Radar on Medicare Advantage

✦ 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.

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.