Medicare Advantage Insurer Anthem Wants to ‘Push Innovation Buttons’ with Senior Living

As senior living providers assess how they can seize new opportunities in Medicare Advantage (MA), they should consider one of the nation’s largest insurance companies an interested potential partner.

Indianapolis-based Anthem Inc. is the largest for-profit managed health company under the Blue Cross and Blue Shield umbrella. It is also the most prominent insurer to announce benefits packages created under newly relaxed Medicare Advantage rules, which allow for coverage of non-skilled in-home care and other services.

The Centers for Medicare & Medicaid Services (CMS) first announced this MA policy change last April. In the months since, senior living operators have been contemplating what the change could mean for them, because the newly allowed benefits cover the sorts of services typically provided in settings like assisted living.

However, it’s been unclear how insurance companies that offer MA plans might structure these benefits and when — and if — these insurers will start to offer this type of coverage.

Anthem has been one of the first insurance companies out the gate, announcing its new benefits packages in early October. These benefits, which take effect in 2019, could be tapped by plan members residing in senior living communities. And Anthem’s speed in bringing these new offerings to market should be a signal to senior living providers that the insurance company wants to be on the leading edge of innovation. As part of that effort, Anthem is open to developing future benefits and business arrangements that are more tailored specifically to the senior housing sector.

“It’s an open question for me, how do we work with these facilities in the future?” Martin Esquivel, vice president of Medicare product management at Anthem, told Senior Housing News. “Going forward, we want to push the innovation buttons and see what we can do together.”

Anthem’s offering

The new benefits offered by Anthem-affiliated health plans are branded “Essential Extras” in Georgia, Indiana, Kentucky, Missouri, Ohio, Virginia and Wisconsin;

“Everyday Extras” in Tennessee, Texas, and New Jersey; and the new benefits are not branded in Anthem’s health plan affiliates in California or Arizona. They cover services such as food delivery, transportation, adult day center visits, installation of assistive devices in the home, and up to 124 hours of in-home non-skilled care. Individuals enrolled in plans with access to “Essential Extras” or “Everyday Extras” will need to choose one of the services offered in the package.

“The reason we could jump so quickly [and offer these benefits] is Anthem and its affiliated health plans are committed to offering plans that offer high-quality medical care and other social and support needs,” Esquivel said. “We had a list we were already contemplating, and when the language came through, we were able to add to that list, pressure-test it all, and identify the items we knew we could deliver. Culturally, we were already there.”

MA insurers have multiple incentives for offering these sorts of benefits. For one, they might build enrollment by differentiating themselves from competing plans, and give consumers access to services that they want. Insurers also could see bottom-line benefits through better cost control. For example, by covering transportation and in-home assistance with daily activities, Anthem might help prevent a beneficiary from missing doctors’ appointments or experiencing a fall - and this in turn should cut down on costly hospital stays.

While the new benefits are most obviously tailored to people who are not living in institutional settings, there are certainly some MA beneficiaries who reside in independent living and assisted living communities, Esquivel acknowledged. Anthem does not track the exact number of its beneficiaries in senior living.

There might need to be some discussion among senior living residents, Anthem representatives and leaders at the senior living community about how to coordinate these newly covered services. For example, an assisted living apartment probably already has grab-bars and similar features installed, but a resident might tap the new MA benefit to get a particular type of toilet seat, Esquivel said. Similarly, a senior living community probably already provides some form of transportation, but a resident might want to supplement that through the new MA coverage. And if there are discussions to be had about residents using MA to pay for some services already being offered in senior living settings, Anthem is also open to those conversations.

“How do we innovate and leverage what [senior living communities are] offering their consumers today?” Esquivel said. “It could be as simple as a contracting arrangement where they bill [the insurer], or something much more innovative that we haven’t thought of yet.”

Anthem may need to ‘get in line’

In light of expanding Medicare Advantage benefits, it’s plausible that residents will be approaching senior living providers and saying, “I’m getting this [service covered] through my MA plan, so I shouldn’t have to pay for it out of pocket,” according to Anne Tumlinson, founder and CEO of Washington, D.C.-based health care consultancy Anne Tumlinson Innovations.

