News Briefs

September 16, 2021

CMS will bar several Medicare Advantage Prescription Drug (MA-PD) plans from enrolling new beneficiaries for 2022 because they did not meet minimum medical loss ratio (MLR) requirements. According to a series of notices posted to the CMS Enforcement Actions page, CMS issued enrollment suspensions to the following organizations: MMM Healthcare, LLC, Triple-S Advantage, Inc., UnitedHealthcare of Arkansas, Inc., UnitedHealthcare of the Midwest, Inc., and UnitedHealthcare of New Mexico, Inc. Because the plans failed to meet the 85% MLR threshold for their Part D contracts for three consecutive years, they will be removed from the list of MA-PD plans during the upcoming Annual Election Period, CMS said.

CMS will bar several Medicare Advantage Prescription Drug (MA-PD) plans from enrolling new beneficiaries for 2022 because they did not meet minimum medical loss ratio (MLR) requirements. According to a series of notices posted to the CMS Enforcement Actions page, CMS issued enrollment suspensions to the following organizations: MMM Healthcare, LLC, Triple-S Advantage, Inc., UnitedHealthcare of Arkansas, Inc., UnitedHealthcare of the Midwest, Inc., and UnitedHealthcare of New Mexico, Inc. Because the plans failed to meet the 85% MLR threshold for their Part D contracts for three consecutive years, they will be removed from the list of MA-PD plans during the upcoming Annual Election Period, CMS said.

CMS is seeking to repeal a Trump-era rule that would have given national Medicare coverage for four years to a “breakthrough” device as soon as it receives FDA approval. The agency on Sept. 13 issued a Notice of Proposed Rulemaking (NPRM) that proposes to fully repeal the Medicare Coverage of Innovative Technology (MCIT) and Definition of “Reasonable and Necessary” final rule (86 Fed. Reg. 2987, Jan. 14, 2021). CMS said it is seeking comment on the proposed repeal and its plan to “conduct future rulemaking to explore an expedited coverage pathway for innovative technologies (balanced with evidence development to ensure beneficial health outcomes for beneficiaries) and a regulatory definition of the Reasonable and Necessary standard for Medicare coverage.” AdvaMed, the global trade association representing medical technology manufacturers, issued a statement calling the move the “wrong decision for countless Medicare patients” and “the wrong decision for American medical innovation.”

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Datapoint: SCAN to Expand to Arizona, Nevada

September 16, 2021

Medicare Advantage insurer SCAN Health Plan will take on its first-ever expansion outside of California in 2022, bringing its products to Arizona and Nevada. The expansion will bring SCAN’s total reach to 17 markets in three states. SCAN currently enrolls 205,316 MA and 14,583 dual eligible members in California.

Medicare Advantage insurer SCAN Health Plan will take on its first-ever expansion outside of California in 2022, bringing its products to Arizona and Nevada. The expansion will bring SCAN’s total reach to 17 markets in three states. SCAN currently enrolls 205,316 MA and 14,583 dual eligible members in California.

Source: AIS’s Directory of Health Plans

Datapoint: Combined Tufts, Harvard Pilgrim Org Select OptumRx as PBM

September 15, 2021

Point32Health, the organization formed by the merger of Tufts Health Plan and Harvard Pilgrim Health Care, has selected OptumRx as its pharmacy benefit manager, according to a Sept. 9 press release. The three-year contract will begin in January 2023, and Point32Health said it expects to see aggregate pharmacy savings of 12-16% in that time. Point32Health currently enrolls 2,091,151 members throughout New England, with 36.4% enrolled in risk-based commercial plans, and 21.4% enrolled in public-sector products.

Point32Health, the organization formed by the merger of Tufts Health Plan and Harvard Pilgrim Health Care, has selected OptumRx as its pharmacy benefit manager, according to a Sept. 9 press release. The three-year contract will begin in January 2023, and Point32Health said it expects to see aggregate pharmacy savings of 12-16% in that time. Point32Health currently enrolls 2,091,151 members throughout New England, with 36.4% enrolled in risk-based commercial plans, and 21.4% enrolled in public-sector products.

Source: AIS’s Directory of Health Plans

Datapoint: Centene to Consolidate Medicare Offerings Under Wellcare Brand

September 14, 2021

As part of a “brand refresh,” Centene Corp. plans to consolidate its Medicare Advantage offerings under its Wellcare brand, according to a Sept. 1 press release. This includes state-level Centene brands such as Fidelis Care, Health Net and Ascension. Centene currently enrolls 1.15 million Medicare Advantage members in the U.S.

As part of a “brand refresh,” Centene Corp. plans to consolidate its Medicare Advantage offerings under its Wellcare brand, according to a Sept. 1 press release. This includes state-level Centene brands such as Fidelis Care, Health Net and Ascension. Centene currently enrolls 1.15 million Medicare Advantage members in the U.S.

