Radar on Medicare Advantage

Medicare Advantage, Medicare-Medicaid Plan and Part D sponsors selected for 2020 program audits will start receiving engagement letters this month, but they face some uncertainty as CMS has yet to finalize a set of proposed changes unveiled last August. While the bulk of those changes were aimed at reducing plan sponsors’ burden, plans are advised to closely monitor the data CMS may no longer collect through the audit process but may obtain from other sources, while continuing to conduct mock audits.

“Audit season is here, and March Madness means something different in the MA-PD world,” remarks Tina Bailey, vice president of compliance solutions with Gorman Health Group, LLC (GHG). “But this year the timing is odd as we’re waiting on new protocols…and we’re not sure what pieces of the proposed changes are going to be finalized and implemented this audit cycle.”

✦ Medicare Advantage enrollment reached nearly 24.7 million members as of the Jan. 1, 2020, payment date, according to the February enrollment report from CMS, which includes final figures from the Annual Election Period. The February data represents year-over-year MA membership growth of 9.2% (vs. an increase of 4.5% in fee-for-service Medicare) and MA penetration of 36.2%, up from 35.2% a year ago, estimated securities analyst A.J. Rice in a Feb. 17 research note from Credit Suisse. Rice added that the five major managed care organizations account for roughly 61.5% of total MA enrollments, with UnitedHealth Group and Humana Inc. leading the pack in MA membership growth. View the report at https://go.cms.gov/2P979OV. Contact Rice at aj.rice@credit-suisse.com.

✦ A federal appeals court on Feb. 14 unanimously struck down the Trump administration’s decision to allow Arkansas to implement Medicaid work requirements and ruled that HHS’s approval of the “Arkansas Works” program was “arbitrary and capricious.” According to the opinion from the U.S. Court of Appeals for the District of Columbia Court (Gresham v. Azar, No. 1:18-cv-01900), a “critical issue” in the case was the HHS secretary’s “failure to account for loss of coverage.” Arkansas Works was implemented in June 2018 and resulted in more than 18,000 Medicaid recipients losing coverage in a six-month period. U.S. District Judge James Boasberg in March 2019 vacated the agency’s approvals of work requirements in Kentucky and Arkansas (RMA 4/4/19, p. 1). HHS appealed the decision, and Kentucky ultimately abandoned its challenged demonstration project. View the ruling at https://bit.ly/38JzGCr.

From engaging members in cooking and self-defense classes to coaching them on specific health conditions, Medicaid managed care organizations are building out brick-and-mortar centers to better serve their enrollees. Three such MCOs shared their experiences at the 11th Annual Medicaid Innovations Forum, hosted by Strategic Solutions Network in Orlando from Feb. 5 to 7.

In an unusual case of competitors joining forces, Blue Shield of California Promise Health Plan and L.A. Care Health Plan said they are building out 14 co-branded “Community Resource Centers” that will serve a projected 1 million individuals in the Los Angeles area annually.

In addition to codifying previous policy changes and extending some new flexibilities to Medicare Advantage organizations, a recent 900-page proposed rule (85 Fed. Reg. 9002, Feb. 18, 2020) from CMS contains some significant changes to the star quality ratings. And while CMS is giving plans plenty of lead time to prepare for proposed modifications that would take effect with the 2021 measurement year, it may be hard for plans to keep up with the sheer volume of planned changes, suggests Melissa Smith, senior vice president of stars & strategy at Gorman Health Group, LLC.

“I think the good news is that CMS is delivering on its promise for transparency and stability and plenty of warning,” says Smith, referring to a 2019 final rule that codified key aspects of the Parts C and D star ratings rather than allowing CMS to continually make retroactive changes to measures (RMA 4/5/18, p. 7).