However, assisted living companies do not have to quickly reassess their fee structures in response to this move by Anthem.

https://seniorhousingnews.com/2018/10/25/medicare-advantage-insurer-anthem-wants-push-innovation-buttons-senior-living/

Venture-Funded Medicare Advantage Plans Launch into 2019 Market

New Medicare Advantage plans backed by venture funding are positioning themselves as innovative alternatives to traditional health plans

Several Medicare Advantage (MA) plans entering the market for the 2019 plan year are backed by millions in venture capital funding and are planning to compete with established payers by promoting new health plan solutions.

The recent uptick in Medicare Advantage competition is not surprising as many payers have experienced billion-dollar profits, high enrollment totals, and health plan expansion opportunities from a booming MA business. Increased participation in the MA market is likely to present competitive challenges between payers vying to attract new health plan enrollees.

Many new MA entrants have received significant funds from private investors and venture capital firms to launch innovative health plan offerings in the Medicare Advantage space. These new MA plans also promote tools such as data analytics, care coordination platforms, and technology suites to improve member experiences and set themselves apart from established MA participants.

DEVOTED HEALTH LAUNCHES FLORIDA-BASED MEDICARE ADVANTAGE PLAN BACKED BY $300 MILLION INVESTMENT

Devoted Health has launched new Medicare Advantage plans in Florida after raising $300 million in Series B funding to implement technologies that enhance operational efficiency and customer service.

Devoted Health raised $61.5 million in previous funding rounds to develop technologies that help members navigate healthcare services and receive care at home.

Leaders at Devoted Health explained that the organization operates as a combination of a payer and provider to deliver integrated healthcare services.

Ed Park, CEO and co-founder of Devoted Health, said partnering with the best possible providers and equipping consumers with user-friendly technology allow the health plan to improve beneficiary experiences.

“Having industry-leading technology is central to what we do. With our latest funding, we will continue to grow the world-class team building out our technology and operations and will expand Devoted into additional markets,” he said.

Devoted Health has employed advisors, secured investors, and hired executive personnel that have several decades of experience in the Medicare Advantage market.

“In various parts of the country, there are local examples of organizations dramatically improving healthcare outcomes and bringing down costs,” said former US Senator Bill Frist, MD, a member of the Devoted Health board and investor.

“What makes Devoted so exciting is that they have the team, operating model, technology, and capital to scale this kind of performance nationwide.”

BRIGHT HEALTH ENTERS INTO NEW MEDICARE ADVANTAGE MARKET FOR A SECOND CONSECUTIVE YEAR

Bright Health has expanded its Medicare Advantage prescription plan option (MA-PD) into Tennessee, making it the second consecutive year the payer has entered a new MA market.

The payer has partnered with large healthcare systems across Tennessee in order to provide high-quality health plan coverage. The health systems include Baptist Memorial Health Care, the University of Tennessee Medical Center, and TriStar Health.

According to Bright Health executives, the partnership with the three health systems will provide beneficiaries with extensive access to high-quality providers.

Collectively, the health systems include 10 hospitals, 13 urgent care centers, six centers of excellence, over 1,000 physicians, and multiple specialist organizations.  

“Bright Health is committed to expanding access to the growing number of people in need of individual health plans and quality healthcare – both in Tennessee and across the country,” said Bob Sheehy, Bright Health's co-founder and chief executive officer.

“Baptist Memorial, TriStar and The University of Tennessee Medical Center have each demonstrated a unique ability to provide superior, personalized care to millions of patients each year, and we are thrilled to partner with them to meet the healthcare needs of hardworking Tennesseans.”

Bright Health has continued to expand at an accelerated rate due to successful fundraising campaigns. In 2017, Bright Health raised $160 million from investors to scale its individual health plan and MA business operations.

CLOVER HEALTH ANNOUNCES SIGNIFICANT MEDICARE ADVANTAGE EXPANSION FOR 2019

Clover Health announced an expansion into six Medicare Advantage markets for plan year 2019.  

