Radar on Medicare Advantage

CMS’s annual release of Medicare Part D payment benchmarks and other bid-related information for the coming plan year tells pretty much the same story as in years past. The national average bid amount will continue to go down, while reinsurance amounts will continue to rise and premiums will see a slight increase.

“It’s just a continuation of things that we’ve seen for a while now. Reinsurance was relatively flat from 2018 to 2020, but it’s been going up” as the expanded use of high-cost therapies leads to higher catastrophic-phase spending, explains Tom Kornfield, senior consultant with Avalere Health. That trend has been closely tracked by the Medicare Payment Advisory Commission, which continues to advocate for a Part D redesign. As Congress considers drug pricing legislation, such information could provide “more support for folks who want to restructure the Part D benefit,” suggests Kornfield.

Sachin Jain, M.D., is a longtime champion of treating certain social factors as medical issues. In his work as president of CareMore Health, a physician-led care delivery subsidiary of Anthem, Inc., he spearheaded efforts to address senior loneliness. He has since brought that commitment to SCAN Health Plan, where he has served as president and CEO for the last year. SCAN, a large, not-for-profit Medicare Advantage plan in California, is now taking on homelessness in a new way with the planned launch of a dedicated medical group that will provide health care and other services to individuals experiencing homelessness.

AIS Health recently spoke with Jain about the new initiative and the importance of addressing unmet social needs that can have a serious impact on health outcomes. Editor’s note: This interview has been edited for length and clarity.

Before the Senate adjourns for its annual summer recess, momentum was building at press time for what would be one of the most significant changes to the Medicare program since the addition of Part D. That would be the expansion of fee-for-service (FFS) Medicare benefits to include dental, vision and hearing, and although details of any such legislative proposal are scarce, industry observers say the potential change could drive more Medicare Advantage plans to innovate.

Along with prescription drug pricing measures, the expanded Medicare benefits were included in a discussion draft of the $3.5 trillion spending package that Senate Democrats aim to pass via budget reconciliation, which requires a simple majority rather than 60 votes typically needed to pass bills in the Senate. That is separate from the Infrastructure Investment and Jobs Act, the Senate’s $1.2 trillion infrastructure proposal that the chamber aims to pass this week and includes delaying the implementation of the controversial Trump-era rebate rule to 2026 — a move that has been discussed as a way to fund enhancements to the Medicare program.

While the COVID-19 pandemic complicated many smaller Medicare Advantage organizations’ efforts to connect with members during the Medicare Annual Election Period (AEP) last fall, reports of aggressive and misleading marketing practices also resulted in the unintentional disenrollment of individuals from their plans, which not only hurts from a revenue perspective but can negatively impact their star ratings. According to several sources who spoke with AIS Health, a division of MMIT, these tactics were more egregious than usual during the 2021 AEP and the Open Enrollment Period (OEP) that ran from January through March, when members who selected an MA plan in the fall may make a one-time coverage switch.

“We’ve always seen some very aggressive marketing practices, especially from some of the large, national players. But over the last two years, and especially in the last six months, it’s gone from aggressive marketing tactics to what many plans would qualify as teetering on the side of deceptive marketing practices. And it’s not just one large player,” says a source who works with health plans and asked not to be identified for this article.

✦ Sens. Bill Cassidy, M.D. (R-La.) and Bob Menendez (D-N.J.) on July 14 introduced legislation seeking to redesign the Medicare Part D benefit structure and limit seniors’ out-of-pocket (OOP) drug costs. The bipartisan Seniors Prescription Drug Relief Act would establish an OOP cap on catastrophic coverage, so that seniors would pay no more than $3,100 in OOP spending, and restructure Part D to “realign these flawed incentives and lower the cost of prescription drugs.”

✦ CMS this month began a National Coverage Determination (NCD) process for the newly approved Alzheimer’s treatment Aduhelm (adacanumab). That analysis, which will create Medicare coverage standards on a national level, will apply to Aduhelm “as well as any future monoclonal antibodies that target amyloid for the treatment of Alzheimer’s disease,” CMS stated. The July 12 start of the NCD process also kicked off a 30-day public comment period; CMS will also host two public listening sessions this month. The FDA last month approved the $56,000-a-year infused drug, despite questions about its clinical efficacy. CMS will first issue a proposed NCD, which will be subject to a second 30-day comment period and is expected within six months, with a final decision posted within nine months. Until then, coverage decisions will be made at the local level by Medicare Administrative Contractors, according to the announcement.