Radar on Medicare Advantage

As the COVID-19 pandemic has shone a bright light on many of the barriers facing low-income Medicaid enrollees and communities of color when it comes to accessing health care, plans have sought more ways to address social factors that are known to impact health outcomes. In an effort to help states address social determinants of health (SDOH), CMS on Jan. 7 issued a new “roadmap” describing how states can use existing program flexibilities to tackle adverse health outcomes that can be impacted by determinants such as nutritious food, affordable and accessible housing, and quality education.

“With the release of today’s SDOH guidance, CMS acknowledges that an understanding of the social, economic, and environmental factors that affect the health outcomes of Medicaid and CHIP populations can be an integral component of states’ efforts to realign incentives, reduce costs, and advance value-based care in their health systems,” said CMS in a Jan. 7 press release.

Amid the changes brought about by the COVID-19 pandemic, Medicare Advantage Special Needs Plans (SNPs) and others serving low-income dually eligible members are looking at ways to promote the use of telehealth and other technologies more broadly across their populations while taking a targeted approach to addressing social determinants of health (SDOH), experts tell AIS Health. At the same time, state efforts to advance the integration of Medicare and Medicaid benefits have been somewhat stymied by the pandemic and will face challenges such as aligning enrollment and measuring quality in an equitable way.

Cheryl Phillips, M.D., president and CEO of The SNP Alliance, says the association of SNPs and Medicare-Medicaid Plans (MMPs) expects the Biden administration to support improvements to the delivery of long-term services and supports — particularly with the federal Home and Community-Based Services model — and explore ways to support caregivers. “I think the next question will be [do] both sides understand the needs of those who are dually eligible? And I think a new administration will do some work in helping them better understand how MA and particularly SNPs can be the best vehicle to align and serve high-risk, high-cost individuals, particularly those who are dually eligible. So, there’s some work for us to do in engaging the administration early on, but I’m certainly optimistic,” she tells AIS Health.

As part of its late-term rulemaking and waiver-approving blitz, the Trump administration on Jan. 8 cleared the way for Tennessee to become the first state to accept a fixed amount of federal funds in exchange for a range of flexibilities in its Medicaid program. Although CMS’s approval of Tennessee’s demo is likely to be revisited by President Joe Biden, who was sworn in as the 46th U.S. president on Jan. 20, experts suggest if implemented it would have a downstream effect on the managed care organizations that serve 1.5 million TennCare beneficiaries.

The Tennessee demo was approved for 10 years, similar to other recently approved section 1115 waiver requests made by nonexpansion states such as Florida and Texas. Through an “aggregate cap” approach, Tennessee will receive federal Medicaid funds based on a fixed budget target that is determined by CMS and the state using “well-established, historical enrollment and Medicaid cost data,” according to a Jan. 8 press release. If it spends less than its target cap while meeting quality goals, Tennessee can earn up to 55% of annual savings to reinvest back into other state health programs, such as those that address the social determinants of health or behavioral health, explained CMS in its approval letter.

With less than a week to spare before the Jan. 20 inauguration of President Joe Biden, CMS on Jan. 15 followed up on its promise for an early release of the 2022 Medicare Advantage and Part D Rate Announcement, indicating that MA organizations will see an average reimbursement increase of more than 4%. At the same time, CMS issued a 272-page rule finalizing several Part D policies that will largely apply to the 2022 plan year. It also codifies some longstanding guidance, potentially making it harder for the Biden administration to quickly reverse course on certain policies, suggests one industry expert.

Although neither document contained anything “earth shattering,” the hefty pay increase is welcome news to plans as they face cost unknowns due to the ongoing COVID-19 pandemic, suggests Milliman Principal and Consulting Actuary Brad Piper.

✦ Humana Inc. in a new lawsuit alleges that Kentucky violated its five Medicaid contracts by allowing Molina Healthcare, Inc. to acquire the Medicaid membership of Passport Health Plan, reports Louisville Business First. After reviewing a second round of bids, Kentucky Gov. Andy Beshear (D) and the Cabinet for Health and Family Services last May named the same five winners in the Medicaid contract awards originally made under former Republican Gov. Matt Bevin (RMA 6/4/20, p. 4). Incumbent bidder Passport, which at the time was on the brink of insolvency, was not chosen. Molina, which was selected for a new contract, acquired Passport’s approximately 315,000 Medicaid members in Kentucky on Sept. 1, 2020. But in a lawsuit filed Dec. 23, 2020, Humana questions whether the takeover entitled Molina to Passport’s membership for a new contract period and asserts that Passport “had no claim to its membership at all beyond its contract” that expired on Dec. 31, according to the business journal. Anthem, Inc., which also was not selected as one of the initial five MCOs, contested the awards and in October won a temporary injunction directing the state to make it the sixth participant. Visit https://bit.ly/3rXRV0U.

✦ Independence Blue Cross and Strive Health this month launched a new initiative to bring specialized care delivery and coordination to Independence Medicare Advantage members living with chronic kidney disease (stages 4 and 5) and end stage renal disease. The program aims to slow disease progression and improve quality of life for these members by assisting with care management and reducing unnecessary hospital stays, according to the Philadelphia-based insurer. Eligible members will receive care from Strive Health’s local team that includes nurse practitioners and dietitians, and will receive direct and virtual clinical services, home dialysis education and training, advanced care planning, and help with social determinants of health. Contact Diana Quattrone at diana.quattrone@ibx.com.