Radar on Medicare Advantage

Medicaid MCOs Are Likely to See COVID-Related Enrollment Growth

April 23, 2020

As the COVID-19 pandemic continues to dominate the news cycle, headlines related to rising unemployment often underscore the impact to Medicaid, but what about the Medicaid managed care organizations that will absorb the newly jobless and uninsured?

“I think that Medicaid MCOs are clearly in the best position to handle the influx of folks,” remarks Jerry Vitti, founder and CEO of Healthcare Financial, Inc. While onboarding a wave of new members may put some initial stress on plans, the real “strain” will come from covering new members who have unmet health care needs, he suggests.

By Lauren Flynn Kelly

As the COVID-19 pandemic continues to dominate the news cycle, headlines related to rising unemployment often underscore the impact to Medicaid, but what about the Medicaid managed care organizations that will absorb the newly jobless and uninsured?

“I think that Medicaid MCOs are clearly in the best position to handle the influx of folks,” remarks Jerry Vitti, founder and CEO of Healthcare Financial, Inc. While onboarding a wave of new members may put some initial stress on plans, the real “strain” will come from covering new members who have unmet health care needs, he suggests.

Vitti says new enrollees will likely fall into one of two buckets. “One is the previously insured folks who had commercial insurance before they lost their job and have been in the health care system,” he observes. This is not likely to be a “super high-demand population.” But the second grouping, previously uninsured individuals who may end up enrolling as awareness goes up and barriers to enrollment go down, are likely to have “pent-up and untreated medical [needs] and substance use issues,” he predicts.

“I’m hearing from plans I’ve worked with that on both the MA and the Medicaid side…their [medical loss ratios] have dropped substantially,” says Jeff Myers, senior vice president, reimbursement strategy and market access with Catalyst Health Care Consulting. “And though I think their net income is certainly looking up, that means they’re busy strengthening their capital position for what they expect to be the next phase, which is a big enrollment spike on both the [Affordable Care Act] marketplace and Medicaid programs.”

Myers points out that this is usually the time when managed care rate negotiations would begin with states. “I think the challenge for the few state folks I’ve talked to is modeling out, in states with extensive managed care programs, what that influx of people is going to look like given what the unemployment rate may look like, and also given whether they’ve expanded [Medicaid] or not,” he adds.

For states whose budgets have been stretched thin by COVID-19 testing and presumptive eligibility determinations to guarantee payments to hospitals, the pandemic could be the driving factor in expanding Medicaid where a legislature has historically blocked it. Or it may result in states seeking to expand federal Medicaid funding rather than limit it through block grants, suggests Myers.

More MAOs Offer Condition-Specific Benefits, But SSBCI Uptake Remains Slow

April 20, 2020

After a relatively modest first year, the number of condition-specific supplemental benefits offered by Medicare Advantage plans more than doubled from approximately 820 in 2019 to 1,850 this year, according to a new report from Faegre Drinker Consulting. And, in the first analysis of new Special Supplemental Benefits for the Chronically Ill (SSBCI) for 2020, Faegre Drinker found that only 245 plans out of approximately 6,000 MA plans (including employer-only plans) total offered them. But the firm observed that adoption of the new “flexible benefits” permitted by CMS may improve as plans see what works and what doesn’t and explore their potential to increase enrollment, improve outcomes and generate net cost savings.

By Lauren Flynn Kelly

After a relatively modest first year, the number of condition-specific supplemental benefits offered by Medicare Advantage plans more than doubled from approximately 820 in 2019 to 1,850 this year, according to a new report from Faegre Drinker Consulting. And, in the first analysis of new Special Supplemental Benefits for the Chronically Ill (SSBCI) for 2020, Faegre Drinker found that only 245 plans out of approximately 6,000 MA plans (including employer-only plans) total offered them. But the firm observed that adoption of the new “flexible benefits” permitted by CMS may improve as plans see what works and what doesn’t and explore their potential to increase enrollment, improve outcomes and generate net cost savings.

“We see a big increase in condition-specific benefits in 2020, but the SSBCI uptake was pretty small,” remarks Michael Adelberg, a principal with Faegre Drinker and a former CMS MA official.

Analyzing condition-specific benefit and SSBCI data from CMS, Faegre Drinker observed that diabetes topped the list of condition-benefit categories and saw a 150% increase in benefits related to that condition. Hypertension had the greatest increase (529%) but is still tied to only 5% of targeted benefit offerings.

While some plans chose to attach certain prerequisites to condition-specific benefits, 60% had no such requirement.

“The conventional wisdom is that the national plans are way out in front, but the data tells a more nuanced story,” says Adelberg. “A handful of regional plans are ahead of the nationals on benefit innovations.”

In offering SSBCI, plans for 2020 were given a list of 15 conditions for which they could offer benefits that aren’t primarily health related so long as there is a “reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee.”

But uptake of those benefits by insurers was modest. “In the long run, we’ll see plans with outcome-improving, actuarially solid condition-specific benefits throughout the MA landscape,” predicts Adelberg. “But it’s going to take a while.”

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.