Radar on Medicare Advantage

Thanks to numerous flexibilities granted to plan sponsors during the COVID-19 public health emergency, nearly 70% of Medicare Advantage Prescription Drug (MA-PD) plans earned an overall rating of 4 stars or higher for 2022, CMS said on Oct. 8. That’s compared with just 49% of MA-PD plans in 2021. But the underlying data shows that quality improvements weren’t as impressive as the 2022 star ratings suggest, and with rising quality bonus payments (QBPs), the 2022 ratings could have major implications for MA revenue in the future, industry experts warn.

According to the CMS fact sheet released alongside the stars data, the average MA-PD star rating weighted by enrollment improved from 4.06 in 2021 to 4.37 for 2022. And 74 MA-PD contracts received the high performing indicator on the Medicare Plan Finder for earning 5 stars, compared with just 21 contracts for 2021 (see infographic). Fifty-three of those plans did not receive 5 stars last year. Weighted by enrollment, approximately 90% of MA-PD members are currently in contracts that will have 4 or more stars in 2022, CMS estimated.

Just eight days into the marketing period for the 2022 Medicare plan year, CMS issued a memo on third-party marketing that, while expected, has led to some confusion among Medicare Advantage plans and their industry partners regarding already finalized marketing materials.

In an Oct. 8 memo from the Medicare Drug & Health Plan Contract Administration Group, Director Kathryn Coleman reminds MA organizations that they are responsible for the activities of first tier, downstream or related entities (FDRs), including those marketing on their behalf. The memo did not come as a surprise given increasing reports of aggressive and misleading marketing practices that plans say has resulted in members leaving the plan who never intended to switch, but experts take issue with the timing.

As Medicare and Medicaid plans seek ways to improve overall care quality by addressing members’ social determinants of health, an emerging source of beneficiary-level SDOH data is a subset of ICD-10 “Z Codes,” which can be attached to claims and encounters to identify causes other than a disease or injury. While there is payer enthusiasm for using these codes, new research suggests that plans have a long way to go to increase provider uptake and establish best practices in this area.

According to an analysis of the most recently available Z code data from the CMS Master Beneficiary Summary File, NORC at the University of Chicago found that just 1.3% of all Medicare beneficiaries had their social needs tracked with a Z code in 2018. In Medicare Advantage, that percentage was slightly higher at 1.5%, compared with 1.2% in fee-for-service Medicare. In an August report prepared on behalf of the Better Medicare Alliance (BMA), NORC estimated that 1.4% of FFS Medicare enrollees had an SDOH-related Z code in 2017.

✦ CMS has given itself another year to finalize a proposal to begin using an extrapolation methodology in recovering overpayments from Medicare Advantage organizations. The Trump administration in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said it planned to extrapolate the results of Risk Adjustment Data Validation Audits, starting with 2011 contract-level audits, and not apply a “fee-for-service adjuster” to account for inaccurate diagnosis codes in FFS Medicare data used to calibrate the MA risk adjustment model. In a Federal Register notice published on Oct. 21, CMS cited “exceptional circumstances” for exceeding the statutory three-year timeline and explained that it received extensive public comments on the proposal and the FFS Adjuster study that it released just prior to publishing the November 2018 proposed rule. CMS said it plans to publish the final rule by Nov. 1, 2022.

✦ As Congressional lawmakers attempt to whittle down President Joe Biden’s $3.5 trillion budget reconciliation package that includes expanding Medicare benefits, Sens. Kyrsten Sinema (D-Ariz.) and Tim Scott (R-S.C.) are leading a bipartisan effort to protect the Medicare Advantage program from potential cuts. “Payment stability is critical to protecting and strengthening this popular choice for seniors, particularly since these seniors have paid into the Medicare program and expect to continue to receive the excellent, reasonably priced care offered by MA,” a group of 13 senators wrote to CMS Administrator Chiquita Brooks-LaSure. “We stand ready to protect MA from payment cuts, which could lead to higher costs and premiums, reduce vital benefits, and undermine advances made to improve health outcomes and health equity for MA enrollees.” Sinema has previously expressed opposition to prescription drug pricing proposals, such as giving Medicare the authority to negotiate drug prices, in the House and Senate versions of the legislation. Trade groups Better Medicare Alliance and AHIP cheered the move to protect MA. AHIP in August released a paper prepared by Wakely that estimated plans would have an average of 48% to 73% fewer rebate dollars to fund supplemental benefits if Congress adds dental, vision and hearing benefits without adjusting the MA benchmark.

Improving access to health care for underserved populations and eliminating health inequities were running themes throughout the AHIP 2021 National Conference on Medicare, Medicaid & Dual Eligibles, which was held virtually from Sept. 21-24. Speakers participating in various health equity-focused sessions discussed the importance of and challenges associated with collecting the right data to target members’ needs, which are often not directly related to health care.

At AmeriHealth Caritas, which operates Medicaid plans in multiple states, health equity has become a strategic priority, a “key business imperative and a market differentiator,” said Director of Health Equity Danielle Brooks. And all types of data — from claims data to demographic data to information on the social determinants of health (SDOH) — collectively “tells a story about what is happening in our populations,” she said during a panel on data and health equity. Such data also can be used to improve and measure the effectiveness of managed care programs and get at the root causes of health inequities, she added.