Radar on Medicare Advantage

Amid COVID-19 Outbreak, CMS Relaxes Rules on MA Data Collection

April 6, 2020

As efforts to contain the outbreak of COVID-19 continue to evolve, the Trump administration on March 30 issued a series of new flexibilities aimed at increasing hospital and provider capacity. At the same time, CMS in a March 30 memo provided some respite to Medicare Advantage and Part D plans dealing with the crisis by suspending audit and quality reporting activities so that plans and states can focus on providing care to the increasing number of beneficiaries affected by the new coronavirus.

By Lauren Flynn Kelly

As efforts to contain the outbreak of COVID-19 continue to evolve, the Trump administration on March 30 issued a series of new flexibilities aimed at increasing hospital and provider capacity. At the same time, CMS in a March 30 memo provided some respite to Medicare Advantage and Part D plans dealing with the crisis by suspending audit and quality reporting activities so that plans and states can focus on providing care to the increasing number of beneficiaries affected by the new coronavirus.

As physicians cater to patients who are or may be infected with COVID-19, and as the federal government advises adults to delay elective surgeries and nonessential procedures during the outbreak, plans are likely to face issues with reporting quality data used to determine future star ratings.

CMS in an interim final rule issued March 30 said it will allow for several key changes to the calculations for the 2021 and 2022 Parts C and D star ratings to account for the expected impact of the public health emergency on data collection and performance.

Up until this point, the potential impact of COVID-19 on CMS’s quality agenda and more specifically quality-based payments to MA plans was a major area of uncertainty for insurers, points out Dan Mendelson, founder of Avalere Health. “The MA quality payment system is based largely on visits that are not possible in a world where COVID-19 has changed the face of American health care, so this program needs to be fundamentally modified for 2021,” says Mendelson. “It appears that CMS still intends to use star ratings, albeit a very different version that relies largely on historical data — which will advantage plans that had a strong prior year.”

But in addition to the interim final rule, more guidance may be needed on the potential impact of COVID-19 on MA payment rates for 2021. And the most important additional guidance that the industry needs, Mendelson says, is for CMS “to allow for telehealth visits to fully substitute for face-to-face visits during this critical and uncertain period of time.”

MA, Medicaid Insurers Employ More Strategies to Protect Members

March 23, 2020

In the week or so leading up to the U.S. declaring a national emergency, Medicare Advantage and other insurers’ early response to the new coronavirus outbreak included waiving cost sharing related to testing, allowing early prescription refills and expanding access to and encouraging the use of telehealth services. But as the virus continues to spread in the U.S., insurers are having to take extra steps to protect the health of their most vulnerable members.

By Lauren Flynn Kelly

In the week or so leading up to the U.S. declaring a national emergency, Medicare Advantage and other insurers’ early response to the new coronavirus outbreak included waiving cost sharing related to testing, allowing early prescription refills and expanding access to and encouraging the use of telehealth services. But as the virus continues to spread in the U.S., insurers are having to take extra steps to protect the health of their most vulnerable members.

While managed care organizations can play a big role in keeping enrollees safe by addressing social determinants of health, they can make the largest impact by disseminating information to particularly vulnerable populations, suggests Jerry Vitti, founder and CEO of Healthcare Financial, Inc. “They are in a unique position to convey accurate and timely information about infection control to Medicaid enrollees who…are more susceptible to disease than the general population.”

UPMC Health Plan, which waived testing-related cost sharing and prescription refill restrictions for enrollees of its MA, Medicaid/CHIP and commercial plans as of March 6, says it is “trying to get the word out” in as many ways as possible to its older and/or chronically ill members.

The insurer is also “pushing telehealth as a first-line screening” and has waived cost sharing for all lines of business for 90 days when using the UPMC AnywhereCare virtual app, says Amy Helwig, M.D., chief quality officer with UPMC.

