Health Plan Weekly

Centene Looks to Expand MA Market, Invests in Data Analytics

June 27, 2019

Centene Corp. is well-positioned to expand in the Medicare Advantage market while continuing strong performance in Medicaid managed care as it works to close its acquisition of WellCare Health Plans, Inc.

That’s the takeaway from analysts who took a close look at the company following its most recent investor day, held June 14. Analysts remain unabashedly bullish on Centene’s ability to outperform the market, particularly with the pending WellCare acquisition, which received its first state approval — from Kentucky — on June 14. The company expects the acquisition to close during the first half of 2020.

By Jane Anderson

Centene Corp. is well-positioned to expand in the Medicare Advantage market while continuing strong performance in Medicaid managed care as it works to close its acquisition of WellCare Health Plans, Inc.

That’s the takeaway from analysts who took a close look at the company following its most recent investor day, held June 14. Analysts remain unabashedly bullish on Centene’s ability to outperform the market, particularly with the pending WellCare acquisition, which received its first state approval — from Kentucky — on June 14. The company expects the acquisition to close during the first half of 2020.

“While Medicaid remains core, the greatest incremental opportunity is in the MA segment, which the company is looking to expand,” said Citi analyst Ralph Giacobbe. Still, he added in an investor note, Centene appears confident about its chances of winning Medicaid bids in three upcoming requests for proposal: Texas, Louisiana and Oregon.

Centene CEO Michael Neidorff, who was the highest earning health plan CEO last year, will have built the company “into a $100 billion government health benefits powerhouse” once the WellCare transaction closes, said SVB Leerink analyst Ana Gupte.

Gupte highlighted Centene’s transition away from pharmacy benefit manager CVS Health Corp. to PBM RxAdvance. The investment in RxAdvance, coupled with similar investments in data analytics firm Interpreta — Centene increased its ownership stake to 80% in Interpreta last year — have helped to make technology Centene’s “core competency accelerating growth and innovation while improving and sustaining margins,” Gupte said.

Troy Medicare Aims to Launch Pharmacist-Centered Model in NC

June 26, 2019

Troy Medicare, a small Medicare Advantage plan start-up, aims to shake up the North Carolina MA marketplace during the coming fall open enrollment by offering a pharmacist-centered delivery model that will pay local, independent pharmacists directly for enhanced care management services to seniors.

“We will go live on Jan. 1, 2020,” in a five-county, “semi-rural” service area around Charlotte, N.C., Troy CEO Flaviu Simihaian tells AIS Health.

By Judy Packer-Tursman

Troy Medicare, a small Medicare Advantage plan start-up, aims to shake up the North Carolina MA marketplace during the coming fall open enrollment by offering a pharmacist-centered delivery model that will pay local, independent pharmacists directly for enhanced care management services to seniors.

“We will go live on Jan. 1, 2020,” in a five-county, “semi-rural” service area around Charlotte, N.C., Troy CEO Flaviu Simihaian tells AIS Health.

Under its model, Troy is working with Community Pharmacy Enhanced Services Network (CPESN). According to Simihaian, the new MA Prescription Drug (MA-PD) plan will contract with CPESN to provide reimbursement of $30 to $50 per member per month (PMPM), relying on participating pharmacists to document their services to determine reimbursement amounts.

Brian Anderson, a principal with Milliman, Inc., tells AIS Health that reimbursement is a key issue.

“It is an innovative model,” he says. “It’s been in the conversation for about 15 years, but the challenge has always been the reimbursement aspect and verifying the [pharmacist] consultations are occurring, and the pharmacist is actually spending time with the patient.”

“It hasn’t worked through the current NCPDP [National Council for Prescription Drug Plans] transaction processes” for Part D plans, Anderson says. “But if they’re just paying an administrative fee PMPM back to those pharmacists, that would be different than having the administrative fee paid through the claims payment system.”

Then there is the question of whether the benefit of pharmacist consultation is offsetting the potentially deeper prescription-drug discounts and higher rebates that large pharmacy chains or mail order pharmacy are able to give, as compared to small independent pharmacies, he says.

Additional Medicaid Funding to Puerto Rico, Virgin Islands Is in Jeopardy

June 24, 2019

Funding that has kept Medicaid programs afloat in Puerto Rico and the U.S. Virgin Islands following the devastating hurricanes that hit two years ago is set to expire in September. And that could lead to steep enrollment cuts, budget shortfalls and increases in the uninsured population, a Kaiser Family Foundation report warns.

If Congress does not take steps to extend the funding, the two territories will face a health care fiscal cliff that could drive residents to the mainland U.S. to obtain Medicaid coverage.

