Radar on Medicare Advantage

As the pandemic underscores the importance of enhanced support for community-dwelling seniors with complex care needs, two not-for-profit Medicare Advantage organizations have teamed up to sponsor an “integrated care delivery organization” designed to serve enrollees who qualify for Programs of All-Inclusive Care for the Elderly (PACE). Long Beach, Calif.-based SCAN Health Plan and Boston-based Commonwealth Care Alliance (CCA) last month unveiled the launch of myPlace Health as part of their shared mission of keeping seniors healthy and independent. 

Robbie Pottharst, CEO of the newly launched company, confirms that myPlace is seeking to become a PACE organization and align with local health plans that may already serve dual eligibles who qualify for PACE and that, in his words, “can lend capability, expertise and a lot of accelerators to build this business.” Pottharst previously held leadership roles with Cityblock Health, Kaiser Permanente and CareMore Health, where Sachin Jain, M.D., served as president and CEO before taking over the reins at SCAN.

After nearly four years, CMS has released an updated version of the Medicare Communications and Marketing Guidelines (MCMG) that serve to interpret and provide guidance on the marketing and communication rules for Medicare Advantage and Part D sponsors. Compliance experts tell AIS Health, a division of MMIT, that the long-awaited document is light on additional guidance and clarification except for a few topics, and plans are encouraged to review all related regulations to stay compliant with marketing rules.

Aside from severely whittling down the document — the 2022 MCMG is now a mere 51 pages, down from 84 pages when last released as a full document for the 2019 plan year and 124 pages in the 2018 version — CMS has noticeably consolidated and reorganized sections, moving some subsections into other areas or removing guidance that was codified. The agency reminded plans that the document is to “be used in conjunction with the regulatory requirements to aid plans in understanding and complying with the regulations.”

Despite better-than-expected financial results posted for its fiscal-year 2022 second quarter, shares of InnovAge — the largest provider of Programs of All-Inclusive Care for the Elderly (PACE) — tumbled last week amid concerns about its ability to grow in the face of intensifying regulatory scrutiny. Between federal audits and issues with its state partners, InnovAge’s many struggles relate to program compliance and may demonstrate the difficulties of scaling up a specialized care model in a highly regulated industry.

Providing services primarily through a dedicated center, PACE organizations support frail, elderly Americans who require a nursing-home level of care by offering comprehensive medical care and social supports to help them remain at home. The PACE market serves about 51,000 participants, most of whom are dually eligible for Medicare and Medicaid, and it is largely composed of regional organizations. As the dominant PACE organization, InnovAge serves 12% of that market.

Aside from a headline-grabbing estimated pay boost of nearly 8% for Medicare Advantage organizations next year, the Biden administration’s first preliminary rate notice didn’t include many surprises for MA and Part D sponsors. Instead, the notice focused largely on potential changes to star ratings in the name of advancing health equity and monitoring member experience. At the same time, the notice addressed one aspect of payments for insurers serving a large portion of patients diagnosed with end-stage renal disease (ESRD) but left another to future policymaking.

“The release of the Advance Notice, coupled with the release of the proposed rule last month, marks an important milestone in the policy and rate setting process, and really represents the first major rate notice developed entirely under the Biden administration,” said Greg Gierer, vice president of policy and research, during a Feb. 9 webinar hosted by Better Medicare Alliance (BMA). Moreover, it “provide[s] an opportunity for the admin and CMS to really shape the program as the administration looks to advance important policy work on shared goals, including advancing health equity, improving the beneficiary experience, lowering out-of-pocket costs, and improving quality of care and health outcomes.”