Radar on Medicare Advantage

As Medicare Advantage organizations prepare for patient experience and access measures to take on a larger weight starting with the 2023 Medicare Parts C and D star ratings, MA Prescription Drug (MA-PD) plan sponsors should pay particular attention to customers’ pharmacy experience. Although there are only two Part D measures based on the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey — Rating of Drug Plan and Getting Needed Prescription Drugs, which will both move from a weight of 2 to 4 — a patients’ overall experience can be heavily influenced by their ability to obtain a prescription drug. That’s why Blue Cross Blue Shield of North Carolina has taken a multidisciplinary approach to assessing member experience and how it can be affected by the pharmacy benefit.

Plan Warns Against Overcommunicating

In addition to their health plans, members are routinely interacting with pharmacies, plans and providers that are all trying to close gaps in care. And some of the questions asked in CAHPS include whether anyone from a doctor’s office, pharmacy or prescription drug plan contacted the member to make sure they filled or refilled a prescription or called to see if the member was taking their medicine as directed. “What we don’t want to have happen as we’re trying to ensure a member is adherent is have a member receive a call from all three entities within one- or two-day period,” said Karen Coderre, Pharm.D., director of clinical and quality pharmacy programs, during the Academy of Managed Care Pharmacy Virtual Annual Meeting in April.

✦ President Joe Biden’s 2022 fiscal year budget plan includes multiple health care-related asks aimed at improving Medicare, Medicaid and Affordable Care Act coverage. The budget calls for, among other things, lowering the Medicare eligibility age to 60, enhancing access to supplemental benefits such as dental and hearing in Medicare, and providing “premium-free, Medicaid-like coverage” through a federal public option in states that have not expanded Medicaid, while financial incentives would remain in place to ensure states keep their existing expansions.

✦ The Senate on May 25 confirmed Chiquita Brooks-LaSure as the new administrator for CMS. The Obama-era policy adviser, who was most recently a managing director with professional services firm Manatt, will be instrumental in carrying out President Joe Biden’s goals of building on the Affordable Care Act (ACA) to improve coverage and controlling prescription drug costs. Matt Eyles, president and CEO of America’s Health Insurance Plans, said the insurer trade group looks forward to “working with Brooks- LaSure to strengthen and improve Medicare, Medicaid, and ACA marketplace coverage.”

In the second example in recent months of a Medicare Advantage insurer disputing the federal government’s method of identifying overpayments, a new HHS Office of Inspector General audit report limited its review to a group of diagnosis codes that it maintained are at a particular risk for being miscoded. In addition to having routine medical record review and auditing activities, MA plan sponsors should take extra precautions to identify provider trends in this high-risk group for more accurate risk adjustment, one industry expert suggests.

Conducted separately from CMS’s contract-level Risk Adjustment Data Validation (RADV) audits that verify the accuracy of payments made to MA organizations, the recent findings are part of a series of audits in which OIG is reviewing the accuracy of diagnosis codes submitted to CMS. In a similar report released in April, OIG estimated that Humana Inc. received nearly $200 million in net overpayments for a contract serving approximately 485,000 enrollees. Humana at the time disputed the findings and said it would have the right to appeal “if CMS does determine that an overpayment exists.”

In a move that was not entirely unexpected but irked one leading value-based provider group, CMS recently said it plans to discontinue the Next Generation ACO Model next year and instead allow NextGen ACOs to apply for the Global and Professional Direct Contracting (GPDC) Model for 2022. At least four Medicare Advantage insurers have Direct Contracting Entities (DCEs) that are serving fee-for-service (FFS) Medicare beneficiaries through the GPDC, which launched April 1. And while CMS is not taking applications from other new DCEs at this time, experts say there is still strong MA plan interest in the GPDC, and they should not discount the possibility that the applicant pool will open again, albeit with a few possible tweaks.

In an email sent to participating NextGen ACOs on May 21, CMS said it will end the Center for Medicare and Medicaid Innovation (CMMI) model on Dec. 31 and invited the organizations to apply to join the GPDC starting in performance year 2022 as a Standard Direct Contracting Entity. One of three options for participating in the model, Standard DCEs are composed of organizations that generally have experience serving FFS beneficiaries, including Medicare-only and dual-eligible beneficiaries.

Medicare Advantage enrollment grew just 1% during the 2021 Open Enrollment Period (OEP) that ran from January to March, compared with growth of 7% during the preceding Annual Election Period (AEP), according to AIS’s Directory of Health Plans (DHP). While the large MA insurers continued to nab the bulk of OEP signups (see infographic, p. 7), an AIS Health analysis finds that of the top 25 OEP performers, regional players ranging from established not-for-profit organizations to rising startup insurers followed their AEP successes with OEP gains that were impressive relative to their size.

After the Medicare AEP that typically runs from Oct. 15 through Dec. 7, the Medicare OEP allows beneficiaries who selected an MA plan to make a onetime coverage change. This year was the third OEP since it was reinstated by the Trump administration, and seniors’ awareness of the opportunity has steadily grown, according to Deft Research. Compared with 67% two years ago, 76% of the MA population was aware of the January through March election period this year, while switch rates during the OEP have stayed between 4% and 5% over the last three years, Deft’s 2021 Open Enrollment Period Study observed.