Radar on Medicare Advantage

✦ Risk scores used to adjust Medicare Advantage plan payments were more than 3% higher than in Medicare fee for service, despite CMS establishing a 5.9% coding intensity adjustment to account for the impact of coding differences for 2019, according to the Medicare Payment Advisory Commission (MedPAC). This generated about $9 billion in “excess payments” to MA plans, MedPAC estimated during a presentation at its December meeting. Differences in diagnosis coding were discussed as the MA risk adjustment program’s “biggest flaw,” and MedPAC is considering an alternative for establishing benchmarks that would blend local area and national fee-for-service spending. One of the challenges cited with such a model is the need to protect smaller MA plans and startups, and MedPAC is still working through such considerations. Go to http://www.medpac.gov/-public-meetings.

✦ The U.S. Supreme Court on Dec. 4 agreed to weigh in on the dispute over the legality of Medicaid work requirements. The cases in question are Gresham v. Azar and Philbrick v. Azar, which respectively challenge Arkansas’ and New Hampshire’s section 1115 demonstration programs that make Medicaid eligibility contingent upon completing “community engagement activities” for a subset of beneficiaries. The two suits will be consolidated into one case — called Azar v. Gresham — and oral arguments will take place at a still-to-be-decided date early next year. The Biden administration, however, could roll back Trump administration-era guidance that paved the way for Medicaid work requirements waivers, making it unclear how such a move would interact with the Supreme Court’s ultimate decision. Visit https://bit.ly/3gsxwfd.

As states face intense budget pressures during the COVID-19 pandemic and beneficiary advocates urge the federal government to provide additional financial support to state Medicaid programs, extending postpartum care access would resolve a longstanding issue impacting children and families and close a significant gap in coverage during the pandemic and beyond, according to advocates and providers.

Roughly 700 women die each year due to pregnancy-related complications, and about 60% of cases are preventable, according to the Centers for Disease Control and Prevention (CDC). The CDC also estimates that more than 44,000 pregnant women have become infected with the coronavirus this year, resulting in an estimated 8,500 hospitalizations. Medicaid is the largest payer of maternity care in the U.S., yet current law does not require state Medicaid programs to cover women for more than 60 days after childbirth, and states must seek waiver approval to use federal matching funds to extend coverage.

Preliminary observations from several Medicare Advantage marketing experts indicate that during the 2021 Medicare Annual Election Period (AEP), consumers were slow to make enrollment decisions early on, and switching may not have been at the levels witnessed in recent years. At the same time, social distancing precautions during the COVID-19 pandemic led to significant traffic in the digital space, possibly signaling a permanent shift in how Medicare consumers shop for coverage.

Cavulus, a technology firm that serves the MA industry, in early November noticed a “slower start to AEP due to the ongoing pandemic and [MA] marketing efforts coinciding with substantial presidential campaign advertising,” says Patrick Phillips, the firm’s CEO. In a Nov. 5 press release, the company observed that while call centers were busy, most callers were asking clarification-type questions about potential changes to their existing insurer’s offerings, and said it expected comparative shopping among competing insurers to ramp up as the AEP neared its end.

With a recent emergency use authorization (EUA) granted to the first COVID-19 vaccine and another one expected at press time, states and the federal government this week began rolling out the vaccine to health care workers across the country. While health plans, particularly those that serve high-risk individuals such as dual-eligible Medicare-Medicaid beneficiaries, may be ideally situated to coordinate care and update members on vaccination opportunities, there are gaps in the current delivery system that could negatively impact the success of the rollout, one expert warns. And with many older adults not included in the first phase, it may fall to Medicare Advantage plans to ensure that seniors are informed about when and how to access the vaccine.

The FDA on Dec. 11 authorized emergency use of the COVID-19 vaccine made by Pfizer Inc. and BioNTech in individuals age 16 and older. And following an advisory panel’s Dec. 15 confirmation of the efficacy and safety of Moderna’s coronavirus vaccine, an EUA for that vaccine is imminent. HHS Secretary Alex Azar has said the federal government, which will cover the costs of the vaccine and its administration for Medicare enrollees, is aiming to have 100 million people vaccinated by the first quarter of 2021 with the two recommended doses. Meanwhile, news reports indicate two more vaccines could be authorized by the end of February, including one that would require only one dose.