Radar on Medicare Advantage

After the special master who reviewed a False Claims Act lawsuit against UnitedHealth Group sided with the defendant, a federal judge gave the U.S. Dept. of Justice (DOJ) an extension on filing an objection. On March 3, a retired judge serving in the court-appointed role of special master concluded that the federal government failed to provide evidence to support its essential claims in U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc. (16-08697). The case, filed by former UnitedHealth employee Poehling in 2011, accuses the insurer of violating the False Claims Act by conducting chart reviews to find additional diagnoses for risk adjustment purposes. The DOJ intervened in 2017 and amended its complaint in 2018. The parties were given 14 days to file motions responding to the special master’s recommendation. The DOJ, which is expected to dispute the recommendation, has until April 2 to file its motion for review. UnitedHealth must file an opposition to the motion by May 2, to which the DOJ must reply by May 19. If the case proceeds to trial, the proposed date is July 7, 2026, according to the parties’ joint order.

While Medicare Advantage enrollment during the 2025 Annual Election Period (AEP) fell slightly short of CMS’s expectations, February enrollment figures reflect sizable growth in the Chronic Condition Special Needs Plan (C-SNP) market. That growth was largely driven by dominant SNP operator UnitedHealthcare, but industry experts say it may indicate a larger trend as state contracting requirements for Dual Eligible Special Needs Plans (D-SNP) pose challenges. Meanwhile, smaller insurers that saw more than their expected share of MA enrollment this AEP could face headwinds if they’re not operationally ready, sources tell AIS Health, a division of MMIT.  

Prior to the start of the AEP, which ran from Oct. 15 through Dec. 7, CMS projected that MA enrollment would climb to 35.7 million, for overall MA penetration of 51%. But AIS Health’s analysis of the Directory of Health Plans (DHP), which includes February enrollment data released by CMS, shows that overall MA enrollment now exceeds 34.2 million, representing just over 50% of the eligible Medicare population. (DHP’s figures do not include enrollment in Medicare-Medicaid Plan demos or Programs of All-Inclusive Care for the Elderly, and therefore they appear lower than CMS’s summary data.)

Medicare-Medicaid dual eligibles are among the health care system’s most vulnerable patients. Their care often requires the management of one or more chronic conditions, which is further complicated by duals commonly experiencing negative health outcomes driven by social determinants of health. Policymakers have turned to managed care organizations to improve care coordination for duals, incentivizing payers to integrate Medicare and Medicaid benefits in a bid to boost outcomes and reduce wasteful spending. More than 6 million people are currently enrolled in Dual Eligible Special Needs Plans (D-SNPs), according to AIS’s Directory of Health Plans, although recent research suggests that these plans can have significant shortcomings when it comes to truly integrated care.

With the last of the baby boomer generation aging into Medicare by 2030, when an estimated one in five people will be over age 65, seniors will be a driving force in health care transformation. At a recent panel moderated by AIS Health, a division of MMIT, three New York-based providers discussed how technologies such as remote patient monitoring and telehealth are just the tip of iceberg when it comes to innovating patient care. Meeting the unique needs of vulnerable seniors and bypassing critical barriers to care will require a nimble and multifaceted approach, agreed the panelists during a discussion hosted by The Bliss Group, a marketing communications agency in New York City.

Given apparent conflicts of interest that came to light in a recent New York Times article, President Donald Trump’s pick for CMS administrator, Mehmet Oz, M.D., is likely to face tough questions from Democrats in upcoming Senate confirmation hearings about his views on Medicare Advantage, among other things. But just because the cardiac surgeon and television personality promoted MA on The Dr. Oz Show, has financial holdings in UnitedHealth Group, and once touted the concept of “Medicare Advantage for All,” insurers would be wise not to get caught up in “MA friendly” expectations regarding the Trump administration or anticipate a complete overhaul of Biden-era regulations, experts tell AIS Health, a division of MMIT.