RISE looks at recent headlines concerning Medicare Advantage (MA).
FAMILIES SUE UNITEDHEALTH FOR MA COVERAGE DENIALS
The class-action lawsuit, filed last week in the U.S. District Court for the District of Minnesota, claims UnitedHealth Group used artificial intelligence (AI) to deny post-acute care to MA members.
Family members of deceased UnitedHealth MA policy holders Gene B. Lokken and Dale Henry Tetzloff, who both lived in Wisconsin, claim the health insurer wrongfully denied the elderly patients the care they needed at skilled nursing facilities by overriding their treating physicians’ determination of medically necessary care based on an AI model that has a 90 percent error rate. Despite the high error rate, the lawsuit said UnitedHealth systemically denied claims using the nH Predict Model because they know only a small number of policyholders will appeal the denied claims. As a result of the care denials, the families said they spent thousands of dollars out-of-pocket so the men could receive the appropriate care. They are seeking a jury trial for damages.
UnitedHealth denied that it used the AI program to make coverage determinations and said the lawsuit has no merit. In a statement to USA Today, the company said, "the tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home.”
AHA CLAIMS MA PLAN POLICIES APPEAR TO VIOLATE 2024 FINAL RULE
The American Hospital Association (AHA) has called on the Centers for Medicare & Medicaid Services (CMS) to take quick action to correct MA policies that don’t comply with requirements contained in the MA final rule for 2024. The trade group wrote to CMS expressing concerns about reports it has received from its members that certain MA organizations (MAOs) have indicated they do not intend to make changes to their utilization management programs in response to the new rule. In other cases, AHA wrote, it appears some plans are making changes to the terminology they use in denial letters that may be intended to circumvent recent CMS rulemaking.
“We are deeply concerned that these practices will result in the maintenance of the status quo where MAOs apply their own coverage criteria that is more restrictive than Traditional Medicare proliferating the very behavior that CMS sought to address in the final rule, resulting in inappropriate denials of medically necessary care and disparities in coverage between beneficiaries in MA and those in the Traditional Medicare program,” AHA wrote.
FIRST LOOK AT MA COVERAGE IN 2024
Two new analyses published by KFF provide an overview of the MA and Medicare Part D marketplace for 2024, including the latest data and key trends.
The typical Medicare beneficiary will have a chose of 43 MA plans for 2024, according to the first analysis. That is the same number available as in 2023, but more than double the number of plans offered in 2018. A second report finds that a typical person covered under traditional Medicare can choose among 21 Medicare stand-alone prescription drug plans (PDPs). The number of PDP options for 2024 is lower and the number of Medicare Advantage prescription drug plan (MA-PD) options is higher than in any other year since Part D started, reflecting the broader trend toward MA, researchers found.
The research finds:
- Of the 43 MA plans that the typical beneficiary can choose from in their local market, 36 plans offer Part D drug coverage, on average.
- Two-thirds (66 percent) of MA plans will not charge an additional premium beyond Medicare’s standard Part B premium in 2024, the same as in 2023. In addition, 19 percent of MA plans will offer some reduction in the Part B premium (also known as “money back”) in 2024, similar to 2023.
- In 2024, nearly all plans (97 percent or more) offer some vision, fitness, hearing, or dental benefits as they have in previous years, though the scope of coverage for these services varies.
- On average, monthly premiums for drug coverage are substantially higher for stand-alone plans compared to MA plans with drug coverage. While the average premium for stand-alone drug plans is projected to increase for 2024 for PDPs, it is expected to remain stable for MA plans with drug coverage.
- Two-thirds of Part D stand-alone drug plan enrollees (excluding Low-Income Subsidy recipients) will see their monthly premium increase in 2024 if they stay in their current plan, while 4.4 million (34 percent) will see a premium reduction if they stay in their current plan.
- Beneficiaries who receive Part D Low-Income Subsidies will have access to fewer premium-free (benchmark) plans in 2024 than in any year since Part D started. Due to changes in benchmark plan availability, an estimated 2.4 million LIS enrollees–half of all LIS enrollees in PDPs need to switch plans during the 2023 open enrollment period if they want to be enrolled in a premium-free benchmark plan in 2024.
HUMANA REPORT: VALUE-BASED CARE BENEFITS MA MEMBERS
MA members who receive care under value-based arrangements spent more time with their primary care physician and were more likely to receive preventive care, with fewer hospitalization, according to Humana’s 10th annual Value-Based Care Report. Meanwhile, physicians who work under the value-based model are more empowered and better positioned to coordinate care while prioritizing outcomes over the quantity of services.
Value-based care reimburses clinicians for the quality of care they provide with a focus on preventive care and better patient health outcomes. A team-based holistic approach to patient care provides coordination across transitions in care, technology and data usage to catch and eliminate gaps in care, and more resources and incentive to manage health-related social needs.
The report finds:
- Patients who received health care under value-based care arrangements grew by 2.3 million over the past decade.
- Seventy percent of individual MA patients were aligned with value-based providers in 2022.
- There were 30 percent fewer inpatient admissions for value-based care patients compared with Original Medicare beneficiaries in 2022.
- Value-based care patients completed preventive screenings at a 14.6 percent higher rate than MA members not in a value-based care arrangement.
- In 2022, Humana MA value-based contractual arrangements saved 23 percent in medical costs compared to Original Medicare.