Radar on Medicare Advantage

  • MedPAC’s June Report Flags Interest in Provider Directory Accuracy

    Taking a breather from the continuing debate over Medicare Advantage plan overpayments, the Medicare Payment Advisory Commission (MedPAC) in its latest report to Congress touched on three crucial aspects of MA plan administration: encounter data, prior authorization and provider networks. Within its discussion of the latter, MedPAC pointed to persistent gaps in provider directory accuracy, something that insurance executives during the 2024 AHIP Conference in Las Vegas described as creating a “horrible experience” for members and providers.
  • News Briefs: Lawmakers Take Another Stab at Improving Prior Authorization in MA

    After the Improving Seniors’ Timely Access to Care Act unanimously passed in the House of Representatives last year but failed to make it through the Senate, leadership from both chambers have reintroduced the bill. The legislation, which aims to streamline the prior authorization process in Medicare Advantage, was reintroduced on June 12 by U.S. Senators Roger Marshall, M.D., (R-Kan.), Kyrsten Sinema (I-Ariz.), John Thune (R-S.D.), Sherrod Brown (D-Ohio), and U.S. Reps. Mike Kelly (R-Pa.), Suzan DelBene (D-Wash.), Larry Bucshon, M.D. (R-Ind.) and Ami Bera, M.D. (D-Calif.). The bill would, among other things, establish an electronic prior authorization process for MA plans including a standard process for transactions and clinical attachments; increase transparency around MA prior authorization requirements and its use; and clarify CMS’s authority to establish timeframes for e-PA requests including expedited determinations and real-time decisions for routinely approved items and services. It would also codify and enhance elements of the Advancing Interoperability and Improving Prior Authorization Processes rule that was finalized by CMS in January, according to the Regulatory Relief Coalition (RRC), which has been advocating for the so-called Seniors’ Act since it was first introduced in 2019. RRC, the American Medical Association, the American Hospital Association, and hundreds of other groups are urging passage of the legislation.
  • 2025 MA Bid Cycle Was ‘Wild Ride’ That Could Lead to Market Exits, Actuaries Say

    Compounded by known challenges in estimating Medicare Part D costs stemming from the Inflation Reduction Act (IRA), the process of finalizing Medicare Advantage insurers’ bids for the 2025 plan year was an “extra wild ride” due to a variety of unknowns, according to Matt Kranovich, principal and consulting actuary with Milliman. And while national insurers in recent months have publicly disclosed their intent to skinny down their MA offerings through things like benefit adjustments and strategic exits, similar reactions to revenue headwinds may play out across the country and lead to more market consolidation than CMS would care to see, warns Tim Murray, principal with Wakely, an HMA company.
  • Aetna, Insurtechs Outpaced Medicare Advantage Peers in Quieter OEP

    Medicare Advantage enrollment grew by 350,000 members during the 2024 Open Enrollment Period (OEP), according to CMS’s May data release and AIS’s Directory of Health Plans. That’s a 31% drop from last year, which saw 507,000 sign-ups from February to May, and it reflects a slowdown in MA growth also seen in the Annual Election Period (AEP).
  • Fast-Growing NY Insurer Credits MA Benefit Stability, Behavioral Health Focus

    CDPHP, a not-for-profit managed care organization serving Medicare Advantage members primarily in Upstate New York and the Hudson Valley, is one of several provider-led insurers that carried a strong growth trajectory from the Medicare Annual Election Period (AEP) through the Open Enrollment Period (OEP) in the first quarter of 2024, according to a recent AIS Health analysis.

    The Albany-based insurer added more than 5,000 MA members during the AEP and another 5,400 between February and May, for overall growth of 20% since October, per AIS’s Directory of Health Plans. According to CDPHP’s senior vice president and chief growth officer, Nicholas Kraft, the plan nabbed 66% of new enrollment in its market and is now the third-fastest growing MA plan in the U.S. CDPHP was also ranked No. 1 in member satisfaction among commercial insurers in New York State by J.D. Power & Co.

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