Source: AIS’s Directory of Health Plans

Datapoint: Court Ruling Shores Up Eliquis Exclusivity Until 2028

September 13, 2021

The U.S. Court of Appeals for the Federal Circuit on Sept. 3 upheld a lower court decision that maintains Bristol Myers Squibb and Pfizer’s U.S. exclusivity for their blockbuster heart drug Eliquis until 2028. The ruling is still subject to appeal, however. Eliquis is one of the top-selling drugs in the U.S., and currently holds covered or better status for 98% of all insured lives under the pharmacy benefit. 82.3% of all covered lives have unrestricted preferred access to Eliquis.

The U.S. Court of Appeals for the Federal Circuit on Sept. 3 upheld a lower court decision that maintains Bristol Myers Squibb and Pfizer’s U.S. exclusivity for their blockbuster heart drug Eliquis until 2028. The ruling is still subject to appeal, however. Eliquis is one of the top-selling drugs in the U.S., and currently holds covered or better status for 98% of all insured lives under the pharmacy benefit. 82.3% of all covered lives have unrestricted preferred access to Eliquis.

SOURCE: MMIT Analytics, as of 9/8/21

Payers Applaud Surprise Billing Rule but Ask for Extension

September 10, 2021

With surprise billing banned by Congress in the No Surprises Act passed in December 2020, HHS has rolled out regulations that will shape the adjudication process for disputed out-of-network claims. Payers and plan sponsors are largely on board with the rules that the agency has released, but insurers have raised concerns about the pace of implementation and the long-term effect the rules will have on health care prices.

America’s Health Insurance Plans (AHIP) on Sept. 7 submitted comments on a July interim final rule (IFR) that, among other matters, outlines the way quasi-benchmark reimbursement rates, known as the qualifying payment amount (QPA), will be calculated. The insurance trade group was largely positive about the IFR, but raised concerns about the scope and timeline of payment database implementation. AHIP called on HHS to extend the implementation deadline and create a “good faith safe harbor” for plans struggling to navigate the early years of the new system’s implementation.

With surprise billing banned by Congress in the No Surprises Act passed in December 2020, HHS has rolled out regulations that will shape the adjudication process for disputed out-of-network claims. Payers and plan sponsors are largely on board with the rules that the agency has released, but insurers have raised concerns about the pace of implementation and the long-term effect the rules will have on health care prices.

America’s Health Insurance Plans (AHIP) on Sept. 7 submitted comments on a July interim final rule (IFR) that, among other matters, outlines the way quasi-benchmark reimbursement rates, known as the qualifying payment amount (QPA), will be calculated. The insurance trade group was largely positive about the IFR, but raised concerns about the scope and timeline of payment database implementation. AHIP called on HHS to extend the implementation deadline and create a “good faith safe harbor” for plans struggling to navigate the early years of the new system’s implementation.

The surprise billing ban, which comes into full effect in 2022, prohibits providers from sending a balance bill to patients. Patients who are treated by an out-of-network provider while incapacitated will pay the same cost sharing that they would have if they had been treated by an in-network provider.

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Census Data Underscores Plans’ Need to Diversify Engagement

September 10, 2021

In mid-August, the U.S. Census Bureau released additional results from the 2020 Census that underscored just how diverse the country has become. While people identifying as white remained the largest ethnic group in the U.S., that population has decreased by 8.6% since 2010. Meanwhile, the Hispanic or Latino population grew 23% over the last decade and the multiracial population ballooned from 9 million in 2010 to 33.8 million in 2020.

With all that demographic change, industry observers say it’s more crucial than ever for health care organizations — especially health plans — to tailor their member engagement strategies to connect with enrollees from a wide variety of backgrounds. But they caution that doing so requires more than just lip service and cursory efforts.

In mid-August, the U.S. Census Bureau released additional results from the 2020 Census that underscored just how diverse the country has become. While people identifying as white remained the largest ethnic group in the U.S., that population has decreased by 8.6% since 2010. Meanwhile, the Hispanic or Latino population grew 23% over the last decade and the multiracial population ballooned from 9 million in 2010 to 33.8 million in 2020.

With all that demographic change, industry observers say it’s more crucial than ever for health care organizations — especially health plans — to tailor their member engagement strategies to connect with enrollees from a wide variety of backgrounds. But they caution that doing so requires more than just lip service and cursory efforts.

“The plans that are doing the right thing are the plans that are moving away from their old approach to how they engage with their members and build a relationship with their members. That old approach, I would describe it as the ‘one size fits all’ approach,” says Abner Mason, the CEO of ConsejoSano, a health equity-focused engagement company that personalizes health plan member experiences through culturally and linguistically aligned preferences.

