Beneath High Ratings, MA-PD Stars Scores Show Shortcomings

Infographic: Number of Highly Rated MA-PD Contracts Soars in Pandemic’s Wake

October 21, 2021

Thanks to numerous flexibilities granted to plan sponsors during the COVID-19 public health emergency, nearly 70% of Medicare Advantage Prescription Drug (MA-PD) plans earned an overall rating of 4 stars or higher for 2022, CMS said on Oct. 8. That’s compared with just 49% of MA-PD plans in 2021. But the underlying data shows that quality improvements weren’t as impressive as the 2022 star ratings suggest, and with rising quality bonus payments (QBPs), the 2022 ratings could have major implications for MA revenue in the future, industry experts warn.

According to the CMS fact sheet released alongside the stars data, the average MA-PD star rating weighted by enrollment improved from 4.06 in 2021 to 4.37 for 2022. And 74 MA-PD contracts received the high performing indicator on the Medicare Plan Finder for earning 5 stars, compared with just 21 contracts for 2021 (see infographic). Fifty-three of those plans did not receive 5 stars last year. Weighted by enrollment, approximately 90% of MA-PD members are currently in contracts that will have 4 or more stars in 2022, CMS estimated.

Thanks to numerous flexibilities granted to plan sponsors during the COVID-19 public health emergency, nearly 70% of Medicare Advantage Prescription Drug (MA-PD) plans earned an overall rating of 4 stars or higher for 2022, CMS said on Oct. 8. That’s compared with just 49% of MA-PD plans in 2021. But the underlying data shows that quality improvements weren’t as impressive as the 2022 star ratings suggest, and with rising quality bonus payments (QBPs), the 2022 ratings could have major implications for MA revenue in the future, industry experts warn.

According to the CMS fact sheet released alongside the stars data, the average MA-PD star rating weighted by enrollment improved from 4.06 in 2021 to 4.37 for 2022. And 74 MA-PD contracts received the high performing indicator on the Medicare Plan Finder for earning 5 stars, compared with just 21 contracts for 2021 (see infographic). Fifty-three of those plans did not receive 5 stars last year. Weighted by enrollment, approximately 90% of MA-PD members are currently in contracts that will have 4 or more stars in 2022, CMS estimated.

“This year’s star ratings are just simply filled with a treasure trove of gifts from CMS to MA plans,” remarks Melissa Smith, executive vice president, consulting and professional services, at HealthMine, Inc., a Dallas-based health activation and engagement company. However, “those of us who eat, sleep and breathe stars believe this is a one-year anomaly.” That’s in part because, given the extraordinary circumstances of the COVID-19 pandemic, CMS in 2020 suspended the collection of Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data that would have impacted the 2021 star ratings and instead used the data from the prior year to calculate those ratings. In other words, explains Smith, about two-thirds of the 2021 star ratings were based on “holdover data.”

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Last-Minute Memo Roils MAOs’ Third-Party Marketing Plans

October 21, 2021

Just eight days into the marketing period for the 2022 Medicare plan year, CMS issued a memo on third-party marketing that, while expected, has led to some confusion among Medicare Advantage plans and their industry partners regarding already finalized marketing materials.

In an Oct. 8 memo from the Medicare Drug & Health Plan Contract Administration Group, Director Kathryn Coleman reminds MA organizations that they are responsible for the activities of first tier, downstream or related entities (FDRs), including those marketing on their behalf. The memo did not come as a surprise given increasing reports of aggressive and misleading marketing practices that plans say has resulted in members leaving the plan who never intended to switch, but experts take issue with the timing.

Just eight days into the marketing period for the 2022 Medicare plan year, CMS issued a memo on third-party marketing that, while expected, has led to some confusion among Medicare Advantage plans and their industry partners regarding already finalized marketing materials.

In an Oct. 8 memo from the Medicare Drug & Health Plan Contract Administration Group, Director Kathryn Coleman reminds MA organizations that they are responsible for the activities of first tier, downstream or related entities (FDRs), including those marketing on their behalf. The memo did not come as a surprise given increasing reports of aggressive and misleading marketing practices that plans say has resulted in members leaving the plan who never intended to switch, but experts take issue with the timing.

“CMS is particularly concerned with national advertisements promoting MA plan benefits and cost savings, which are only available in limited service areas or for limited groups of enrollees, as well as using words and imagery that may confuse beneficiaries or cause them to believe the advertisement is coming directly from the government,” writes Coleman. Moreover, the agency has received complaints from beneficiaries and caregivers about “sales tactics designed to rush or push beneficiaries into enrolling into a plan.”

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Plans Seek Ways to Promote Provider Use of Z Codes

October 21, 2021

As Medicare and Medicaid plans seek ways to improve overall care quality by addressing members’ social determinants of health, an emerging source of beneficiary-level SDOH data is a subset of ICD-10 “Z Codes,” which can be attached to claims and encounters to identify causes other than a disease or injury. While there is payer enthusiasm for using these codes, new research suggests that plans have a long way to go to increase provider uptake and establish best practices in this area.

