Radar on Medicare Advantage
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News Briefs: House Committee Advances Bill Requiring Electronic Prior Authorization in MA
CMS at press time unveiled substantive changes to its Medicare Parts C and D enrollee grievances, organization/coverage determinations and appeals guidance. Effective immediately, the Aug. 3 memo from the Medicare Enrollment and Appeals Group contained numerous redlined edits to the guidance for Medicare Advantage organizations, Prescription Drug Plans, Cost plans, Medicare-Medicaid Plans and Programs of All-Inclusive Care for the Elderly. These included guidance on ensuring that enrollees with limited English proficiency have the same level of access to plan representatives and information regarding initial determinations, appeals, and grievances as those who are proficient in English; new specifications regarding plan delivery of notifications; detailed procedures when an initial determination request is withdrawn; and a clarification that a non-contracted provider who has furnished a service to an enrollee may request that an organization determination be reconsidered by the plan.
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Plans Build Trust, Mine Data to Dash Medication Adherence Barriers
When it comes to medication adherence rates, disparities among racial and ethnic groups pose a common challenge to health plans. But leaders in the Medicare Advantage space are working to disrupt the status quo with patient-centric, data-driven solutions that are helping to bridge the gap.
A recent initiative at SCAN Health Plan, a not-for-profit insurer serving 270,000 MA members in Arizona, California and Nevada, sought to narrow the gap between member groups by engaging in a top-down endeavor that wrapped in multiple departments, from human resources to pharmacy. “Our goal was to improve adherence,” relays Romilla Batra, M.D., chief medical officer with SCAN, “and to reduce gaps among African American and Latinx [members].”
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New CMS Bulletin Could Mean Greater Oversight of Medicaid Network Adequacy
CMS in a recent bulletin unveiled a “suite of new resources” aimed at guiding states and CMS in their oversight of Medicaid and CHIP programs, including managed care programs. Two items of particular interest to managed care organizations in a July 6 Center for Medicaid and CHIP Services Informational Bulletin (CIB) are templates that provide a standard format for states to report managed care medical loss ratios and network adequacy to determine how well a plan actually delivers its benefits. As plans struggle to meet network adequacy standards, the new template could lead to more intense oversight of network adequacy within managed care, industry experts suggest.
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As Audit Season Picks Up, CMS Is Scrutinizing Rx Access Issues
As Medicare Advantage plans and their providers operate under a new normal two-and-a-half years into the COVID-19 public health emergency (PHE), CMS is resuming its normal pace of auditing MA organizations as another program audit cycle gets underway, according to compliance experts. During a June 21 session of AHIP 2022, held in Las Vegas, panelists observed that CMS continues to be focused on ensuring seniors’ smooth access to prescription drugs and emphasized the importance of audit readiness.
CMS’s audit activity was limited during the previous cycle, especially in 2020, and its latest audit report reflected that. Released in June, the 2021 Part C and Part D Program Audit and Enforcement Report said CMS imposed 16 civil monetary penalties amounting to roughly $1 million and, between 2019 and 2021, it audited about 20% of currently active sponsors representing approximately 89% of Parts C and D enrollment — which is lower than CMS’s typical goal of 95%.
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Centene Will Join Delaware in Value-Based, Person-Centered Medicaid Revamp
With a focus on value-based care, health equity and social determinants of health, Delaware this month selected three managed care organizations to serve some 280,000 Medicaid and CHIP recipients through the statewide Diamond State Health Plan and DSHP Plus managed care programs. Incumbents AmeriHealth Caritas and Highmark Health Options Blue Cross Blue Shield were both selected for the new pacts, while Centene Corp.’s Delaware First Health will round out the trio of plans, the state’s Dept. of Health and Social Services (DHSS) said on July 12.
Delaware’s Medicaid managed care program, comprised of DSHP and DSHP Plus, is currently operating under the authority of a Section 1115 demonstration waiver that was most recently extended through Dec. 31, 2023. It provides integrated physical health, behavioral health and long-term services and supports (LTSS) to eligible Medicaid and CHIP enrollees.
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