Radar on Medicare Advantage

One of the biggest benefits of Medicare Advantage, according to its proponents, is its ability to reduce low-value care — the delivery of services that provide little or no clinical benefit — via its capitated payment model and the use of prior authorization. But a new study reveals that while some of the largest insurers are successfully cutting down on unnecessary services relative to traditional, fee-for-service Medicare, others are lagging behind, with rates of low-value care delivery similar to FFS Medicare.

The research, published this month in JAMA Network Open, shines a spotlight on how major players like UnitedHealthcare, Humana Inc. and Centene Corp. are leading the charge in reducing low-value services, while others like CVS Health Corp.’s Aetna, Elevance Health, Inc. and non-Elevance Blue Cross and Blue Shield plans still have room for improvement.

Just weeks into the 2025 Annual Election Period (AEP), several major insurers stopped paying broker commissions for new enrollments into certain Medicare Advantage products. Now, sources say more are following suit, including smaller regional plans that have performed well during the AEP. And that raises questions as to whether the consequence of outsized performance by one notorious carrier spooked the rest of the industry and whether such disruption should be allowed to continue.

It’s not unusual for MA plans to rethink their marketing strategy mid-AEP, especially after a general election. But even before the Nov. 5 election resulted in former President Donald Trump winning a second, nonconsecutive term, insurers like CVS Health Corp.’s Aetna, Cigna Healthcare and Elevance Health, Inc. were notifying brokers of their intentions, according to the National Association of Benefits and Insurance Professionals (NABIP).

As Medicare Advantage insurers attempt to differentiate themselves in competitive markets, plans have been springing up that specifically cater to the Asian American and Pacific Islander (AAPI) population, which has a large presence on the West Coast. During a recent Johns Hopkins University webinar, speakers discussed these as part of a growing group of “tailored plans,” which aim to serve specific populations such as racial minorities and the LGBTQ+ community. According to executives at two such plans, Medicare-eligible AAPI beneficiaries may have more linguistic customer service needs and preferences for culturally appropriate benefits and providers than traditional MA plans are used to providing.

Mark Meiselbach, Ph.D., a health economist and assistant professor at Johns Hopkins, says he and his colleagues have identified 61 tailored MA health plans serving about 46,000 total enrollees. Those are primarily targeting AAPI beneficiaries, and the vast majority are HMOs. Enrollment in such plans is “still fairly limited but rapidly growing,” observed Meiselbach during the webinar.

Medicaid coverage of GLP-1 drugs, which were initially developed for Type 2 diabetes but have made global headlines for their effectiveness in treating obesity, remains limited due to their high costs. Just 13 state Medicaid programs currently cover GLP-1s for weight loss, according to new research from KFF. But while most states don’t cover any obesity medications, KFF found that about half are considering adding coverage in the future with the promise of longer-term savings in mind.

Medicaid prescriptions for GLP-1s surged by more than 400% from 2019 to 2023, while gross spending grew by 500% to nearly $4 billion. This is largely driven by diabetes patients, but the versions of the drug indicated for weight loss made up a rising share in overall prescriptions and spending in 2023. KFF found that every state that does cover GLP-1s under Medicaid for obesity treatment has implemented utilization management practices, such as prior authorization, comorbidity requirements and BMI requirements, to manage the expense.