Radar on Medicare Advantage

MA Insurers Grab Post-Midterm Growth Opportunities

November 19, 2018

Health care was a pivotal issue during the recent midterm elections. For Medicare Advantage plans that are in the middle of the 2019 Annual Election Period (AEP), they’ll be happy to cut the noise and get back to business, industry experts tell AIS Health.

By Lauren Flynn Kelly

Health care was a pivotal issue during the recent midterm elections. For Medicare Advantage plans that are in the middle of the 2019 Annual Election Period (AEP), they’ll be happy to cut the noise and get back to business, industry experts tell AIS Health.

“The election was a pretty big distraction for market share growth for the AEP,” says Jeff Fox, president of Gorman Health Group, who heard from health plan clients that enrollment slowed down. With mixed messages in the media about the Affordable Care Act, pre-existing conditions and “Medicare for All,” “seniors were confused about what’s real and tend to assume a lot of these things pertain to them, so agents were out there trying to explain what’s going on and it was tough from a sales perspective.”

Fox adds, “We knew the elections were going to impact the early sales in MA, but now that the noise is off the TV, off the radio, out of the mailboxes, plans can get back to focusing on their market share opportunities for 2019. And seeing how crazy this election was made them realize how crazy it’s going to be in two years, so I think plans will really dial in on market share opportunities in 2019 and 2020, because who knows what’s going to happen in two years?”

“I see companies putting in a much bigger stake and effort around Medicare, and I think MA will just continue on an upward trajectory. It’s a stable market on an uptick,” weighs in Lindsay Resnick, executive vice president at Wunderman Health, which provides data analytics and technology-enabled marketing to national and regional MA plans.

And as discussions around Medicare for All — and what it means — continue, Resnick says he sees that bringing even more attention to MA as a model of public-private partnership. “Although I don’t expect any action around Medicare for All, it’ll be a policy debate in the 2020 elections. The problem right now is Medicare for All isn’t really defined consistently,” he adds.

MOM Model Allows States, MCOs to Address Care Barriers

November 8, 2018

By Lauren Flynn Kelly

Medicaid managed care organizations will soon have a new opportunity to address the growing and costly burden of maternal opioid misuse. Just a day before President Trump signed a sweeping package of bills addressing the opioid epidemic, CMS on Oct. 23 unveiled the Maternal Opioid Misuse (MOM) model. Under that program, the Innovation Center will award up to 12 cooperative agreements with states, whose Medicaid agencies will implement the model with one or more “care-delivery partners” in their communities,

By Lauren Flynn Kelly

Medicaid managed care organizations will soon have a new opportunity to address the growing and costly burden of maternal opioid misuse. Just a day before President Trump signed a sweeping package of bills addressing the opioid epidemic, CMS on Oct. 23 unveiled the Maternal Opioid Misuse (MOM) model. Under that program, the Innovation Center will award up to 12 cooperative agreements with states, whose Medicaid agencies will implement the model with one or more “care-delivery partners” in their communities, including health plans.

In a fact sheet unveiling the model, CMS said it is intended to “address fragmentation in the care of pregnant and post-partum Medicaid beneficiaries with opioid use disorder (OUD) through state-driven transformation of the delivery system surrounding this vulnerable population” and to ensure that mothers with OUD receive a comprehensive set of services delivered in a coordinated and integrated fashion.

Not only has there been a surge in recent years in substance-use related illness and death among pregnant and postpartum women, but the number of babies born with neonatal abstinence syndrome (NAS) — an opioid withdrawal syndrome that can lead to lengthy and costly hospital stays — jumped 300% between 1999 and 2013 in 28 states with publicly available data on opioid addiction. And Medicaid pays the largest portion of hospital charges for maternal substance use, as well as the bulk of the $1.5 billion annual cost of NAS, according to CMS.

Yet despite this significant impact, opioid-addicted pregnant women face various barriers to treatment. The MOM model will award cooperative agreements to states to support Medicaid agencies, providers and health systems to address the fragmentation of care that currently exists. The state will be expected to complete the application, which must demonstrate that it has teamed up with at least one care-delivery partner, which could be a health system or payer, suggested CMS.

State Medicaid agencies will develop and implement coverage and payment strategies, while their partners will provide services to beneficiaries.

To support the model’s goals, a maximum of $64.6 million will be distributed among up to 12 state awardees over a five-year period.

New Opioid Law Has Implications for MA, Medicaid Plans

November 5, 2018

By Lauren Flynn Kelly

One year after the Trump administration declared the opioid crisis a public health emergency, the president signed The SUPPORT for Patients and Communities Act (H.R. 6), a bipartisan legislative package containing myriad provisions aimed at addressing the opioid epidemic. One of the main objectives of the law is to expand access to substance use disorder (SUD) treatment in Medicaid.

The new law contains certain flexibilities related to the IMD exclusion,

By Lauren Flynn Kelly

One year after the Trump administration declared the opioid crisis a public health emergency, the president signed The SUPPORT for Patients and Communities Act (H.R. 6), a bipartisan legislative package containing myriad provisions aimed at addressing the opioid epidemic. One of the main objectives of the law is to expand access to substance use disorder (SUD) treatment in Medicaid.

The new law contains certain flexibilities related to the IMD exclusion, which refers to a longstanding exception that prevented state Medicaid programs from using federal funds to cover care for patients in mental health and SUD residential treatment facilities with more than 16 beds. The primary change is that Section 5052 amends federal Medicaid law by giving state programs the option to cover care in certain IMDs, which may be otherwise not reimbursable for federal funds, for Medicaid beneficiaries aged 21 to 64 with an SUD for fiscal years 2019 to 2023. Through a state plan amendment, states may receive federal reimbursement for up to 30 total days of care in an IMD during a 12-month period for eligible individuals.

