Radar on Medicare Advantage
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Rumored Cigna MA Spinoff Could Clear Ground for Government Megamerger
The Cigna Group could be fielding offers for its Medicare Advantage book, according to a Nov. 6 Reuters report. Experts say that a spinoff is plausible given the small size of Cigna’s MA book and Cigna’s heavy focus on commercial insurance — and Wall Street analysts say the move could be a first step towards a megamerger with a government-focused insurer.
Wells Fargo and RBC analysts say that the move could be an effort to preempt the intense antitrust scrutiny Cigna might face if it sought to merge with a government insurance-focused firm such as Humana Inc. or Centene Corp., because Cigna would have only commercial and Affordable Care Act marketplace books after an MA spinoff.
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News Briefs: Suit Accuses UnitedHealth of Using AI to Wrongfully Deny MA Care
In a proposed class action lawsuit filed in the U.S. District Court of Minnesota, UnitedHealth Group and its subsidiary, NaviHealth, are accused of using an artificial intelligence algorithm with a known error rate of 90% to systematically deny Medicare Advantage enrollees’ care. The lawsuit, filed by the estates of two deceased patients who were enrolled in a UnitedHealthcare MA plan and “on behalf of all others similarly situated,” alleges that the insurer continued to use its AI model to “wrongfully deny” and override physicians’ recommendations for post-acute care “because they know that only a tiny minority of policyholders (roughly 0.2%) will appeal claims, and the vast majority will either pay out-of-pocket costs or forgo the remainer of their prescribed post-acute care,” according to the complaint posted by STAT. The complaint follows and cites a STAT investigation of internal documents showing that NaviHealth employees were pressured to keep MA patients’ skilled nursing facility stays to targets developed by the nH Predict algorithm, or they would face disciplinary action. In a statement provided to STAT, UnitedHealth asserted that the NaviHealth tool is “used as a guide” but does not make coverage determinations.
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Looming Request for Supplemental Benefits Data Opens ‘Pandora’s Box’ for MAOs
Plans participating in the Medicare Advantage Value-Based Insurance Design (VBID) Model next year must begin reporting beneficiary-level utilization data on three key supplemental benefit categories: food, transportation, and general supports for living (e.g., utilities assistance). That requirement was included in a 2024 request for applications released late last year, and CMS officials have since hinted that the agency is interested in gathering additional information about supplemental benefit usage from the MA industry at large. But in a move that flew largely under the radar, the agency in September issued a proposal to begin requiring all MA organizations to submit information about supplemental benefits at a greater level of detail than some plans may be able to provide at this time, industry experts tell AIS Health, a division of MMIT.
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Provider-Sponsored Plans Cite Localized, Comprehensive Approaches to Achieving 5 Stars
Despite declines in the average overall Star Rating for Medicare Advantage Prescription Drug plans and the number of MA-PD contracts earning 4 stars or higher, the 2024 Star Ratings data released by CMS last month indicates that about two-thirds of performers held onto their 5-star rating from the previous year. For our annual series on the success stories of highly rated MA plans, leadership at several repeat 5-star performers touted comprehensive, integrated and localized approaches to continually delivering quality care.
For Quartz Health Plan, simplifying the member journey and working closely with its provider owners have been two areas of focus, according to Christina Ott, chief growth officer. Formed by the 2017 combination of Gundersen Health Plan, UnityPoint Health and Physicians Plus Insurance Corp., and then rebranded as Quartz, the insurer’s MA-PD contract serving enrollees in select counties of Minnesota has earned 5 stars for the 16th time, according to Ott. Quartz also has MA membership in Illinois, Iowa and Wisconsin; Advocate Aurora Health joined as a minority owner in 2021. While Quartz is focused on selling its products where its provider owners can best serve seniors and “has a narrower network than most,” it does have other providers in the network and “aligns with providers in ways that work for the individual,” she tells AIS Health, a division of MMIT.
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With Some Supplemental Benefits on the Decline for 2024, Do Payers Just See Them as Marketing Tools?
Fewer Medicare Advantage plans are using Special Supplemental Benefits for the Chronically Ill (SSBCI) to offer non-primarily health-related benefits (NPHRB) in 2024, according to an Oct. 30 report on 2024 non-medical supplemental benefits from ATI Advisory, funded by the SCAN Foundation. The health care research and advisory services firm observed some significant changes across supplemental benefit categories, and one social determinants of health (SDOH) expert expressed disappointment in MA organizations’ uptake of these benefits.
About 30% of MA plans are offering any NPHRB for 2024, just a 2.4% increase from the current plan year. And while fewer plans are using SSBCI to offer these benefits, the Center for Medicare and Medicaid Innovation’s Value-Based Insurance Design (VBID) model got a boost, with 10.4% of MA plans offering NPHRBs through the VBID model in 2024 vs. 5.5% of plans in 2023. (Plans participating in the newly extended VBID model are required to start offering supplemental benefits that address key SDOH in 2025, and ATI suggested some payers may be getting a jump on this.)
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