By Jane Anderson

Funding that has kept Medicaid programs afloat in Puerto Rico and the U.S. Virgin Islands following the devastating hurricanes that hit two years ago is set to expire in September. And that could lead to steep enrollment cuts, budget shortfalls and increases in the uninsured population, a Kaiser Family Foundation report warns.

If Congress does not take steps to extend the funding, the two territories will face a health care fiscal cliff that could drive residents to the mainland U.S. to obtain Medicaid coverage.

In addition, if the crisis isn’t resolved in time, “the local government will run out of money to finance the Medicaid program, risking access to care for hundreds of thousands of vulnerable U.S. citizens,” says Orlando González Rivera, president of Medicare Advantage Medicare and Mucho Más, a subsidiary of InnovaCare.

If Puerto Rico reverted to pre-ACA Medicaid financing, available funds would fall short of projected program costs by $1 billion in fiscal year 2020 and $1.5 billion in fiscal year 2021, which is equal to half of Medicaid projected program costs, the Kaiser report said.

In the Virgin Islands, meanwhile, a return to traditional financing would leave the territory with a projected $31.3 million shortfall in fiscal year 2020, which represents about 40% of projected program costs.

González Rivera says he expects a temporary solution to be in place by the end of September 2019, when the current agreement expires. However, “from what we have heard the solution will not be sufficient as it will be a temporary fix and not a permanent solution for the long-standing issue of inadequate funding for the Medicaid program to more than 1.3 million vulnerable U.S. citizens,” he says.

California Adds Mandate, Expands Health Care to Some Undocumented Immigrants

June 18, 2019

California created its own state-based individual mandate, added help for middle-income consumers purchasing coverage on the individual market, and agreed to pay for Medi-Cal coverage for undocumented young adults in a $213 billion legislative budget deal.

In the budget pact, approved June 13, California became the first state in the nation to offer subsidies for health coverage for those between 400% and 600% of the federal poverty level.

By Jane Anderson

California created its own state-based individual mandate, added help for middle-income consumers purchasing coverage on the individual market, and agreed to pay for Medi-Cal coverage for undocumented young adults in a $213 billion legislative budget deal.

In the budget pact, approved June 13, California became the first state in the nation to offer subsidies for health coverage for those between 400% and 600% of the federal poverty level.

The penalties paid by those who fail to purchase qualifying health insurance will help pay for those subsidies, according to the state. Beginning in 2020, adults will be charged $695 or 2% of their household income, whichever is more, for failing to purchase health insurance.

The legislation also expands Medi- Cal coverage to undocumented young adults ages 19 through 25 at the state’s expense, which will add approximately 90,000 young adults to the Medicaid program at a cost of around $98 million per year.

“We think for the long-term health of the exchange, having a mandate will help to get lower-risk people into the exchange,” L.A. Care Health Plan CEO John Baackes says. “It also gets the younger cohort used to participating and getting access to care whenever they need it.”

The budget deal left two other top issues for health insurers — a tax on managed care organizations and a new statewide drug purchasing plan — unresolved.

HCSC’s Care Vans Help Address Measles Outbreak

June 13, 2019

Several Blue Cross and Blue Shield plan subsidiaries of Health Care Service Corp. (HCSC) are leveraging what they acknowledge may be considered an “old-fashioned” outreach strategy — mobile care vans — in their efforts to help address the worst resurgence of measles in more than a quarter century in the U.S.

As of May 20, HCSC’s 26 care vans this year had nearly 127,000 patient visits and provided 66,188 immunizations and 90,503 other health services, HCSC spokesperson Jori Fine tells AIS Health.

By Judy Packer-Tursman

Several Blue Cross and Blue Shield plan subsidiaries of Health Care Service Corp. (HCSC) are leveraging what they acknowledge may be considered an “old-fashioned” outreach strategy — mobile care vans — in their efforts to help address the worst resurgence of measles in more than a quarter century in the U.S.

As of May 20, HCSC’s 26 care vans this year had nearly 127,000 patient visits and provided 66,188 immunizations and 90,503 other health services, HCSC spokesperson Jori Fine tells AIS Health.

Year-to-date, the Texas Blues plan has provided 328 measles, mumps and rubella (MMR) vaccines, and the Oklahoma Blues plan has provided 272 MMR shots via the care van program, Fine says.

The mobile outreach program’s increase in MMR vaccinations following the U.S. measles outbreak is “a great example of how we’re able to respond to emerging health threats by removing barriers like transportation and affordability to bring health education and services directly to the people who need it most,” says Derek Robinson, M.D., vice president and chief medical officer for Blue Cross and Blue Shield of Illinois.

The bottom line, according to Joe Paduda, principal with Health Strategy Associates, LLC, is health care organizations can only go so far with technology. “Reaching out to patients is critical, especially for those that are difficult to reach,” he says. “While technology, AI [artificial intelligence], big data, and all the rest is certainly useful, it comes down to people serving people.”