As a condition of receiving federal payments, states will be subject to a “maintenance of effort” provision that essentially says they have to maintain the same levels of funding for “what they’ve been doing in other areas of care, so having IMDs doesn’t mean you can cut back on some of the home and community-based services that were going on for opioid treatment,” remarks Stephanie Kennan at McGuireWoods Consulting. “It’ll be expensive for the states, but it’s important for the continuum of care. The trade-off is that you’ll have patients hopefully who are getting the kind of care they need faster and won’t need other things on the other end.”

As states add IMDs to their programs, plans will have to figure out who will be eligible and how to manage the care, “because not everyone is going to need inpatient treatment and it is only for 30 days,” adds Kennan. “And I think in general whether it’s Medicare or Medicaid, the plans are going to have to do some identifying and managing of patients, but in a little more detail than they had to do it before.”

Trump Admin Says Nothing is Off the Table for Part D, Drug Cost Reform

October 25, 2018

by Lauren Kelly

Addressing the opioid crisis, improving transparency for Medicare beneficiaries and operationalizing new Medicare Advantage benefit flexibility were all hot topics at AHIP’s National Conference on Medicare, held Oct. 15-16 in Washington, D.C. But as the Trump administration continues to ramp up efforts around drug pricing, one area that generated the most debate and uncertainty was the future of the Medicare Part D program.

Panelists during a session on Oct.

by Lauren Kelly

Addressing the opioid crisis, improving transparency for Medicare beneficiaries and operationalizing new Medicare Advantage benefit flexibility were all hot topics at AHIP’s National Conference on Medicare, held Oct. 15-16 in Washington, D.C. But as the Trump administration continues to ramp up efforts around drug pricing, one area that generated the most debate and uncertainty was the future of the Medicare Part D program.

Panelists during a session on Oct. 15 — the same day that CMS issued a proposed rule to require manufacturers to disclose drug prices in direct-to-consumer television ads — agreed that in considering all the potential changes that could be made in Part D, there’s an overarching concern of whether reducing the burden in one area ends up inflating costs elsewhere.

The way the program is designed now, high-cost enrollees are driving overall Part D spending growth, and some beneficiaries can easily reach the catastrophic phase just by obtaining one high-cost specialty medication, pointed out the panelists. “We need to look deeper now at some of the mechanisms for Part D…and incentivize more management of the benefit,” said Larry Kocot, principal and national leader of the Center for Healthcare and Regulatory Insight at KPMG, LLP.

“We need to free up the plans to use the tools better, but work in the beneficiary protections,” he continued.

During a separate session on President Trump’s “blueprint” to lower drug prices, two HHS advisors said the administration is looking at all its authority — regulatory, statutory, demonstration — to tackle the issue of drug pricing. And Dan Best, senior advisor for drug pricing reform to the HHS secretary, acknowledged the recommendations made by MedPAC, saying the commission has “spoken sensibly on the need to change the program.”

The president’s goal is “to lower list price for all Americans,” stated Best. “Sometimes people get lost in the fact that we’re just focused on the programs under our authority, but the reality is the president’s been clear that his objective is to develop a system that will [lower] prices for everybody. And in that, we are all aware of how complex the system is.”

MA Plans Prepare to Expand Benefits for 2019 AEP

October 23, 2018

by Lauren Kelly

CMS is expecting Medicare Advantage enrollment to grow by 11.5% next year, with more than 36% of Medicare eligible consumers projected to be in an MA plan in 2019. And plans are using improved payment rates and new benefit design flexibility from CMS to sweeten the deal for customers, as evidenced in the slew of press releases that have come out since Oct. 1, when marketing for the 2019 Annual Election Period (AEP) began two weeks ahead of open enrollment.

by Lauren Kelly

CMS is expecting Medicare Advantage enrollment to grow by 11.5% next year, with more than 36% of Medicare eligible consumers projected to be in an MA plan in 2019. And plans are using improved payment rates and new benefit design flexibility from CMS to sweeten the deal for customers, as evidenced in the slew of press releases that have come out since Oct. 1, when marketing for the 2019 Annual Election Period (AEP) began two weeks ahead of open enrollment.

“This was probably the first year in the past 15 that I have seen 100% of our clients add benefits and not take them away in order to combat health care trends,” says Jeff Fox, president of Gorman Health Group (GHG). “It was a really good bid season with plans getting more creative, and I think the ones that thought outside the box in terms of benefit design are going to see a win here during the AEP.”

Many plans have said they were able to reduce premiums and/or expand their $0 premium plan offerings for 2019, and will offer some combination of dental, vision and hearing as a benefit. But Fox says the “heavy hitters” for 2019 are over-the-counter (OTC) drug coverage and nutritional benefits. “OTC is one of those few benefits that touches every beneficiary,” he tells AIS Health. “It helps the healthy, it helps the unhealthy, and it helps everybody who’s going into the store for those medicines the government doesn’t cover.”

Meanwhile, several GHG clients that had tested offering nutritional benefits on a small scale in 2018 and saw a return on their investment expanded that offering in 2019, thanks to CMS broadening the scope of health-related supplemental benefits that can be included in bids. “Health plans have been doing certain things in care management programs, but they were not able to advertise and market them,” says Fox. “So having [these benefits] is going to be a huge success with members and I think it will play well from a marketing perspective.”