Radar on Medicare Advantage

T-MSIS Fails to Maintain Full Medicaid Managed Care Payment Data, OIG Reports

April 7, 2021

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS.

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “OIG: T-MSIS Lacks Full Medicaid Managed Care Payment Data.”

By Lauren Flynn Kelly

A new review of the CMS Transformed Medicaid Statistical Information System (T-MSIS) found that most states did not provide complete or accurate data on managed care payments to providers for January 2020, according to an HHS Office of Inspector General report released March 30.

Managed care organizations, which cover about 70% of the Medicaid population, are required to submit an encounter claim for each enrollee encounter or visit to a provider. States must then validate those claims for accuracy before submitting them to T-MSIS.

Having accurate payment data is essential to monitoring and administering the Medicaid program, OIG explained. For example, states use payment data to set capitation rates for MCOs and to monitor the services they provide. CMS and other stakeholders can use the data to manage and oversee plans, and to examine payments to detect fraud, waste and abuse. And with more individuals enrolling in and using Medicaid over the last year, “[p]rotecting the fiscal integrity of Medicaid during the pandemic has taken on a new urgency,” OIG argued.

Yet 31 out of 39 states with managed care last year did not provide complete or accurate data to T-MSIS on provider payments for January 2020 made by their largest plan. A record was considered incomplete or inaccurate if it had inappropriate zeros, missing data or negative amounts, clarified OIG. Moreover, many states had incomplete or inaccurate information for two or more types of payment data.

Although CMS has identified improving data quality in the system as a priority, OIG maintained that CMS must “strengthen its efforts to improve the accuracy and completeness of managed care payment data in T-MSIS.” Specifically, it recommended that CMS:

✦ Review states’ managed care payment data in T-MSIS and certify that states have corrective action plans to improve data completeness and quality, as appropriate;

✦ Publicize the findings of such reviews, including the extent to which the payment data are complete and accurate for each individual managed care plan; and

✦ Clarify and expand its initiative on payment data.

CMS did not agree with any of the recommendations. In a letter dated Jan. 19, then-CMS Administrator Seema Verma responded that the agency has over the last several years taken steps to improve T-MSIS.

Diabetes Reversal Platform Shows Positive Outcomes, Calif. Blues Plan Reports

April 5, 2021

Diabetes prevention and diabetes management are both key tenets of Medicare Advantage insurers’ approach to addressing this costly condition that impacts one in three Medicare enrollees. But one tech-savvy startup aims to popularize a third category — diabetes reversal — and early adopter Blue Shield of California says the program has achieved very desirable results in less than two years.

Utilizing a nutrition protocol combined with high frequency interaction with health coaches to achieve significant reductions in blood glucose levels — all done virtually — Virta Health has a mission of reversing type 2 diabetes in 100 million people by 2025.

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “Calif. Blues Plan Sees Promise in Diabetes Reversal Platform.”

By Lauren Flynn Kelly

Diabetes prevention and diabetes management are both key tenets of Medicare Advantage insurers’ approach to addressing this costly condition that impacts one in three Medicare enrollees. But one tech-savvy startup aims to popularize a third category — diabetes reversal — and early adopter Blue Shield of California says the program has achieved very desirable results in less than two years.

Utilizing a nutrition protocol combined with high frequency interaction with health coaches to achieve significant reductions in blood glucose levels — all done virtually — Virta Health has a mission of reversing type 2 diabetes in 100 million people by 2025.

“It is a highly individualized virtual care team that’s working with the member,” says Steve Hastings, health plan sales leader with Virta. As part of the nutrition protocol, coaches work with patients to figure out what they can eat in their own “food environment,” and interact with members based on their preference.

Blue Shield of California includes Virta as an optional benefit enhancement in its Wellvolution platform, which offers online and in-person programs for general wellbeing and disease reversal.

Blue Shield Senior Director of Lifestyle Medicine Angie Kalousek says Virta is one of Wellvolution’s highest-performing providers, and in the short time members have been engaging with the program, they have demonstrated improved outcomes and reported multiple positive side effects.

In aiming to get members “off the medications they’re sort of shackled to as diabetics, they’re not only tackling the cost of health care but they’re really improving the life of the member,” says Kalousek of Virta. For the members who have engaged with Virta, nearly 65% have achieved statistically significant clinical outcomes.

In a small study looking at prescription drug claims for 60 members using the Virta treatment platform, Blue Shield of California observed that 85% of members lost weight. In addition, more than half of members narrowed their diabetes medications down to one agent, and 30% discontinued their medications altogether.

