Radar on Medicare Advantage

In a series of steps that were largely expected, the Biden administration in its early days moved to revisit policies approved by the prior administration that it views as weakening Medicaid and Affordable Care Act (ACA) coverage. At the same time, the administration delayed the implementation of an HHS final rule to eliminate rebates in Medicare Part D, giving it more time to consider the rule’s full impact and potentially amend or rescind it after a comment period.

“When it comes to health policy, the Biden administration is taking a really hard look at policies in the Medicaid and Medicare space that they view [as] significant and that they want to make sure are in line with their view…[including] looking at the larger rules that impact a space like the rebate rule,” observes Stephanie Kennan, a member of McGuireWoods Consulting’s federal public affairs group and former senior health policy adviser to Sen. Ron Wyden (D-Ore.).

✦ Anthem, Inc. stands to acquire more than 267,000 Medicare Advantage members and over 305,000 Medicaid members in Puerto Rico through the planned purchase of MMM Healthcare, LLC from InnovaCare Health. The deal, unveiled Feb. 2, will expand Anthem’s presence in the duals market. Financial terms of the transaction were not disclosed. The acquisition is expected to close by the second quarter of 2021, subject to regulatory approvals and other closing conditions. Visit https://bit.ly/2LgUfzL.

✦ A bipartisan bill reintroduced in the Senate seeks to require CMS to consider diagnoses from audio-only telehealth visits for risk adjustment payments to Medicare Advantage plans. Trade associations America’s Physician Groups and America’s Health Insurance Plans applauded the bill, which would improve MA enrollees’ access to telehealth and ensure that such visits are reimbursed as if they were in-person visits during the COVID-19 public health emergency. The bill is sponsored by Sens. Catherine Cortez Masto (D-Nev.) and Tim Scott (R-S.C.) and was first introduced in July 2020. Visit https://bit.ly/2Ms8gej.

✦ UnitedHealth Group’s fourth-quarter 2020 adjusted earnings per share (EPS) fell 35% from the prior year to $2.52, as “care patterns normalized, while COVID-19 costs rose, and further rebates were recognized,” according to a Jan. 20 press release. Revenues for full-year 2020 increased 6.2% from the prior year to $257.1 billion, reflecting growth across the firm’s businesses, including UnitedHealthcare’s Medicare & Retirement segment, which grew revenues by 7.5% to nearly $22.2 billion. The insurer’s full-year medical loss ratio was 79.1%, down from 82.5% in 2019, largely stemming from the return of the Affordable Care Act health insurer fee and disrupted care patterns earlier in the year, but offset by COVID-19 assistance measures and testing and treatment costs, explained UnitedHealth. The company affirmed its 2021 full-year earnings outlook, including $17.75 to $18.25 adjusted EPS. Visit https://bit.ly/360Ff06.

✦ The Pharmaceutical Care Management Association (PCMA) on Jan. 12 filed a lawsuit challenging the HHS rebate rule that was finalized in late November. The lawsuit, filed in the U.S. District Court for the District of Columbia, argued that HHS’s “herky-jerky, last-minute rulemaking process” violated the Administrative Procedure Act and should be invalidated. PCMA, the lobbying trade group for pharmacy benefit managers, asked the court to declare that federal law protects rebates issued to Medicare Part D sponsors under safe harbor regulations. View the suit at https://bit.ly/2KtlNl2.

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.