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COVID Impact, Rate Hikes in Exchanges Could Be Modest

September 10, 2021

Now that actuaries have more information about how COVID-19 affects health care spending, individual market insurers are more likely to include adjustments in their 2022 rates to account for the pandemic, concludes a new issue brief from the American Academy of Actuaries. However, “those impacts are not expected to be material,” the brief says, perhaps conflicting with the gloomy view of the pandemic’s trajectory that is dominating media reports.

Academy Senior Fellow Cori Uccello explains that while more information is now known about how the pandemic has affected health care spending and utilization since early 2020, “just because COVID may have had a big impact in 2020 and 2021 doesn’t necessarily mean it’s going to have a big impact on 2022.”

Now that actuaries have more information about how COVID-19 affects health care spending, individual market insurers are more likely to include adjustments in their 2022 rates to account for the pandemic, concludes a new issue brief from the American Academy of Actuaries. However, “those impacts are not expected to be material,” the brief says, perhaps conflicting with the gloomy view of the pandemic’s trajectory that is dominating media reports.

Academy Senior Fellow Cori Uccello explains that while more information is now known about how the pandemic has affected health care spending and utilization since early 2020, “just because COVID may have had a big impact in 2020 and 2021 doesn’t necessarily mean it’s going to have a big impact on 2022.”

Insurers in the individual market therefore may not make major rate adjustments related to the pandemic, she tells AIS Health, a division of MMIT. She cautions, though, that “there’s still a lot of uncertainty about…how the rest of this year is going to be, never mind next year.”

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Facing Low Supplier Interest, CMS Floats MDPP Changes

September 10, 2021

Hoping to boost enrollment in the struggling Medicare Diabetes Prevention Program (MDPP) expanded model, CMS has proposed changes that would increase reimbursement and significantly shorten the services period for participants. While stakeholders agree that the changes are needed, some warn they’re only incremental steps to shore up the MDPP, which has faced a shortage of suppliers and challenges posed by the requirement that the program be delivered to beneficiaries in person.

“The MDPP rules and regulations, including the payment mechanism and the two-year commitment — in contrast to one year for the CDC DPP [U.S. Centers for Disease Control and Prevention Diabetes Prevention Program] — have made enrollment very difficult if not impossible for MDPP suppliers,” asserts Liz Joy, M.D., senior medical director for wellness and nutrition at Intermountain Healthcare.

Hoping to boost enrollment in the struggling Medicare Diabetes Prevention Program (MDPP) expanded model, CMS has proposed changes that would increase reimbursement and significantly shorten the services period for participants. While stakeholders agree that the changes are needed, some warn they’re only incremental steps to shore up the MDPP, which has faced a shortage of suppliers and challenges posed by the requirement that the program be delivered to beneficiaries in person.

“The MDPP rules and regulations, including the payment mechanism and the two-year commitment — in contrast to one year for the CDC DPP [U.S. Centers for Disease Control and Prevention Diabetes Prevention Program] — have made enrollment very difficult if not impossible for MDPP suppliers,” asserts Liz Joy, M.D., senior medical director for wellness and nutrition at Intermountain Healthcare.

“The CMS regulations reduced the number of DPPs that could become MDPP suppliers, thereby limiting access for Medicare Advantage members,” Joy tells AIS Health, a division of MMIT. “Additionally, CMS did not allow the virtual DPPs to become suppliers, so for MA members who live in more rural areas, access is even more limited.”

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Public Coverage Gains Offset Losses of Employer-Sponsored Insurance During Pandemic

September 10, 2021

Unlike during previous recessions, the national uninsured rate held steady at 11% during the COVID-19 pandemic and its resulting economic fallout, according to a recent analysis by the Urban Institute and Robert Wood Johnson Foundation. Between March 2019 and April 2021, the share of nonelderly adults covered by employer-sponsored insurance declined from 65.0% to 62.3%, while the share of enrollees with public coverage jumped from 13.6% to 17.5%. States that had not expanded Medicaid under the Affordable Care Act saw a higher uninsured rate in 2021 (18.2%) than in 2020 (16.5%) and 2019 (17.2%). In Medicaid expansion states, that rate remained around 8% across all three years.

By Jinghong Chen

Unlike during previous recessions, the national uninsured rate held steady at 11% during the COVID-19 pandemic and its resulting economic fallout, according to a recent analysis by the Urban Institute and Robert Wood Johnson Foundation. Between March 2019 and April 2021, the share of nonelderly adults covered by employer-sponsored insurance declined from 65.0% to 62.3%, while the share of enrollees with public coverage jumped from 13.6% to 17.5%. States that had not expanded Medicaid under the Affordable Care Act saw a higher uninsured rate in 2021 (18.2%) than in 2020 (16.5%) and 2019 (17.2%). In Medicaid expansion states, that rate remained around 8% across all three years.

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