As Medicare and Medicaid plans seek ways to improve overall care quality by addressing members’ social determinants of health, an emerging source of beneficiary-level SDOH data is a subset of ICD-10 “Z Codes,” which can be attached to claims and encounters to identify causes other than a disease or injury. While there is payer enthusiasm for using these codes, new research suggests that plans have a long way to go to increase provider uptake and establish best practices in this area.

According to an analysis of the most recently available Z code data from the CMS Master Beneficiary Summary File, NORC at the University of Chicago found that just 1.3% of all Medicare beneficiaries had their social needs tracked with a Z code in 2018. In Medicare Advantage, that percentage was slightly higher at 1.5%, compared with 1.2% in fee-for-service Medicare. In an August report prepared on behalf of the Better Medicare Alliance (BMA), NORC estimated that 1.4% of FFS Medicare enrollees had an SDOH-related Z code in 2017.

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News Briefs

October 21, 2021

CMS has given itself another year to finalize a proposal to begin using an extrapolation methodology in recovering overpayments from Medicare Advantage organizations. The Trump administration in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said it planned to extrapolate the results of Risk Adjustment Data Validation Audits, starting with 2011 contract-level audits, and not apply a “fee-for-service adjuster” to account for inaccurate diagnosis codes in FFS Medicare data used to calibrate the MA risk adjustment model. In a Federal Register notice published on Oct. 21, CMS cited “exceptional circumstances” for exceeding the statutory three-year timeline and explained that it received extensive public comments on the proposal and the FFS Adjuster study that it released just prior to publishing the November 2018 proposed rule. CMS said it plans to publish the final rule by Nov. 1, 2022.

CMS has given itself another year to finalize a proposal to begin using an extrapolation methodology in recovering overpayments from Medicare Advantage organizations. The Trump administration in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said it planned to extrapolate the results of Risk Adjustment Data Validation Audits, starting with 2011 contract-level audits, and not apply a “fee-for-service adjuster” to account for inaccurate diagnosis codes in FFS Medicare data used to calibrate the MA risk adjustment model. In a Federal Register notice published on Oct. 21, CMS cited “exceptional circumstances” for exceeding the statutory three-year timeline and explained that it received extensive public comments on the proposal and the FFS Adjuster study that it released just prior to publishing the November 2018 proposed rule. CMS said it plans to publish the final rule by Nov. 1, 2022.

As Congressional lawmakers attempt to whittle down President Joe Biden’s $3.5 trillion budget reconciliation package that includes expanding Medicare benefits, Sens. Kyrsten Sinema (D-Ariz.) and Tim Scott (R-S.C.) are leading a bipartisan effort to protect the Medicare Advantage program from potential cuts. “Payment stability is critical to protecting and strengthening this popular choice for seniors, particularly since these seniors have paid into the Medicare program and expect to continue to receive the excellent, reasonably priced care offered by MA,” a group of 13 senators wrote to CMS Administrator Chiquita Brooks-LaSure. “We stand ready to protect MA from payment cuts, which could lead to higher costs and premiums, reduce vital benefits, and undermine advances made to improve health outcomes and health equity for MA enrollees.” Sinema has previously expressed opposition to prescription drug pricing proposals, such as giving Medicare the authority to negotiate drug prices, in the House and Senate versions of the legislation. Trade groups Better Medicare Alliance and AHIP cheered the move to protect MA. AHIP in August released a paper prepared by Wakely that estimated plans would have an average of 48% to 73% fewer rebate dollars to fund supplemental benefits if Congress adds dental, vision and hearing benefits without adjusting the MA benchmark.

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Datapoint: Two MA-PD Contracts Score Below 3 Stars in 2022 Ratings

October 21, 2021

Just two Medicare Advantage Prescription Drug contracts (MA-PDs), from Imperial Health Plan of California and Centene Corp.’s Buckeye Health, scored a 2.5 or below in CMS’s 2021 star quality ratings. The four contracts currently serve 8,353 members. No contracts received a low performance warning for 2022.

Just two Medicare Advantage Prescription Drug contracts (MA-PDs), from Imperial Health Plan of California and Centene Corp.’s Buckeye Health, scored a 2.5 or below in CMS’s 2021 star quality ratings. The two contracts currently serve 8,353 members. No contracts received a low performance warning for 2022.

Source: AIS’s Directory of Health Plans

Datapoint: Priority Health Launching Travel-Focused Plans

October 20, 2021

Michigan-based insurer Priority Health on Oct. 18 said it will launch new, travel-focused insurance products beginning in January 2022. Partnering with Cigna, the MyPriority Travel plans will provide in-network coverage via Cigna providers when members are outside of Michigan for remote work or personal travel. Priority Health is the second-largest insurer in Michigan, behind Blue Cross Blue Shield of Michigan, with 1,071,559 members.

Michigan-based insurer Priority Health on Oct. 18 said it will launch new, travel-focused insurance products beginning in January 2022. Partnering with Cigna, the MyPriority Travel plans will provide in-network coverage via Cigna providers when members are outside of Michigan for remote work or personal travel. Priority Health is the second-largest insurer in Michigan, behind Blue Cross Blue Shield of Michigan, with 1,071,559 members.

