Medicare and Medicaid

CMS Extends Options to States to Test Innovative Dual-Eligible Care Models

May 8, 2019

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency’s commitment to proving the value of the models as well as testing alternatives.

By Lauren Flynn Kelly

Although independent evaluations of ongoing demonstrations to integrate care for dual-eligible Medicare-Medicaid beneficiaries are still underway, an April 24 letter from CMS Administrator Seema Verma signaled the agency’s commitment to proving the value of the models as well as testing alternatives.

In the letter to state Medicaid directors, CMS extended three new opportunities to “test state-driven approaches” for integrating duals’ care:

(1) For interested states with capitated Financial Alignment Initiative (FAI) model demos, CMS said it is “open to partnering on revisions.”

(2) For interested states without capitated demos, CMS said it welcomes interest in testing the model through new demos in additional states.

(3) CMS said it is open to partnering with states on testing new state-developed models to better serve dual eligibles and invited states to respond with ideas, concept papers and/or proposals.

Kevin Malone, a senior counsel in the Health Care and Life Sciences practice in the Washington, D.C., office of Epstein Becker & Green, P.C. and a former duals officer at CMS, predicts that, for states with existing demos, they will not only revisit their memoranda of understanding that outline the terms of their agreements with CMS, but will use it as a chance to amend their three-way contracts with CMS and plans. This presents a unique opportunity for the plans to suggest changes around certain programmatic requirements or provider training that may reduce some of their burden and streamline some of the technical details of their arrangements.

Leavitt Partners Presents Multiyear MA Framework

May 6, 2019

In the age of value-based contracts and social determinants of health, why shouldn’t plans have an opportunity to serve Medicare Advantage (MA) beneficiaries for longer periods of time and maximize the potential to improve health outcomes and reduce costs?

That’s the question at the center of “Multi-Year Medicare Advantage Plans: A Framework for Action,” a new white paper by consulting firm Leavitt Partners.

By Lauren Flynn Kelly

In the age of value-based contracts and social determinants of health, why shouldn’t plans have an opportunity to serve Medicare Advantage (MA) beneficiaries for longer periods of time and maximize the potential to improve health outcomes and reduce costs?

That’s the question at the center of “Multi-Year Medicare Advantage Plans: A Framework for Action,” a new white paper by consulting firm Leavitt Partners.

Under the MyMAP demonstration project proposed in the paper, MA insurers would be able to offer a multiyear product to beneficiaries with certain high-cost chronic disease needs or high-cost acute medical episodes and test the hypothesis that making “upfront investments” would be recovered over a multiyear period because they produced better care management and better outcomes for beneficiaries.

The authors recommended a contract period of at least three years between health plan and member. To incentivize members to enroll in a multiyear plan, the MyMAP framework suggested that plans could focus on attractive benefits and cost-sharing. Moreover, it might be possible for insurers to guarantee beneficiaries $0 premiums across multiple years of the model, they added.

Moving forward, “the idea will be acted on with specifics,” says former Utah Governor and HHS Secretary Mike Leavitt. He adds that the firm is working with two organizations that are not yet prepared to go public and that focus on certain conditions that would fit well within the framework.

“Multiyear contracting deserves further thought — perhaps as a demonstration,” says Michael Adelberg, a principal with Faegre Baker Daniels Consulting and a former top CMS MA official. “If beneficiaries are locked in, that begs the question of whether plan benefits, networks, service areas also will be locked in.”

Datapoint: Anthem Makes MA Gains Addressing Social Determinants of Health

May 2, 2019

Anthem, Inc. experienced a 13.7% gain in Medicare Advantage enrollment from the fourth quarter of 2018 to the first quarter of 2019, according to the latest update to AIS’s Directory of Health Plans. Anthem CEO Gail Boudreaux in a recent earnings call pointed to the insurer’s new benefits package, which addresses social determinants of health, such as food insecurity, lack of transportation and the need for in-home care services, as the driving force behind this boost. Anthem currently enrolls 1,099,100 MA lives nationwide.

Anthem, Inc. experienced a 13.7% gain in Medicare Advantage enrollment from the fourth quarter of 2018 to the first quarter of 2019, according to the latest update to AIS’s Directory of Health Plans. Anthem CEO Gail Boudreaux in a recent earnings call pointed to the insurer’s new benefits package, which addresses social determinants of health, such as food insecurity, lack of transportation and the need for in-home care services, as the driving force behind this boost. Anthem currently enrolls 1,099,100 MA lives nationwide.

Source: AIS’s Directory of Health Plans

Medicaid Churn Adds Burden to Health Plans

May 2, 2019

Newly implemented state paperwork requirements caused around 1.6 million Medicaid beneficiaries to lose coverage in 2018, the advocacy group Families USA says.

