RADAR on Medicare Advantage

  • Humana, Elevance Realign Business Segments, Anticipate Strong 2023 AEP

    After seeing improved medical cost trends and, in some cases, lower administrative costs, select insurers serving the Medicare Advantage space recently lifted their earnings projections for the full year. Conference calls to discuss second-quarter 2022 earnings were full of questions about pricing and changes related to their MA products as the 2023 Annual Election Period (AEP) approaches, but executives were more focused on touting efforts to serve members holistically, including through rebranding strategies as companies attempt to align their various business segments.
  • Florida Blue, Prime Post Encouraging Results of Opioid Intervention Pilot

    After the Centers for Disease Control and Prevention reported alarming increases in the number of opioid-related deaths in the U.S., HHS in 2017 declared the opioid crisis a public health emergency. Insurers across the country have responded with initiatives to address opioid overuse and misuse among their member populations, including Medicare Advantage enrollees. And CMS has deployed numerous strategies to ensure the appropriate use of pain treatments among Medicare, Medicaid and CHIP beneficiaries, including requiring that all Medicare Part D sponsors adopt drug management programs by 2022. Yet opioid overuse continues to be a concern for MA and Part D organizations.
  • Could MA-Focused Request for Information Foreshadow Sweeping Program Changes?

    Signaling what some say is an unusual move, CMS late last month released a request for information (RFI) in which it encouraged a variety of stakeholders to submit responses to questions related to nearly every aspect of the Medicare Advantage program, from supplemental benefits and social determinants of health to risk adjustment and other payment-related policies. And while that could mean CMS is looking to change multiple aspects of the program, industry experts say the agency is asking the right questions and are encouraged that it signals a willingness to understand the potential impact of program changes on MA organizations.  

    Although previous administrations have issued more general RFIs on Medicare and the Biden administration in February released an RFI on Medicaid and CHIP coverage and access, Avalere Senior Consultant Tom Kornfield says he can’t recall seeing one that was so explicitly focused on MA. When asked whether he thinks the request was prompted by a recent hearing on Capitol Hill regarding MA oversight and beneficiary access, Kornfield suggests it’s more likely that CMS is seeking information as it works on a proposed MA and Part D rule that would come out in the fall and contain policies for plan year 2024. “They could be using this opportunity to collect information that could then help them determine what types of policies to put into that proposed rule,” he tells AIS Health, a division of MMIT. And the RFI could generate a lot of feedback, he says.

  • CMS Takes Next Steps Toward Phasing Out D-SNP Look-alikes

    In a new enrollment transition memo issued to Medicare Advantage organizations with a significant number of dual eligible enrollees in products that are not Dual Eligible Special Needs Plans, CMS appears to be pushing so-called D-SNP look-alike plans to the brink of extinction. But the two-year transition process, which will wrap up for the 2023 plan year, still allows traditional MA plans to enrollee a limited number of duals. And one trade organization suggests more could be done to incentivize MAOs to set up D-SNPs.

    CMS in 2019 first began cracking down on D-SNP look-alikes — MA plans that are marketed to duals but are not D-SNPs or integrated products — when it released draft revisions to the Medicare Communications and Marketing Guidelines that stated look-alikes cannot imply that the plan is for dual eligibles, cannot claim or infer that they have a relationship with the state, and cannot exclusively market to duals. A year prior, the Medicare Payment Advisory Commission (MedPAC) in its June report to Congress had argued that more needed to be done to promote the development of integrated plans and raised the issue of D-SNP look-alikes. At the time, approximately 2.7 million dual eligibles were enrolled in one of four types of managed care plans available to them, yet only 8% of full-benefit duals were in a plan with a high level of Medicare and Medicaid integration. More than 4.1 million individuals are now enrolled in a SNP, of which nearly 3.7 million are in a D-SNP.

  • Seniors’ Unmet Social Needs Drive Greater Acute Care Utilization

    Health-related social needs (HRSNs) can increase acute care utilization among Medicare Advantage members — including avoidable hospital stays and emergency department (ED) visits — asserts a July 8 investigation published in the Journal of the American Medical Association’s Health Forum. Researchers studied a group of about 56,000 older adults enrolled in MA plans offered by Humana Inc., and found that HRSNs, such as housing, utility and food insecurity, limited access to transportation, and financial difficulties, were associated with significantly higher acute care usage. Notably, 13.6% of the selected population were Medicare-Medicaid dual eligibles, a particularly vulnerable cohort.
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