Radar on Medicare Advantage

With a new administration that will be focused on the COVID-19 pandemic and improving health care coverage, industry experts do not anticipate major changes to the Medicare Advantage program, although many agree the pandemic will leave a lasting impact on the industry. And as President-elect Joe Biden looks to expand coverage, MA will likely be held up as a “successful example of a public-private mechanism to take Medicare eligibility to age 60,” predicts Wunderman Thompson Health’s Lindsay Resnick.

For AIS Health’s annual roundup of predictions about the year ahead for MA organizations, numerous experts weigh in on how doing business in 2021 might look different than in previous years.

Following the recent acquisition of PANTHERx Rare, LLC and the first- quarter 2020 addition of WellCare Health Plans, Inc., Centene Corp. kicked off the new year with an agreement to purchase Magellan Health, Inc. for $2.2 billion. Magellan also just completed the previously disclosed sale of its managed care division to Molina Healthcare, Inc. The newer transaction will allow Centene to expand its behavioral health platform, increase its specialty health and pharmacy capabilities and enhance its ability to address members’ whole health.

During a Jan. 4 conference call to discuss the planned transaction, Centene Chairman, President and CEO Michael Neidorff said the combination is in line with the company’s diversification strategy and boosts Centene’s capacity to “provide comprehensive care to the most complex and vulnerable populations,” especially as it relates to behavioral health care.

✦ 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.