“As the coronavirus becomes a more pressing concern for New Yorkers and Americans across the country,” EmblemHealth has deployed a multichannel communications strategy to reach members, according to a spokesperson for the insurer. It is also offering a “bevy of virtual and telephonic options to help reinforce social distancing and the fact that we know the elderly are a vulnerable population.”

President Donald Trump on March 13 declared the coronavirus outbreak a national emergency, which means CMS can waive certain federal requirements in Medicare, Medicaid and CHIP to expand efforts to contain the virus.

“With the CMS directives, MA plans have to eliminate cost sharing for testing and extend other emergency flexibilities to enrollees. However, the issue with the pandemic seems to be the insufficient availability of testing and ultimately the ability to receive care, not how it’s covered or paid for,” says Larry Kocot, a principal at KPMG LLP and a former top CMS official.

Major Insurers Report Strong Earnings and MA Membership Growth

March 10, 2020

The majority of publicly traded insurers reporting fourth-quarter and full-year 2019 earnings over the last month identified government business as a significant earnings contributor, with momentum from the recent Medicare Advantage open enrollment period carrying that growth into 2020.

Reporting its first full year of earnings with Aetna Inc., CVS Health Corp. on Feb. 12 said that acquisition was the main driver of consolidated growth of 32% to nearly $256.8 billion. Total revenues in the company’s Health Care Benefits segment continued to benefit from strong membership in government products, said Eva Boratto, CVS Health chief financial officer, during a conference call to discuss recent earnings.

By Lauren Flynn Kelly

The majority of publicly traded insurers reporting fourth-quarter and full-year 2019 earnings over the last month identified government business as a significant earnings contributor, with momentum from the recent Medicare Advantage open enrollment period carrying that growth into 2020.

Reporting its first full year of earnings with Aetna Inc., CVS Health Corp. on Feb. 12 said that acquisition was the main driver of consolidated growth of 32% to nearly $256.8 billion. Total revenues in the company’s Health Care Benefits segment continued to benefit from strong membership in government products, said Eva Boratto, CVS Health chief financial officer, during a conference call to discuss recent earnings.

During a Feb. 6 earnings call, Cigna Corp. President and CEO David Cordani said the company is focused on growing its MA business in geographies where its commercial business “has deep ties in delivery systems.” For 2020, Cigna anticipates MA membership growth of 13% to 16%, contributing to earnings growth of 11% to 13% in its Integrated Medical segment.

Reporting earnings on Feb. 5, Humana Inc. touted strong membership gains in both MA and Medicaid last year and said 2019 was its most successful year for growth in individual MA enrollment, which climbed 17% to 3.59 million members as of Dec. 31.

Fresh off closing its acquisition of WellCare Health Plans, Inc., Centene Corp. on Feb. 4 reported fourth-quarter 2019 revenues of $18.9 billion, up 14% from the prior-year quarter. That increase was primarily due to growth in its Affordable Care Act marketplace business, but it was partially offset by the health insurer fee moratorium in 2019, said CFO Jeff Schwaneke.

As Centene continued to grow leadership positions in the Medicaid and exchange markets last year, the insurer lost approximately 3% of its Medicare membership but is “focused on addressing the underlying drivers of this underperformance,” added President and CEO Michael Neidorff during a Feb. 4 earnings call.

During a Jan. 29 earnings call, Anthem, Inc. President and CEO Gail Boudreaux said the insurer’s government segment continues to be the “faster-growing portion” of the business and that MA enrollment increased by more than 20% in 2019. That momentum is carrying into 2020.

Medicaid MCOs Deploy Resource Centers to Better Serve Members

February 26, 2020

From engaging members in cooking and self-defense classes to coaching them on specific health conditions, Medicaid managed care organizations are building out brick-and-mortar centers to better serve their enrollees. Three such MCOs shared their experiences at the 11th Annual Medicaid Innovations Forum, hosted by Strategic Solutions Network in Orlando from Feb. 5 to 7.

By Lauren Flynn Kelly

From engaging members in cooking and self-defense classes to coaching them on specific health conditions, Medicaid managed care organizations are building out brick-and-mortar centers to better serve their enrollees. Three such MCOs shared their experiences at the 11th Annual Medicaid Innovations Forum, hosted by Strategic Solutions Network in Orlando from Feb. 5 to 7.

