Radar on Medicare Advantage

✦ CMS’s 2019 Medicare Parts C and D program audits resulted in civil monetary penalties amounting to nearly $1.2 million imposed on six organizations, according to CMP notices posted at www.cms.gov. The agency in a memo dated Feb. 28 released the audit scores of the 13 organizations that underwent 2019 program audits, with scores ranging from 0 to 1.74 (the lower the score, the better the performance). Outside of the program audit process, CMS barred Medicare Advantage and Prescription Drug Plan operator Delaware Life Insurance Co. from marketing and enrollment activities and imposed a CMP on Miami-based Solis Health Plans, Inc. for failing to ensure that its agents and brokers followed Medicare marketing rules during the 2019 Annual Election Period. View all the notices at https://go.cms.gov/2x1Q7vP.

✦ After two cycles of marketing Medicare Advantage plans during the Annual Election Period, Mutual of Omaha has decided to sell its MA businesses to Essence Healthcare, sister company of Lumeris. According to a Feb. 24 press release from Essence and Lumeris, Essence will acquire the two Mutual of Omaha subsidiaries that offer MA plans in the Cincinnati, Dallas, Denver, El Paso and San Antonio markets. Lumeris has served as an operating partner to Mutual of Omaha since 2018 and operates MA plans under the Essence Healthcare brand (RMA 4/5/18, p. 1). The companies did not disclose financial terms of the deal, which is expected to close by mid-2020, and declined to provide additional details when queried by AIS Health. According to AIS’s Directory of Health Plans, Mutual of Omaha had 2,416 total enrollees in MA plans in Colorado, Kentucky, Ohio and Texas as of February, compared with 920 members this time last year, when it served just the Cincinnati and San Antonio markets. Contact Lumeris spokesperson Marcus Gordon at mgordon@lumeris.com.

In the midst of a financial turnaround, Molina Healthcare, Inc. impressed analysts with its fourth-quarter and full-year 2019 earnings reported on Feb. 10. Namely, the company reported a better-than-expected medical loss ratio (MLR) of 86.0%, which it attributed to improvements in the Medicaid business.

That fourth-quarter 2019 MLR was a slight increase from 85.1% for the fourth quarter of 2018, but Molina attributed that to a heightened MLR in its Affordable Care Act exchange business and said the company’s Medicaid MLR improved sequentially by 80 basis points to 87.3%. The overall MLR was 20 basis points below Wall Street consensus and 10 points below Evercore ISI’s expectation, pointed out securities analyst Michael Newshel on Feb. 10. For the year ending Dec. 31, 2019, the company’s Medicaid MLR was 88.0%, compared with 90.0% in 2018, “due to improvement in all programs.”

The majority of publicly traded insurers reporting fourth-quarter and full-year 2019 earnings over the last month identified government business as a significant earnings contributor, with momentum from the recent Medicare Advantage open enrollment period carrying that growth into 2020.

Reporting its first full year of earnings with Aetna Inc., CVS Health Corp. on Feb. 12 said that acquisition was the main driver of consolidated growth of 32% to nearly $256.8 billion. Total revenues in the company’s Health Care Benefits segment continued to benefit from strong membership in government products, said Eva Boratto, CVS Health chief financial officer, during a conference call to discuss recent earnings.

From commercial insurers addressing lonely millennials to CMS allowing supplemental benefits that address non-medical needs for the Medicare Advantage population, social determinants of health (SDOH) are ubiquitous in health care these days. But Medicaid managed care organizations for years have been working within a fragmented delivery system and getting creative to address social determinants, which research has suggested drive up to 80% of health outcomes. Speaking at the 11th Annual Medicaid Innovations Forum, hosted by Strategic Solutions Network in Orlando from Feb. 5 to 7, several Medicaid insurers detailed how they are forging unique partnerships with local organizations to tackle a range of issues that often intertwine.

As the only not-for-profit insurer in its market that is owned by a network of 20 federally qualified health centers (FQHCs), it’s in the DNA of Community Health Plan of Washington (CHPW) to partner with its health centers “to work in the communities to address those social determinants of health that really impact our member population,” said Melissa Stevens, vice president of community engagement and growth. CHPW is also the only locally based plan in its market and competes with four national, for-profit insurers, she said.

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.”