Radar on Medicare Advantage

“Truly shocking” and “huge setback” were just two of a flood of analyst reactions to Humana Inc.’s Oct. 2 disclosure that its percentage of Medicare Advantage members in plans with 4 or more stars will plummet to 25% next year. That’s down from an estimated 94% for 2024 and is largely the result of a decline in Star Ratings for its largest contract, according to a new filing from Humana. Although the full set of Star Ratings data won’t be released until next week, this development confirmed industry fears that rising cut points will diminish ratings — and related revenue.  

In advance of the Medicare Annual Election Period that starts on Oct. 15, preliminary Stars data became available in the CMS Medicare Plan Finder on Oct. 1. According to Humana’s filing with the U.S. Securities and Exchange Commission (SEC), contract H5216 fell from a 4.5-star rating to a 3.5-star rating for next year, which impacts quality bonus payments in 2026. That contract holds approximately 45% of Humana’s MA membership, including more than 90% of its group MA membership, Humana clarified.

Amid reports of increasing prior authorization (PA) requests and coverage denials, dozens of hospitals and health systems are exiting or threatening to exit insurers’ Medicare Advantage networks. Although some departures have already taken effect, many will impact the 2025 plan year, which MA insurers have begun promoting in advance of the Annual Election Period (AEP). While on the surface the disputes reflect providers’ growing frustrations with insurers’ PA policies, two industry experts say hospitals’ latest round of muscle-flexing may reflect a trend of health systems looking more strategically at their markets and seeking the best deals. 

As Oct. 1, Becker’s Hospital Review had counted at least 27 health care providers nationwide that have unveiled MA network departures this year. And that is not an exhaustive list, as additional reports of providers joining the exodus continue to pour in from local news outlets across the U.S.

After partnering with fledgling primary care startup Herself Health in January 2023, Blue Cross and Blue Shield of Minnesota recently announced a new contract structure that will incentivize the provider to drive “results-driven health solutions” for the Blues plan’s female Medicare Advantage population. Retroactive to Jan. 1, 2024, the partners have entered a value-based agreement that will include specific, measurable quality targets aimed at improving overall health outcomes for women.

Co-founded in 2022 by Kristen Helton, who previously led Amazon’s now-shuttered Amazon Care service for employees, Herself Health is a value-based health care technology company focused on delivering advanced primary care to women ages 65 and older. Since securing $7 million in seed round funding led by investment firm and founding partner Juxtapose, Herself Health has opened four clinics in the Twin Cities and is preparing to launch a fifth clinic in nearby Eagan, Minnesota.