Datapoint: CMS Approves Arizona Work Requirements

January 22, 2019

The Trump administration last week approved Arizona’s request to add work requirements to its Medicaid program, set to begin as early as January 2020. Arizona currently serves 1,748,597 Medicaid beneficiaries, and is the eighth state to win CMS’s approval on implementing work requirements.

The Trump administration last week approved Arizona’s request to add work requirements to its Medicaid program, set to begin as early as January 2020. Arizona currently serves 1,748,597 Medicaid beneficiaries, and is the eighth state to win CMS’s approval on implementing work requirements.

Source: AIS’s Directory of Health Plans

To Cover or Not to Cover? Prenatal DNA Test Creates Quandary for Payers

January 22, 2019

As genetic tests become increasingly accessible, they’re helping transform health care by connecting patients with more personalized diagnoses and treatments. But it’s often challenging for health plans to decide whether to pay for them.

One prime example can be found in obstetrics, where cell-free DNA-based noninvasive prenatal testing (NIPT) has been rising in popularity among patients and clinicians alike, yet payers differ in terms of how they cover it.

By Leslie Small

As genetic tests become increasingly accessible, they’re helping transform health care by connecting patients with more personalized diagnoses and treatments. But it’s often challenging for health plans to decide whether to pay for them.

One prime example can be found in obstetrics, where cell-free DNA-based noninvasive prenatal testing (NIPT) has been rising in popularity among patients and clinicians alike, yet payers differ in terms of how they cover it.

Part of the popularity of NIPT is due to the fact that it’s a simple blood test that allows expecting parents to learn a baby’s sex in the first trimester. But the test’s main purpose is to analyze maternal and fetal DNA fragments to screen for Down syndrome and other chromosomal abnormalities. Supporters point out — and research verifies — that it’s more accurate at screening for Down syndrome than an older, “standard” method of screening, which combines a blood test known as serum screening with a fetal ultrasound.

NIPT is now widely covered for “high-risk” pregnant women, according to the Coalition for Access to Prenatal Screening. Plus, 40 commercial insurers cover NIPT for all pregnant women, including Cigna Corp., Geisinger Health Plan, Anthem, Inc. and slew of regional Blue Cross Blue Shield plans. But many state Medicaid programs and two of the country’s largest private insurers — Aetna Inc. and UnitedHealthcare — are not yet on board with paying for all pregnant women to have the test.

According to Blair Stevens, a prenatal expert for the National Society of Genetic Counselors, “insurance coverage has not caught up to the demand” for NIPT. One reason is likely because the newer screening method is more expensive than its older counterpart, she suggests. In addition, while “it’s clear that NIPT is a better test for Down syndrome,” there’s been mixed data on whether it’s a better screen for more rare conditions, she adds.

For genetic tests of all varieties, one major issue is there’s no single entity like the FDA to evaluate them, says Lon Castle, M.D., chief of molecular diagnostics and specialty drug management at eviCore healthcare. “What we’re left with is the health plans and the government agencies doing their best to keep up with these things as they come out and evaluating the evidence and making recommendations on them,” he adds.

Datapoint: Blue Cross and Blue Shield of North Carolina to Launch Value-Based Payment Model

January 21, 2019

Blue Cross and Blue Shield of North Carolina said it will launch value-based agreements with most of the state’s health systems next year. In 2020, about 500,000 of the insurer’s 2,311,411 members will be part of the program, which BCBS NC says will be the largest move toward value-based care ever made by a commercial insurer. The insurer aims to enroll all members in a value-based contract within five years.

Blue Cross and Blue Shield of North Carolina said it will launch value-based agreements with most of the state’s health systems next year. In 2020, about 500,000 of the insurer’s 2,311,411 members will be part of the program, which BCBS NC says will be the largest move toward value-based care ever made by a commercial insurer. The insurer aims to enroll all members in a value-based contract within five years.

Source: AIS’s Directory of Health Plans

Advocates, Brokers, MAOs Promote Enrollees’ ‘Second Chance’

January 21, 2019

From brokers and insurers to medical societies and patient advocacy groups, everyone with an interest in Medicare this month appeared to begin promoting the newly reinstated Open Enrollment Period (OEP), which allows Medicare enrollees who selected a Medicare Advantage plan during the recent Annual Election Period (AEP) to make one change.

The 2019 AEP ran from Oct. 15 through Dec. 7, and while final enrollment results won’t be available until February, MA enrollment as of the Jan. 1, 2019, payment date was nearly 22.4 million, up 6.8% from 20.9 million a year earlier, according to new CMS data. The OEP, which last occurred in 2010 and was eliminated with the Affordable Care Act, began on Jan. 1 and will run through March 31. Various stakeholders are making an educational push to ensure that seniors are adequately informed of their options.

By Lauren Flynn Kelly

From brokers and insurers to medical societies and patient advocacy groups, everyone with an interest in Medicare this month appeared to begin promoting the newly reinstated Open Enrollment Period (OEP), which allows Medicare enrollees who selected a Medicare Advantage plan during the recent Annual Election Period (AEP) to make one change.

The 2019 AEP ran from Oct. 15 through Dec. 7, and while final enrollment results won’t be available until February, MA enrollment as of the Jan. 1, 2019, payment date was nearly 22.4 million, up 6.8% from 20.9 million a year earlier, according to new CMS data. The OEP, which last occurred in 2010 and was eliminated with the Affordable Care Act, began on Jan. 1 and will run through March 31. Various stakeholders are making an educational push to ensure that seniors are adequately informed of their options.

The National Council on Aging has been using Twitter to advise seniors of their “second chance” to change MA plans. And the Center for Medicare Advocacy has been informing seniors of this opportunity while posting charts aimed at clearly outlining the differences between Original Medicare and MA.

Meanwhile, CMS made clear in the updated Medicare Communications and Marketing Guidelines that plans may not knowingly target beneficiaries because they made a choice during the AEP. As a result, plans have focused their OEP efforts on education by adding OEP facts and information to their websites, posting blogs and articles on their Facebook pages and in newsfeeds, and sponsoring TV ads, observes Renee Mezzanotte with DMW Direct.

“One of the ways we monitor industry activity and spend is through Kantar Media,” Mezzanotte tells AIS Health. “Medicare TV activity just for the first week is up over 17%. We anticipate this will increase as the quarter progresses.”

Deft Research’s 2018 Medicare Member Experience study showed that more than 25% of Medicare beneficiaries are aware of the OEP. Michael Blix, research manager with Deft, says that the same study observed the kinds of member experiences people have early in the plan year that might cause them to be dissatisfied and take advantage of the OEP’s return. Those included members being billed more than they were expecting for a medical service and attempting to obtain a drug they used to fill that is no longer covered.

People on the Move

January 18, 2019