In an unusual case of competitors joining forces, Blue Shield of California Promise Health Plan and L.A. Care Health Plan said they are building out 14 co-branded “Community Resource Centers” that will serve a projected 1 million individuals in the Los Angeles area annually.

The first joint site opened in December 2019 in Pomona, Calif. The next resource center is due to open at the end of April. The partners will jointly open seven new resource centers, remodel four existing centers and relocate three others to larger locations.

“One of the big shifts for us is to move from more generic programming that is attractive to anyone who walks in the door to programming that will continue to serve the non-member community but also integrating a lot more programming is that is member-specific,” such as case management for diabetes prevention, said Francisco Oaxaca, senior director of communications and community relations of L.A. Care.

In the case of Trusted Health Plan, Inc., which was recently acquired by CareFirst BlueCross BlueShield, the Washington, D.C. MCO’s center model is focused on health and wellness for low-risk populations.

Using a data-driven approach to stratify members into five groups and properly manage its population, Trusted assigns members identified as “in crisis” to complex case management, those who are seen as “struggling” to case management and those it views as “at risk” to disease management, according to Trusted President and CEO George Aloth.

Those who are identified as stable or healthy generally do not require ongoing support but may need one-time assistance or intermittent assistance and referrals. The health plan recommends these individuals enroll in the “Wellness Navigation Program,” which features an assigned staff member and offerings such as health risk assessments, member services and health education that they can access through one of two wellness centers.

CMS Medicare Advantage Rule Features Highlights for Health Plans

February 24, 2020

CMS on Feb. 5 issued a 900-page proposed rule containing a slew of non-rate-related changes to the Medicare Advantage and Part D programs for contract years 2021 and 2022.

“There are not game-changers in this regulation, but there are another series of program tweaks that are, in total, pretty helpful to MAOs,” observes Michael Adelberg, a principal with Faegre Drinker Consulting.

By Lauren Flynn Kelly

CMS on Feb. 5 issued a 900-page proposed rule containing a slew of non-rate-related changes to the Medicare Advantage and Part D programs for contract years 2021 and 2022.

“There are not game-changers in this regulation, but there are another series of program tweaks that are, in total, pretty helpful to MAOs,” observes Michael Adelberg, a principal with Faegre Drinker Consulting.

One of the more interesting proposals includes CMS’s first attempt to regulate imitators of Dual Eligible Special Needs Plan (D-SNPs), points out Adelberg. CMS in the 2020 draft Call Letter had discussed the proliferation of so-called “D-SNP look-alike” plans, and the agency maintained that they may undermine state efforts to promote further integration of Medicare and Medicaid benefits.

CMS in the new proposed rule said it would not enter into or renew an MA contract for a non-SNP plan if: (1) a plan projected in its bid that 80% or more of its total enrolled population is also eligible for Medicaid benefits, or (2) 80% of its actual enrollment are dual eligibles. MA plans whose membership exceeds this threshold would be able to transition their membership into a D-SNP or another $0 premium plan offered by the MAO, suggested CMS.

“CMS could have twisted itself and everyone else into pretzels seeking to define a D-SNP look-alike,” points out Adelberg. “But instead, they propose an enrollment threshold, which is a much more straightforward approach.”

Meanwhile, one plan-friendly change was a proposal around network adequacy and telehealth. CMS in the new rule proposed allowing MA plans to receive a “10 percent credit” on meeting published time and distance standards when contracting with telehealth providers for five specialty types.

Another piece of good news for plans was a proposal to include in their medical loss ratio (MLR) calculation covered services delivered by entities that do not meet the definition of “provider.” As CMS codifies subregulatory guidance and statutory changes that have expanded the types of supplemental benefits that MA plans may include in their plan benefit packages, the agency said that such benefits need not be delivered by an individual or entity that falls under the provider standard.