Meanwhile, the insurer is starting to look at ways to measure the cost effectiveness of using such a program. Considering the estimated lifetime expense of treating a diabetic patient is $100,000, and Blue Shield can pay up to $3,900 per member to Virta — although most members achieve maintenance levels at a lower cost — “there’s an argument that there’s a lot of cost savings on the table,” says Kalousek.

MA Insurers Deploy New Benefit Flexibilities in Diabetes Management

March 22, 2021

From lowering cost sharing on select services to participating in the new Part D insulin model, Medicare Advantage insurers are incorporating new benefit flexibilities into their overall management of diabetes, which impacts one in every three Medicare beneficiaries.

Diabetes accounts for more than $300 billion in U.S. health care spending, including $17 billion spent on insulin in the Part D program. According to a Faegre Drinker analysis, 23.7% of plans offering condition-specific benefits this year are targeting diabetes. The most popular benefits include reduced cost sharing on podiatry, physician specialist and primary care physician services, and additional supplemental benefits related to podiatry, meals and worldwide urgent coverage.

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “MA Plans Test New Flexibilities Targeted to Diabetic Members.”

By Lauren Flynn Kelly

From lowering cost sharing on select services to participating in the new Part D insulin model, Medicare Advantage insurers are incorporating new benefit flexibilities into their overall management of diabetes, which impacts one in every three Medicare beneficiaries.

Diabetes accounts for more than $300 billion in U.S. health care spending, including $17 billion spent on insulin in the Part D program. According to a Faegre Drinker analysis, 23.7% of plans offering condition-specific benefits this year are targeting diabetes. The most popular benefits include reduced cost sharing on podiatry, physician specialist and primary care physician services, and additional supplemental benefits related to podiatry, meals and worldwide urgent coverage.

And the fact that more than 1,600 MA and Part D plans this year are participating in the CMS Part D Senior Savings Model — which aims to lower out-of-pocket costs for diabetic seniors by featuring predictable copayments of no more than $35 for a broad set of insulins — speaks to plan sponsors’ confidence in serving the diabetes population effectively, suggests Tim Murray, director and senior consulting actuary with Wakely Consulting.

SelectHealth says many of its MA members in Idaho, Nevada and Utah already have $0 cost sharing on several services, but it has incrementally enhanced its diabetes-specific benefits in select markets and observed a “small, yet positive increase in these benefit utilizations.” The insurer focuses on reducing costs associated with essential services that are key to diabetes management, and says it targets behaviors as opposed to looking at the severity of the disease or risk scores when considering benefit design.

Blue Cross & Blue Shield of Rhode Island (BCBSRI) offers multiple flex benefits for members with diabetes, including routine foot care and additional dental services. That’s all part of a whole-person approach that includes education and ongoing clinical coaching and management, explains Michael Menard, managing director of Medicare strategy, product and business operations. New for 2021, BCBSRI is also participating in the Part D insulin model.

MVP Health Care, which sells MA plans in New York and Vermont, says it has offered many low- and no-cost services related to diabetes for several years, and for 2021 has removed the cost of routine podiatry care.

Independence Blue Cross has also made incremental adjustments to its diabetes-specific programs, including the expansion of a post-discharge meal benefit, the addition of a medical nutrition therapy benefit, and a dedicated diabetes case and condition management program to improve utilization and reduce gaps in care.

MA Insurers Use Direct Plan Comparisons, Digital Engagement to Compete During OEP

March 11, 2021

With reports of low Medicare Advantage switching during the recent Annual Election Period (AEP) and major national carriers capturing two-thirds of new enrollment, smaller regional players are looking at the current Open Enrollment Period (OEP) as an opportunity to foster satisfaction and retention and to promote their brand through multiple marketing channels.

“Even before the end of AEP, we were planning with our regional clients to ensure they had a strong presence in the marketplace during the OEP,” says Renee Mezzanotte, executive vice president of client engagement with Chesterbrook, Pa.-based DMW Direct. “A combination of media channels — digital, direct response TV and direct mail — are proving to keep our clients top of mind. As in years past, to make the most of limited budgets, DRTV schedules are flighted around direct mail drops to boost awareness and response. We can’t outspend national players, but we can outsmart them.”

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “OEP Tactics Include COVID Comms, Direct Plan Comparisons.”

By Lauren Flynn Kelly

With reports of low Medicare Advantage switching during the recent Annual Election Period (AEP) and major national carriers capturing two-thirds of new enrollment, smaller regional players are looking at the current Open Enrollment Period (OEP) as an opportunity to foster satisfaction and retention and to promote their brand through multiple marketing channels.

“Even before the end of AEP, we were planning with our regional clients to ensure they had a strong presence in the marketplace during the OEP,” says Renee Mezzanotte, executive vice president of client engagement with Chesterbrook, Pa.-based DMW Direct. “A combination of media channels — digital, direct response TV and direct mail — are proving to keep our clients top of mind. As in years past, to make the most of limited budgets, DRTV schedules are flighted around direct mail drops to boost awareness and response. We can’t outspend national players, but we can outsmart them.”

