Health Plan Weekly
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Optimism, Doubts Abound Regarding Tailored Medicare Advantage Plans
With more Medicare Advantage plans tailored to specific populations such as racial minorities and the LGBTQ+ community, insurers are doing a better job serving historically underserved groups, according to speakers at a recent Johns Hopkins University webinar. Sachin Jain, M.D., CEO of SCAN Health Plan, said the tailored plans “have a ton of potential,” but he cautioned that the offerings are in the “first inning” and are mixed in terms of their effectiveness and differentiation from more standard plans.
“I think some of the execution has been really good, and some of it’s been really shallow,” Jain said. “Shallow looks like websites that are translated using outside vendors to mimic the language of the beneficiaries that they were targeting, and then excellent looks like plans that are actually contracting with specific provider networks, thinking differently about their benefits, thinking differently about the overall messaging.”
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News Briefs: Lawsuit Alleges Anthem’s NY Plan Has ‘Ghost Networks’
A proposed class-action lawsuit accuses Anthem Blue Cross Blue Shield of New York of maintaining “ghost networks” of mental health providers. According to the complaint, Anthem maintained a directory of thousands of mental health care providers who did not accept that type of insurance, were duplicate listings, had incorrect phone numbers, or simply did not exist. As a result, patients delayed or abandoned treatment, or paid substantial out-of-pocket costs for out-of-network providers. Attorneys for the plaintiffs contacted 100 providers in secret shopper calls and found that only seven of those providers accepted Anthem insurance and took new patients.
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Centene, Molina Beat Expectations in 3Q Amid Medicaid Upheaval
Centene Corp. and Molina Healthcare, Inc., two of the largest managed Medicaid insurers in the U.S., both beat expectations in their third-quarter earnings reports. While the companies saw higher care utilization among their Medicaid members, their medical loss ratios (MLRs) were better than investors anticipated.
Wells Fargo analyst Stephen Baxter in an Oct. 25 note wrote that Centene’s Medicaid MLR of 93.1% was below the Wall Street consensus of 93.3% and “much better than feared.” Baxter also wrote in an Oct. 24 note that Molina’s Medicaid MLR of 90.5% “was above guidance but by less than feared” following UnitedHealth Group’s and Elevance Health, Inc.’s earnings releases from earlier this month.
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OIG: CMS Paid MA Insurers Billions for Questionable Use of In-Home Assessments
Medicare Advantage insurers received an estimated $4.2 billion in risk-adjusted reimbursement in 2023 for diagnoses gleaned from home visits designed to assess members’ care needs, according to a new report by the HHS Office of Inspector General. These assessments were often administered by third-party vendors hired by the insurers and led to no treatment, according to OIG. While MA plans are allowed to use chart reviews and HRAs as sources of diagnoses for risk adjustment purposes, the Oct. 21 report builds on OIG’s documented concerns regarding misuse of health risk assessments and HRA-related chart reviews for the purposes of risk adjustment.
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Deal or No Deal? Cigna, Humana Reportedly Resume Talks, But Analysts Remain Skeptical
After scuttling merger talks early this year, The Cigna Group is again potentially looking to acquire Humana Inc., according to an Oct. 18 Bloomberg report. The article mentioned the companies have held “informal discussions” about a tie-up but noted “the discussions are in early stages,” citing people familiar with the matter.
Wall Street analysts, meanwhile, are not surprised the companies have resumed talks. However, they are skeptical a deal could be consummated due to antitrust concerns, especially if Kamala Harris wins the presidential election and current antitrust leadership remains in place.
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