Source: AIS’s Directory of Health Plans

Datapoint: CMS Releases 2022 Star Ratings

October 19, 2021

More than 7.1 million people are currently enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan that earned an overall 5-star rating from CMS for the 2022 plan year. Just 8,353 people are enrolled in an MA-PD plan scoring an overall 2.5. No plans scored below a 2.5 this year.

More than 7.1 million people are currently enrolled in a Medicare Advantage Prescription Drug (MA-PD) plan that earned an overall 5-star rating from CMS for the 2022 plan year. Just 8,353 people are enrolled in an MA-PD plan scoring an overall 2.5. No plans scored below a 2.5 this year.

Source: AIS’s Directory of Health Plans

Datapoint: AmeriHealth Caritas to Enter Exchange Market

October 18, 2021

Longtime Medicaid insurer AmeriHealth Caritas will launch its first Affordable Care Act exchange products in North Carolina, with coverage beginning Jan. 1, 2022. The six plans will be available in 25 counties in the state. The insurer said its “Next Generation Model of Care” aims to address its members social needs and improve health equity. Blue Cross and Blue Shield of North Carolina currently dominates the state’s exchange market with about 400,000 members, 77.8% of all exchange lives.

Longtime Medicaid insurer AmeriHealth Caritas will launch its first Affordable Care Act exchange products in North Carolina, with coverage beginning Jan. 1, 2022. The six plans will be available in 25 counties in the state. The insurer said its “Next Generation Model of Care” aims to address its members social needs and improve health equity. Blue Cross and Blue Shield of North Carolina currently dominates the state’s exchange market with about 400,000 members, 77.8% of all exchange lives.

Source: AIS’s Directory of Health Plans

Telehealth SUD Treatment Needs More Research, Oversight

October 15, 2021

A growing amount of treatment for substance use disorders (SUDs) has moved to telehealth providers due to the COVID-19 pandemic. This trend likely increased patients’ access to treatment, among other benefits, but researchers and plan sponsors say that the efficacy and value of virtual care modalities in SUD settings is still an open question.

Last year, during the first wave of the pandemic, the entire health care system had to make internet and telephone care available in a short time. SUD treatment was no different. A good deal of SUD treatment traditionally takes place in person, especially in peer support groups and inpatient drug detox. Researchers were already investigating whether remote SUD care is useful before the pandemic, but their work became urgent last spring and summer as providers rushed to meet social distancing requirements.

A growing amount of treatment for substance use disorders (SUDs) has moved to telehealth providers due to the COVID-19 pandemic. This trend likely increased patients’ access to treatment, among other benefits, but researchers and plan sponsors say that the efficacy and value of virtual care modalities in SUD settings is still an open question.

Last year, during the first wave of the pandemic, the entire health care system had to make internet and telephone care available in a short time. SUD treatment was no different. A good deal of SUD treatment traditionally takes place in person, especially in peer support groups and inpatient drug detox. Researchers were already investigating whether remote SUD care is useful before the pandemic, but their work became urgent last spring and summer as providers rushed to meet social distancing requirements.

A year later, those researchers are still learning about this dramatic change. Their findings will be important to both health systems and payers because virtual care in SUD treatment is here to stay. However, researchers and industry insiders say that the health system has to make intentional, well-informed decisions on what amounts and types of telehealth will work best for patients and clinicians.

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UnitedHealth Reports Solid 3Q Despite Rising COVID Costs

October 15, 2021

UnitedHealth Group’s third-quarter 2021 financial results impressed Wall Street, with equities analysts describing the company’s performance as “solid across the board” and “generally positive” even though the company did see health care costs related to COVID-19 rise during the quarter.

The diversified health care giant and parent company of the country’s largest health insurer reported an adjusted earnings per share (EPS) of $4.52 for the third quarter, beating the Wall Street consensus of $4.41. The firm’s revenues increased 11% year over year to $72.3 billion, which it attributed to “balanced, double-digit growth at both Optum and UnitedHealthcare.” And the company’s medical loss ratio for the quarter was 83%, slightly beating the consensus estimate of 83.4% but representing an increase compared to last year’s 81.9%, which UnitedHealth said was due to the repeal of the health insurance tax.

UnitedHealth Group’s third-quarter 2021 financial results impressed Wall Street, with equities analysts describing the company’s performance as “solid across the board” and “generally positive” even though the company did see health care costs related to COVID-19 rise during the quarter.

The diversified health care giant and parent company of the country’s largest health insurer reported an adjusted earnings per share (EPS) of $4.52 for the third quarter, beating the Wall Street consensus of $4.41. The firm’s revenues increased 11% year over year to $72.3 billion, which it attributed to “balanced, double-digit growth at both Optum and UnitedHealthcare.” And the company’s medical loss ratio for the quarter was 83%, slightly beating the consensus estimate of 83.4% but representing an increase compared to last year’s 81.9%, which UnitedHealth said was due to the repeal of the health insurance tax.

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