Medicare and Medicaid

CMS Report Shows Increasing Racial Disparities in MA Plans

June 22, 2020

As protests erupt across the U.S. calling for racial justice and police reforms, the COVID-19 pandemic continues to bring to light many of the racial disparities in health care, putting pressure on policymakers and the industry to take a hard look at health and access inequities.

Meanwhile, CMS’s Office of Minority Research in April released a stratified report highlighting the racial and ethnic differences in health care experiences and care of Medicare Advantage (MA) enrollees. The data showed that black members enrolled in MA plans in 2018 received worse clinical care than white enrollees on 20 out of 44 measures, similar care for 20 and better care for four. And all minority populations reported experiences with care that were either worse than or similar to the experiences reported by white enrollees, including the experience measure for getting appointments and care quickly.

By Lauren Flynn Kelly

As protests erupt across the U.S. calling for racial justice and police reforms, the COVID-19 pandemic continues to bring to light many of the racial disparities in health care, putting pressure on policymakers and the industry to take a hard look at health and access inequities.

Meanwhile, CMS’s Office of Minority Research in April released a stratified report highlighting the racial and ethnic differences in health care experiences and care of Medicare Advantage (MA) enrollees. The data showed that black members enrolled in MA plans in 2018 received worse clinical care than white enrollees on 20 out of 44 measures, similar care for 20 and better care for four. And all minority populations reported experiences with care that were either worse than or similar to the experiences reported by white enrollees, including the experience measure for getting appointments and care quickly.

Not getting the proper care when it’s needed is a reflection of the provider network, says John Gorman, chairman and CEO of Nightingale Partners LLC. “And then when you look at the clinical measures where there’s huge racial disparities, all of those tie back to a lack of culturally competent physicians serving these populations in a manner that speaks to the way that they need to access health care,” he observes.

John Weis, president and co-founder of Quest Analytics, LLC, predicts that “there will be a significant impact on practice consolidation” from the pandemic. “Given the potential risk to providers, we predict that coming out of COVID, we’ll see an uptick in providers that want to minimize their exposure and consider retirement,” he suggests. And with fewer providers available, “if plans are not prepared, this will drive both out-of-network utilization and increase health care costs in rural areas.”

Dan Mendelson, founder of Avalere Health, suggests that while MA plans have the tools to address racial disparities, they don’t necessarily have the incentives to prioritize them. “I think Medicare Advantage plans are uniquely equipped to measure, understand, identify and mitigate disparities…. So, a proactive form of engagement that is focused on disparities can work,” says Mendelson. “One thing that is not there at this point is any kind of direct incentive to the plans to act.”

Datapoint: Oklahoma to Decide on Medicaid Expansion in June Election

June 17, 2020

Oklahoma residents on June 30 will vote on whether to bring Medicaid expansion to the state, following a successful ballot initiative. Oklahoma currently serves 735,379 Medicaid beneficiaries and does not contract with any managed care plans. Medicaid expansion could bring benefits to about 500,000 additional residents, according to state data.

Oklahoma residents on June 30 will vote on whether to bring Medicaid expansion to the state, following a successful ballot initiative. Oklahoma currently serves 735,379 Medicaid beneficiaries and does not contract with any managed care plans. Medicaid expansion could bring benefits to about 500,000 additional residents, according to state data.

Source: AIS’s Directory of Health Plans

Datapoint: Illinois Medicaid Insurer to Shut Down

June 15, 2020

NextLevel Health, a Chicago-based Medicaid insurer, will shut down in July, per a June 5 statement from CEO Cheryl Whitaker. NextLevel was set to be acquired by Molina Healthcare, already an Illinois Medicaid veteran, but an April 14 Securities and Exchange Commission filing revealed the deal broke down “due to the seller’s stated unwillingness to close pursuant to the terms of the acquisition agreement. The insurer currently serves 58,202 members, just 2.7% of Illinois’ managed Medicaid population.

NextLevel Health, a Chicago-based Medicaid insurer, will shut down in July, per a June 5 statement from CEO Cheryl Whitaker. NextLevel was set to be acquired by Molina Healthcare, already an Illinois Medicaid veteran, but an April 14 Securities and Exchange Commission filing revealed the deal broke down “due to the seller’s stated unwillingness to close pursuant to the terms of the acquisition agreement. The insurer currently serves 58,202 members, just 2.7% of Illinois’ managed Medicaid population.

Source: AIS’s Directory of Health Plans

Current Market Access to Key Insulins That Will Be Featured in Part D Senior Savings Model

June 12, 2020

Medicare enrollees this fall will be able to sign up for prescription plans that cap copayments for insulin at $35 a month. Sixty insulins of various types are included in the Part D Senior Savings Model, and over 1,750 stand-alone Part D plans and Medicare Advantage plans with prescription drug coverage have applied to offer lower insulin costs through the demonstration for the 2021 plan year. As of May 2020, only long-acting and combination insulins were available to more than half of covered lives through preferred tier/preferred with prior authorization or step therapy status. The graphics below show how different types of insulins are covered among Medicare plans.

by Jinghong Chen

Medicare enrollees this fall will be able to sign up for prescription plans that cap copayments for insulin at $35 a month. Sixty insulins of various types are included in the Part D Senior Savings Model, and over 1,750 stand-alone Part D plans and Medicare Advantage plans with prescription drug coverage have applied to offer lower insulin costs through the demonstration for the 2021 plan year. As of May 2020, only long-acting and combination insulins were available to more than half of covered lives through preferred tier/preferred with prior authorization or step therapy status. The graphics below show how different types of insulins are covered among Medicare plans.

