Radar on Medicare Advantage

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(D) and the Cabinet for Health and Family Services last May named the same five winners in the Medicaid contract awards originally made under former Republican Gov.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.

As the novel coronavirus erupted across the U.S. and created a widespread economic downturn, it led to increased enrollment in state Medicaid programs and created devastating budget shortfalls for states. Yet Congress’ latest pandemic relief effort — the Consolidated Appropriations Act signed by President Donald Trump on Dec. 27 — does not include direct financial help for states, which are now rolling out newly authorized COVID-19 vaccines with limited resources and guidance from the federal government.

Earlier legislation, the Families First Coronavirus Response Act, afforded states a temporary increase of 6.2% in their federal match rate, yet multiple stakeholders including managed care plans have beseeched Congress to enact another temporary boost during the public health emergency.

With the aim of improving care for dual eligible individuals while promoting value-based care in fee-for-service Medicare, CMS last month introduced a new option for certain Medicaid managed care organizations to become Direct Contracting Entities (DCEs) that will coordinate care and share risk for duals who access their Medicare benefits through FFS. But some MCOs have questions about the design of the model, and one organization warns that the arrangement could have a detrimental impact on accountable care organization (ACOs) that have made significant investments in value-based care.

Model Promotes Value-Based Care

Starting Jan. 1, 2022, CMS will test whether holding these entities accountable for health outcomes and Medicare FFS costs for their full-benefit dually eligible Medicaid MCO enrollees will lead to innovative strategies for improving care for this high-risk population. Operated by the CMS Center for Medicare & Medicaid Innovation (CMMI), the overall aim of the Direct Contracting Model is to “test financial risk-sharing arrangements to reduce Medicare expenditures while preserving or enhancing the quality of care furnished to beneficiaries,” according to a Dec. 17 press release from the agency. And a key tenet of that program is inviting a variety of different organizations to participate in value-based care arrangements in Medicare FFS.