Radar on Medicare Advantage
-
Senators Hope to Build Momentum on New Duals Integration Bill
After circulating a discussion draft in the first half of 2023, Sen. Bill Cassidy, M.D. (R-La.) on March 14 released his long-awaited bipartisan bill aimed at improving coverage for Medicare-Medicaid dual eligibles. The Delivering Unified Access to Lifesaving Services Act of 2024 calls for comprehensive changes to the way states and plans currently deliver care to dual eligibles, who often have multiple chronic conditions and account for a disproportionate share of spending.
The bill was introduced by Cassidy and his cosponsors, Sens. Tom Carper (D-Del.), John Cornyn (R-Texas), Mark Warner (D-Va.), Tim Scott (R-S.C.) and Bob Menendez (D-N.J). It would, among other things, require all states to establish an “integrated health plan” for duals — either building off their own or existing options — and require managed care organizations to develop and update comprehensive care plans that include a designated care coordinator for each beneficiary. The legislation also includes “passive enrollment” of qualifying dual eligibles into such plans and continuity of care requirements. The legislation also seeks to expand access to Programs of All-Inclusive Care for the Elderly (PACE) to individuals aged 55 and older.
-
Part D Formularies Get More Restrictive, but MA-PDs Beat PDPs on Access
Medicare Part D formularies are becoming more restrictive over time, asserts new research published in the March issue of Health Affairs. Studying Medicare administrative data that included Part D claims and plan formulary characteristics, researchers from the University of Southern California and Blaylock Health Economics found that utilization management tactics such as prior authorization, step therapy and formulary exclusions became far more commonplace between 2011 and 2020. In 2011, an average of 31.9% of drugs were restricted in some form, vs. 44.4% in 2020.
Restrictions varied based on drug costs and the availability of generic alternatives to brand-name drugs. Nearly 70% of brand-name compounds with no generic alternatives were restricted in 2020, compared to 30% of drugs with generic availability. Additionally, the lower the cost of the drug, the less likely it was to be restricted. In 2020, only 16.7% of drugs with generic availability that cost less than $100 per prescription faced restrictions, vs. 83.7% of brand-name only drugs that cost more than $1,000.
-
False Claims Act Suits Offer Lessons Learned for MA Plans, Lawyer Says
As Medicare Advantage organizations continue to face intense scrutiny — from the government’s latest probe into UnitedHealthcare to the Medicare Payment Advisory Commission calling attention to the cost of higher coding in MA — a new report underscores the power of whistleblower lawsuits in enforcing program requirements. Recent False Claims Act (FCA) settlements with the Dept. of Justice reflect a continued focus on MA insurers submitting inaccurate diagnosis information for the purposes of inflating reimbursement, and while the DOJ isn't involved in proposed class action lawsuits accusing major insurers of using artificial intelligence to wrongfully deny claims, such litigation “bears continued watching as it progresses.”
-
News Briefs: Biden Budget Eyes Supplemental Benefit MLRs
President Joe Biden’s fiscal year 2025 budget proposal included a familiar item from the previous year: a proposal to establish new medical loss ratio (MLR) requirements for supplemental benefits in Medicare Advantage. Without an estimated economic impact or additional detail, that proposal was included as a line item in the 188-page document released by the White House Office of Management and Budget. According to a March 11 fact sheet on the budget, the administration also aims to build on recent efforts to improve prescription drug affordability by accelerating the pace of Medicare drug price negotiations, expanding the Inflation Reduction Act’s inflation rebates and $2,000 out-of-pocket cap beyond Medicare and into the commercial market, and extending the IRA-established $35 cost sharing limit for Medicare-covered insulin to the commercial sector. Further, the budget seeks to strengthen Medicare by “modestly increasing” the Medicare tax rate on incomes above $400,000 and “directs an amount equivalent to the savings from the proposed Medicare drug reforms” into the Medicare Hospital Insurance trust fund.
-
Bigger Footprints, Stable Benefits, Value Adds Assisted AEP Wins
Nearly 33 million individuals were enrolled in Medicare Advantage as of February, demonstrating a year-over-year increase of 7.1% and Annual Election Period growth of 4.0%, according to AIS Health’s analysis of the latest AEP data. Those figures reflect a continued slowdown in MA growth as fewer baby boomers age into Medicare. At the same time, switching among MA consumers continues to rise, and with less rebate and risk adjustment revenue expected this year, insurers had tough decisions to make to stay competitive.
According to the latest Medicare Shopping and Switching Study from Deft Research, MA switching during the 2024 AEP reached a “multiyear high” of 16%, compared with 15% in the 2023 AEP and 12% in the prior two periods. While previous Deft studies identified increasing levels of frustration with supplemental benefits as a top driver of switching, this year’s changes were “more so due to reductions in benefits and added cost,” says George Dippel, president of Deft Research.
The Latest
Meet Our Reporters
Meet Our Reporters