NOTES: The number of total covered lives under Medicare formularies is 46.4 million. Rapid-acting insulins include Admelog U-100, Apidra, Apidra SoloStar, Fiasp, Fiasp FlexTouch, Humalog, Humalog Junior KwikPen, Humalog KwikPen, Novolog, Novolog FlexPen and Novolog Penfill. Short-acting insulins include Humulin R, Humulin R U-500, Novolin R and Novolin R FlexPen. Intermediate-acting insulins include Humulin N, Humulin N KwikPen, Novolin N and Novolin N FlexPen. Long-acting insulins include Lantus, Levemir, Toujeo, Toujeo Max SoloStar and Tresiba. Mix insulins include Humalog Mix 50-50, Humalog Mix 75-25, Novolin 70/30 and Novolog Mix 70-30. Combination insulins include Soliqua and Xultophy.

SOURCE: Managed Markets Insight & Technology, LLC database as of May 2020.

Datapoint: Hawaii Withdraws Medicaid Contract Awards

June 11, 2020

The state of Hawaii on May 29 rescinded its recently finalized Medicaid contract awards, which would have extended the contracts of its four incumbent MCOs through 2029, and issued a new request for proposals. The four insurers (Kaiser, WellCare Health Plans, Inc., Hawaii Medical Service Association and UnitedHealthcare) currently serve a combined 342,011 Medicaid beneficiaries. State officials cited the COVID-19 pandemic, which has caused a surged in new Medicaid applications, as the catalyst for the decision. Hawaii has seen about 24,000 new Medicaid sign-ups since the crisis hit, according to state Medicaid documents.

The state of Hawaii on May 29 rescinded its recently finalized Medicaid contract awards, which would have extended the contracts of its four incumbent MCOs through 2029, and issued a new request for proposals. The four insurers (Kaiser, WellCare Health Plans, Inc., Hawaii Medical Service Association and UnitedHealthcare) currently serve a combined 342,011 Medicaid beneficiaries. State officials cited the COVID-19 pandemic, which has caused a surged in new Medicaid applications, as the catalyst for the decision. Hawaii has seen about 24,000 new Medicaid sign-ups since the crisis hit, according to state Medicaid documents.

Source: AIS’s Directory of Health Plans

2021 MA, Part D Bids Face Challenges Amid COVID-19

June 8, 2020

There are always uncertainties when it comes to projecting plan costs for the year ahead, but Medicare Advantage and Part D organizations that submitted bids on June 1 faced a particularly unpredictable set of circumstances created by the COVID-19 pandemic.

“I think we will all look back on the 2021 bids as the year of COVID-19,” says Brad Piper, a principal and consulting actuary in Milliman’s Milwaukee office. “That was a big challenge for the organizations that are in the Medicare Advantage program — [perhaps more so] than on the Part D side — and it impacted both sides of the coin: costs and revenue.”

By Lauren Flynn Kelly

There are always uncertainties when it comes to projecting plan costs for the year ahead, but Medicare Advantage and Part D organizations that submitted bids on June 1 faced a particularly unpredictable set of circumstances created by the COVID-19 pandemic.

“I think we will all look back on the 2021 bids as the year of COVID-19,” says Brad Piper, a principal and consulting actuary in Milliman’s Milwaukee office. “That was a big challenge for the organizations that are in the Medicare Advantage program — [perhaps more so] than on the Part D side — and it impacted both sides of the coin: costs and revenue.”

From a cost perspective, unknowns include whether there will be “pent-up demand” for health care services next year given that many beneficiaries have deferred doctors’ appointments and elective/non-urgent procedures to avoid the risk of coronavirus exposure.

Adding to that is the question of whether there will be a second wave of COVID-19 “and how much COVID-related utilization and services will occur that plans will have to bear,” points out Matt Kazan, principal with Avalere Health. A third concern is “how much of the cost of all the things Congress is saying plans will need to cover in terms of testing, vaccines…will impact plans,” says Kazan, referring to various legislative requirements, some of which are still pending.

Preparing bids on the revenue side was equally challenging, since it’s the 2020 diagnosis information that drives reimbursement for next year, adds Piper. “As we’re trying to forecast what 2021 revenue will look like, we’ve got to look at what’s going on in today’s environment and understand if we’re not seeing our members as often…that potentially creates a challenge for health plans to capture all that diagnosis information in 2020, which in turn drives their 2021 revenue amount.”

On the Part D side, Milliman principal and consulting actuary Shelly Brandel says COVID-19 had less of an impact on costs because prescription drug utilization or fills weren’t “delayed to the same degree as medical services had been.” The risk score impact, however, created a similar challenge because Part D risk scores are based on medical diagnoses, she adds.