Radar on Medicare Advantage
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2021 in Review: Top 25 Medicare Advantage Insurers Enroll Nearly 90% of Market
The top 25 Medicare Advantage insurers enroll a combined 24.3 million lives, or 87.8% of the national market, according to the December 2021 update to AIS’s Directory of Health Plans. That’s up from 21.4 million lives at year-end 2020. Among the large national insurers, Centene Corp. saw staggering growth of nearly 40%, fueled by the insurer’s significant 2021 market expansion, followed by Anthem, Inc. at 30.7%. Anthem completed its acquisition of InnovaCare Health’s MMM Holdings, the largest MA organization in Puerto Rico, in July 2021. Highmark Health and Molina Healthcare also completed deals that boosted their MA presence this year. Just one insurer in the top 25, Triple-S Management Corp., saw an enrollment loss, though it was less than 1%. See the complete list in the table below.
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PACE Is Poised for Expansion as COVID Highlights Home Needs
As Congressional lawmakers consider additional funding for home and community-based services (HCBS) in Medicaid and the pandemic underscores the importance of enhanced support for community-dwelling seniors, a small but growing segment of the Medicare market is experiencing a resurgence. Programs of All-Inclusive Care for the Elderly (PACE) are designed to support frail, elderly Americans who require a nursing home level of care by providing comprehensive medical care and social supports to help them remain at home, and sources tell AIS Health that PACE competition is heating up as more venture capital firms look to invest in PACE organizations and as multiple states expand their programs.
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PACE Market Sees Steady Growth, Diverse Pool of Providers
Enrollment in Programs of All-Inclusive Care for the Elderly (PACE) topped 51,000 people in 2021, according to AIS’s Directory of Health Plans, representing a small but impactful segment of the Medicare market that’s seen consistent annual growth. Notably, no large national entities have a significant PACE presence, leaving regional actors to control the market. The largest PACE organization, InnovAge, enrolls just 12% of all lives, and the average PACE organization enrolls about 430 participants, per AIS data. There will be 14 new PACE plan IDs on the market in 2022, according to research from Clear View Solutions, LLC, up from 12 in 2021. And just two IDs have exited the market for 2022, Clear View found. See an overview of the current PACE market below.
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Rewards and Incentives Rule Has Compliance, Stars Implications
Although it may have gone largely unnoticed by Medicare Advantage plans this year, a clarification regarding rewards and incentives (R&I) programs embedded in an 894-page final rule issued in January 2021 could have significant implications for plans’ star ratings strategy in addition to posing compliance risks and added costs in 2022. Industry experts say now is the time for plans to get compliant with the provision, which goes into effect on Jan. 1, 2022, and to begin rethinking their R&I programs to incentivize healthy behavior across the broader MA population and not just those members who are falling behind in their star measures.
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Stakeholders Consider Impact of BBBA Drug Pricing Reforms on Formularies, Innovation
The Build Back Better Act (BBBA), which passed the House on Nov. 19 but at press time was looking less and less likely to meet Democrats’ self-imposed Christmas deadline, contains multiple drug pricing reforms that could lead to more than $300 billion in savings over the next decade, according to estimates from the Congressional Budget Office (CBO). These provisions include an overhaul of the Medicare D benefit, which a recent Avalere Health analysis suggests could lead to greater increases in mandatory manufacturer discounts on brand drugs within the benefit’s six “protected classes” compared with brand Part D drugs overall.
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