The OEP, which runs from Jan. 1 to March 31 each year, allows beneficiaries who selected an MA plan during the AEP to make a one-time switch to another plan or change their coverage to Original Medicare.

“In addition to the emails and direct mail touches welcoming members and outlining specific benefits, member webinars have been an important part of our clients’ outreach,” adds Mezzanotte.

Getting in front of members with a strong onboarding strategy is critical, and that should start at the point of sale, says consultant Diane Hollie. It could be something simple that clearly describes the next steps. This should help avoid potential confusion or the feeling of buyer’s remorse, she suggests.

Another strategy Hollie is seeing clients explore is “understanding from the AEP where members have gone and how they can advertise against that.” This is the second OEP that CMS has allowed plans to make direct comparisons to other plans in their marketing, as long as the information is accurate and can be supported. Plans are also proactively using these direct plan comparisons in their age-in campaigns, she says.

“Member communication regarding COVID-19 has been an integral part of our clients’ plans over the last year and it continues in 2021 through email, mail, social media, and text,” Mezzanotte says. “While information is changing almost daily, it is crucial for plans not to shy away from speaking to their members even if it is to just to provide basic guidance.”

Care Deferrals Show Negative Impacts on MA Risk Adjustment Payments in 2021

March 2, 2021

Although many publicly traded insurers touted enrollment growth from the 2021 Medicare Annual Election Period (AEP) when reporting fourth-quarter and full-year 2020 earnings, some expressed the concern that care deferrals seen last year may have a negative impact on Medicare Advantage risk adjustment payments this year.

Humana Inc. on Feb. 3 posted a loss of $2.30 per share on an adjusted basis, which was driven by three main factors: (1) higher treatment and testing costs related to COVID-19 that were more than offset by a decline in non-COVID utilization, (2) ongoing pandemic relief efforts, and (3) increased expenses associated with the AEP. Humana ended the year with approximately 4.6 million total MA members, reflecting year-over-year growth of 11%, driving consolidated revenue growth of 90% in 2020.

NOTE: The abstract below is a shortened version of the RADAR on Medicare Advantage article “Care Deferrals Pose Headwinds For MA Risk Adjustment in ’21.”

By Lauren Flynn Kelly

Although many publicly traded insurers touted enrollment growth from the 2021 Medicare Annual Election Period (AEP) when reporting fourth-quarter and full-year 2020 earnings, some expressed the concern that care deferrals seen last year may have a negative impact on Medicare Advantage risk adjustment payments this year.

Humana Inc. on Feb. 3 posted a loss of $2.30 per share on an adjusted basis, which was driven by three main factors: (1) higher treatment and testing costs related to COVID-19 that were more than offset by a decline in non-COVID utilization, (2) ongoing pandemic relief efforts, and (3) increased expenses associated with the AEP. Humana ended the year with approximately 4.6 million total MA members, reflecting year-over-year growth of 11%, driving consolidated revenue growth of 90% in 2020.

Adjusted EPS for the full year was $18.75, and the Medicare-focused insurer expects to achieve $21.50 per share at the midpoint for 2021. That includes an estimated Medicare risk adjustment headwind of approximately $700 million to $1 billion, representing 1% to 1.5% of Medicare premium for the full year.

For the full year of 2020, Cigna Corp. reported adjusted EPS of $18.45, in line with expectations that included the “ongoing elevated cost of COVID-19-related services,” stated President and CEO David Cordani during a Feb. 4 earnings call.

For 2021, the company expects to achieve at least $20 adjusted EPS, which includes the “expected COVID-19 related headwind of approximately $1.25 per share,” said CFO Brian Evanko. He clarified that is related to Cigna’s limited ability to collect “all of the risk adjustment codes” that it would gather in a typical year “due to the unique nature of 2020 and the COVID-19 headwinds.”

Molina Healthcare, Inc. — which recorded a loss of $3.80 per share in the quarter — also said it expects its 2021 earnings to be impacted by care deferrals. For 2021, Molina anticipates adjusted EPS with a midpoint of $12.75, compared with the “normalized” EPS of $12.97 for 2020. That guidance, which includes the continuation of COVID risk-sharing corridors in Molina’s Medicaid programs, also reflects the challenge of lower-than-expected Medicare risk scores.

Lastly, CVS Health Corp. on Feb. 16 reported fourth-quarter adjusted EPS of $1.30 — beating Wall Street’s projections of $1.24 — and full-year EPS of $7.50. For 2021, the company said it is targeting an adjusted EPS range of $7.39 to $7.55.