Radar on Medicare Advantage

Following up on its October 2021 “Third Party Marketing” memorandum warning of misleading tactics by some organizations, CMS in its latest Medicare Advantage and Part D proposed rule said it believes “additional regulatory oversight” is needed to protect beneficiaries from “bad actors” in this space. The agency observed that an increase in third-party marketing activities in recent years has been accompanied by a rise in marketing-related complaints from beneficiaries, such as those who do not understand how an agent or broker obtained their information.

While previous guidance and rules have focused more on MA organizations’ relationships with agents and brokers, the new proposed rule serves to address the prevalence of lead-generating entities that may not directly contract with MAOs but qualify as first tier, downstream or related entities (FDRs), explains Helaine Fingold, a partner in the Health Care and Life Sciences practice at the law firm Epstein, Becker & Green, P.C.

In a highly anticipated but not-so-surprising move, CMS on Jan. 11 released a proposed National Coverage Determination (NCD) that would restrict Medicare coverage of Biogen and Eisai, Co., Ltd.’s Aduhelm (aducanumab-avwa) and any other FDA-approved monoclonal antibodies that target beta amyloid plaque for the treatment of Alzheimer’s disease. Industry experts say the coverage proposal — coupled with a recent price cut on Aduhelm — is unlikely to alter commercial payers’ hesitancy toward covering the drug, while one actuary says the decision supports Medicare Advantage plans’ expectations that coverage would be limited.

According to the proposed NCD, which is now open to a 30-day comment period, Medicare would cover the therapies under Coverage with Evidence Development (CED), requiring that patients be enrolled in approved randomized controlled trials that are conducted in a hospital-based outpatient setting. Participants must have a “clinical diagnosis of mild cognitive impairment (MCI) due to AD or mild AD dementia; and evidence of amyloid pathology consistent with AD.” The NCD also would allow coverage of one beta amyloid positron emission tomography (PET) scan per patient as part of the protocol. 

For the Medicare Advantage industry, change wasn’t a major outcome of the Biden administration’s first year in office. But for 2022, MA organizations face a host of unknowns — such as potential risk adjustment and star ratings changes that could impact plan revenue — and challenges that include staying competitive in an increasingly rich benefits landscape. For AIS Health’s annual roundup of perspectives on the year ahead, industry experts weigh in on how doing business in 2022 might differ from previous years.

AIS Health: What do you view as some of the biggest challenges or uncertainties facing MAOs in 2022?

With continued emphasis on member experience, several new Part C measures and a directional shift to closing health care inequities, 2022 stands to be a landmark year in terms of changes to Medicare Advantage organizations’ star ratings strategies, industry experts tell AIS Health, a division of MMIT.

“There is so much earth-shattering change on the horizon that most plans are just not thinking about,” cautions Melissa Newton Smith, executive vice president, consulting and professional services with Healthmine, Inc. “We’re worried that COVID took up way too much airtime and that plans have lost sight of the forest through the trees in MA a little bit.”