceeded the number of plans dropped.

As publicly traded insurers report their third-quarter 2023 financials this fall, two of the Medicare Advantage organizations most impacted by the 2024 Star Ratings recently expressed confidence in their ability to regain higher marks, driven in part by increased adoption of value-based care models.

For the quarter ending Sept. 30, Elevance Health, Inc. beat Wall Street expectations with adjusted earnings per share (EPS) of $8.99, an increase of roughly 20% over the third quarter of 2022, and recorded operating revenue of $42.5 billion, up 7.2% from the prior-year quarter. Its health benefits operating margin of 5.0% was also above consensus, aided by a medical loss ratio of 86.8%, which came in lower (better) than 87.2% reported in the year-ago quarter — fundamentals that Goldman Sachs viewed as “generally favorable” in an Oct. 18 note to investors. The insurer ended the quarter with 47.3 million medical members, a year-over-year increase of 42,000 lives, reflecting growth in its Affordable Care Act, BlueCard and MA businesses. During the quarter, however, membership fell by 664,000, driven by attrition in Medicaid due to eligibility redeterminations and a new entrant into one of the insurer’s state programs in July, explained Chief Financial Officer John Gallina during a conference call held on Oct. 18 to discuss third-quarter 2023 earnings.

UnitedHealth Group on Oct. 13 said overall revenues for the third quarter of 2023 climbed 14% from a year ago to $92.4 billion, reflecting double-digit growth at both its Optum and UnitedHealthcare divisions. The company also recorded a medical loss ratio of 82.3%, which was higher (worse) than the 81.6% reported for the third quarter of 2022. UnitedHealth said that was largely due to the previously disclosed uptick in inpatient care, primarily among seniors, and business mix. Revenues for the UnitedHealthcare insurance segment rose 13% from a year ago to $69.9 billion, reflecting growth in the number of people served. The company estimated it will have added nearly 1 million Medicare Advantage customers by the end of the year. The company raised its 2023 adjusted earnings per share outlook to a range of $24.85 to $25, from a previous range of $23.60 to $23.75 per share.