State policy decisions to engage in more frequent eligibility redeterminations are responsible for a large part of the enrollment drops, particularly in three states: Tennessee, Arkansas and Missouri, according to the group’s report, “The Return of Churn.”

By Jane Anderson

Newly implemented state paperwork requirements caused around 1.6 million Medicaid beneficiaries to lose coverage in 2018, the advocacy group Families USA says.

State policy decisions to engage in more frequent eligibility redeterminations are responsible for a large part of the enrollment drops, particularly in three states: Tennessee, Arkansas and Missouri, according to the group’s report, “The Return of Churn.”

Federal law and regulations require state Medicaid agencies to renew beneficiaries’ eligibility determinations every 12 months. However, Families USA says some states make this process much more difficult than others, with barriers including significant paperwork requirements and a lack of online enrollment options.

“A health plan’s onboarding process for a new member involves considerable paperwork,” says Meg Murray, Association for Community Affiliated Plans CEO. “This involves significant administrative and overhead costs that would be avoided were a member to be continuously enrolled.”

Increased churn may also result in reduced revenue streams for Medicaid plans where beneficiaries are being dropped from the rolls in large numbers, says Gerard (Jerry) Vitti, founder and CEO of Healthcare Financial, Inc.

“The most vulnerable members are those who are the least able to comply with these onerous roadblocks they are teeing up,” he adds. If these beneficiaries lose coverage, they ultimately may cost the system more money because they may end up with a hospital stay or emergency room visit that might have been prevented, Vitti says.

Still, Alex Shekhdar, founder of Sycamore Creek Healthcare Advisors, notes that enrollment of ineligible people is a significant problem in Medicaid, and the redetermination procedures are designed to address that.

Datapoint: CMS Announces New Care Model for Dual Eligibles

April 29, 2019

CMS last week announced a new model for states to test integrated care delivery for Medicare-Medicaid dual eligibles. The agency’s letter to state Medicaid directors urges states to test both capitated financial alignment with health plans and a fee-for-service model, similar to its original duals demonstrations. CMS is also giving states the option to design their own care model. Eleven states are currently running CMS-backed demonstrations for dual eligibles, with 419,450 total members. There are currently about 2.94 million people enrolled in duals plans nationwide.

CMS last week announced a new model for states to test integrated care delivery for Medicare-Medicaid dual eligibles. The agency’s letter to state Medicaid directors urges states to test both capitated financial alignment with health plans and a fee-for-service model, similar to its original duals demonstrations. CMS is also giving states the option to design their own care model. Eleven states are currently running CMS-backed demonstrations for dual eligibles, with 419,450 total members. There are currently about 2.94 million people enrolled in duals plans nationwide.

Source: AIS’s Directory of Health Plans

Final Flexibility Rule Expands Telehealth Benefits Under Medicare Advantage

April 25, 2019

With the April 5 release of the Calendar Year 2020 Medicare Advantage and Part D Flexibility Final Rule that implements many provisions of the Bipartisan Budget Act of 2018, MA organizations may offer telehealth services on a scale that’s never been allowed before.

Under the final rule, MA plans starting in 2020 will be able to offer as part of the basic benefit package “additional telehealth benefits” beyond what is available to Medicare fee-for-service beneficiaries and to include more telehealth services in their basic benefit bid paid by the capitation rate.

By Lauren Flynn Kelly

With the April 5 release of the Calendar Year 2020 Medicare Advantage and Part D Flexibility Final Rule that implements many provisions of the Bipartisan Budget Act of 2018, MA organizations may offer telehealth services on a scale that’s never been allowed before.

Under the final rule, MA plans starting in 2020 will be able to offer as part of the basic benefit package “additional telehealth benefits” beyond what is available to Medicare fee-for-service beneficiaries and to include more telehealth services in their basic benefit bid paid by the capitation rate.

CMS also finalized a requirement that if an MA plan covers a Part B service as an additional telehealth benefit, it must also provide access to such a service through an in-person visit and not only through “electronic exchange.”

“I think this is going to be a positive impact from a health plan perspective and I think this is something that health plans wanted CMS to implement for a while,” remarks Brian Collender, specialist leader in the health actuarial practice of Deloitte Consulting. For those larger MA plans that already have telehealth relationships set up with national vendors, expanding telehealth is a low cost/low risk opportunity, he says. Smaller health plans, meanwhile, may not have the capabilities to offer telehealth as a benefit right away, but have options when it comes to vendors that specialize in telehealth.

Moreover, “by reclassifying telehealth services as Medicare-covered under Parts A and B, MA plans can offer telehealth without using up precious rebate dollars that fund supplemental benefits,” says Michael Adelberg, a principal with Faegre Baker Daniels Consulting and a former top CMS MA official.