Medicare and Medicaid

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

Major Expansions, Rich Benefits Will Drive Competitive AEP

October 7, 2021

As the 2022 Annual Election Period (AEP) approaches, CMS expects the Medicare Advantage program to continue its upward trajectory, with enrollment climbing 10% to an estimated 29.5 million people next year while average monthly premiums will drop by more than $2 to $19, according to agency projections. In addition to the continued expansion of supplemental benefits, including those tailored toward the chronically ill, more MA organizations are expanding their Dual Eligible Special Needs Plan (D-SNP) presence and testing benefit innovations through the Part D Senior Savings Model (SSM) and MA Value-Based Insurance Design (VBID) model in 2022, CMS said on Sept. 29.

As the 2022 Annual Election Period (AEP) approaches, CMS expects the Medicare Advantage program to continue its upward trajectory, with enrollment climbing 10% to an estimated 29.5 million people next year while average monthly premiums will drop by more than $2 to $19, according to agency projections. In addition to the continued expansion of supplemental benefits, including those tailored toward the chronically ill, more MA organizations are expanding their Dual Eligible Special Needs Plan (D-SNP) presence and testing benefit innovations through the Part D Senior Savings Model (SSM) and MA Value-Based Insurance Design (VBID) model in 2022, CMS said on Sept. 29.

During the AEP — which runs from Oct. 15 to Dec. 7 — seniors in nearly every state will have more MA plan options. According to a CMS state-by-state fact sheet based on the 2022 MA and Part D Landscape files, 29 states will see double-digit increases in the number of available MA plans, with a dozen seeing their plan options rise by more than 20%. Participation in the insulin-focused SSM will rise nearly 40% from 76 sponsors offering 1,635 plans in 2021 to 106 sponsors featuring the benefit in 2,159 plans in 2022, including stand-alone Prescription Drug Plans (PDPs) and MA Prescription Drug (MA-PD) plans.

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