Radar on Medicare Advantage

As the COVID-19 pandemic continues to dominate the news cycle, headlines related to rising unemployment often underscore the impact to Medicaid, suggesting that a “Record number of unemployed Americans will stress state Medicaid programs” (NBC News) and that the new coronavirus will hit Medicaid “like a punch in the mouth” (USA Today), to quote the National Association of Medicaid Directors’ Matt Salo. But what about the Medicaid managed care organizations that will absorb the newly jobless and uninsured?

“I think that Medicaid MCOs are clearly in the best position to handle the influx of folks. They have the systems, they have the infrastructure and they have the experience to do this,” remarks Jerry Vitti, founder and CEO of Healthcare Financial, Inc., which connects low-income elderly and disabled populations with public benefit programs. While onboarding a wave of new members may put some initial stress on plans, the real “strain” will come from covering new members who have unmet health care needs, he suggests.

✦ A new lawsuit filed by the U.S. Attorney for the Southern District of New York accuses Anthem, Inc. of bilking the federal government out of millions of dollars through a one-sided chart review program. The civil fraud action (U.S. v. Anthem, Inc., 1:20-cv-02593) alleges that while conducting chart reviews aimed at identifying additional diagnosis codes for obtaining risk adjusted payment through the Medicare Advantage program from 2014 to 2018, the insurer neglected “its duty to delete thousands of inaccurate diagnoses” and “often generated $100 million or more a year in additional revenue” as a result. UnitedHealth Group was the subject of similar allegations in two separate whistleblower suits; the Justice Dept. in 2017 intervened in both but has since dropped one. View the complaint at https://go.aws/3axP1qP.

✦ As states pursue 1135 waivers to expand access to their Medicaid programs during the COVID-19 outbreak, CMS on March 24 withdrew a proposed rule that would have allowed states to tighten their Medicaid eligibility determinations, Modern Healthcare reports. The proposed rule was scheduled to publish in April, according to www.reginfo.gov. CMS as of March 31 had approved 38 waivers allowing states to make various modifications to their Medicaid programs in response to the outbreak. These approvals include the ability to quickly enroll out-of-state or new providers and temporarily suspend prior authorization requirements. Visit https://go.cms.gov/39zDSEt.

As states consider new standards for Dual Eligible Special Needs Plans (D-SNPs) that will satisfy statutory requirements beginning in calendar year 2021, the enrollment of dual- eligible beneficiaries in Medicare and Medicaid plans that are offered by the same entity has been discussed as a way to promote better coordination of care. A new Government Accountability Office (GAO) report highlights the various approaches some states have taken to encourage the concept of aligned enrollment and recommends that CMS gather more information on one method in particular — the auto- assignment, or default enrollment, of newly eligible duals into an aligned D-SNP.

Along with granting permanent authorization to D-SNPs, the Bipartisan Budget Act of 2018 called for D-SNPs and states to better unify appeals and grievances processes across the Medicare and Medicaid programs and set new minimum standards for D-SNPs integrating Medicaid benefits. According to the March report, “Alignment of Managed Care Plans for Dual-Eligible Beneficiaries,” that legislation also directed GAO to review the integration between D-SNP and state Medicaid programs.

An earlier version of this story incorrectly stated that during the 2020 Medicare Annual Election Period, Bright Health increased its membership by 36% to more than 5 million members and Devoted Health nearly tripled in size to 4.3 million lives. Bright Health has more than 5,000 members, and Devoted Health has 16,000 enrollees. This version has been corrected.

Although individual HMO plans continued to capture the bulk of enrollment in Medicare Advantage plans during the 2020 Annual Election Period (AEP), overall gains by individual PPO plans were not far behind those of the historically popular HMOs, according to a recent analysis from Pareto Intelligence, a Convey Health Solutions company. Based on CMS’s February data release (which reflects enrollments accepted through Jan. 1 and is regarded as demonstrating the final AEP figures), Pareto estimates that enrollment in individual PPOs climbed 10.25% during the AEP to more than 4.8 million enrollees, outpacing individual HMO growth of 5.43% to nearly 11.3 million members.