Clover Health uses AI-driven technology to help risk stratify its 30,000 beneficiaries and identify opportunities to improve outcomes. The payer estimates that its platform is accurate 85 percent of the time when identifying patients at risk for a hospital readmission within 28 days. Leaders at Clover Health believe that the company’s AI solutions allow the payer to create optimal beneficiary experiences at scale.

“Expanding into new cities and deploying our AI platform with international partners are both core to Clover's mission of improving the health of our customers by uniting cutting-edge technology with committed, personalized medical care,” said Vivek Garipalli, CEO of Clover Health.

“We are already seeing the extremely positive results that our technology is having on the lives of our members and are optimistic about how we can begin to impact health on a global scale.”

Clover Health has received $425 million in investor funding since 2015, the company said.

OSCAR HEALTH EYES BIG MEDICARE ADVANTAGE MARKET FOR 2020

Oscar Health expanded into several new individual health plan markets and has for an even larger Medicare Advantage expansion in 2020.

The payer offers personalized Medicare Advantage plans through which consumers can use mobile apps and web-based services to make health plan choices.

MA beneficiaries can also access telemedicine and concierge services that help members receive care as needed, according to a recent press release about Oscar’s MA benefits.

Oscar Health CEO Mario Schlosser explained that the company has developed claims administration technology, enrollment services, and communications services to streamline health plan operations.

“Each new member and interaction with the healthcare system offers Oscar an opportunity to refine our member apps and make better recommendations for care; to enable our population health leads and concierge teams to drive more personalized interventions; to empower providers with easier tools that let them focus on delivering care,” Schlosser said.

Oscar recently made national headlines after Alphabet, Google’s parent company, invested $374 million to help the payer expand MA operations for 2020. The investment is expected to help Oscar Health hire more engineers to build out concierge services and member engagement technologies.

https://healthpayerintelligence.com/news/venture-funded-medicare-advantage-plans-launch-into-2019-market

How Prior Authorization Can Impede Access to Care in Medicare Advantage

While Medicare Advantage (MA) plans are required to cover the same health services as Original Medicare, they are not required to offer the same level of provider access and can impose coverage restrictions—like prior authorization—that require enrollees to take additional steps before accessing prescribed care. If a service is covered “with prior authorization,” enrollees must get approval from the plan prior to receiving the service. If approval is not granted or sought, the plan generally will not cover it.

A new analysis from the Kaiser Family Foundation looks at the prevalence of prior authorization in MA and found that many plans utilize this flexibility: 80% of MA enrollees are in plans that require prior authorization for at least one Medicare-covered service. Original Medicare, in contrast, does not require prior authorization for the vast majority of services, making this an important distinction between the two coverage options.

In some instances, prior authorization may be an appropriate utilization management tool. In particular this is true when both beneficiaries and providers are likely to benefit from advance knowledge of Medicare coverage. However, MA’s broad application of prior authorization can impede access to care.

On our National Helpline, we frequently hear from MA enrollees who are experiencing a range of denials for health-related services, and who are concerned and confused about their plan’s service denials and coverage requirements. While each MA plan has different rules, as the KFF report indicates, many require enrollees to obtain approval before receiving an array of critical services:

• At least 70% of enrollees are in plans that require prior authorization for Part B drugs and inpatient hospital stays.
• 60% of enrollees are in plans that require prior authorization for ambulance, home health, procedures, and laboratory tests.
• More than half of enrollees are in plans that require prior authorization for mental health services.

In such situations, there is minimal value to beneficiaries or providers in procuring pre-service determinations. Instead, these requirements can often create barriers that may delay or prevent timely access to needed, affordable care.

Additionally, coverage denials can have significant financial implications for the enrollee. Many face high out-of-pocket costs as a result, in particular those who miss the short 60-day window of time to appeal. Unlike Original Medicare, MA enrollees must appeal within 60 days of the date of service. If they miss this deadline, they are held responsible for the charges.

While we support efforts to lower Medicare program costs and increase certainty about the scope of coverage, the potential consequences of such policies must be carefully considered, and any harms to to people with Medicare must be thoughtfully and thoroughly mitigated.

We are pleased to see that many in Congress recognize the severity of these adverse impacts. Earlier this month, more than 100 lawmakers sent a letter to the Centers for Medicare & Medicaid Services (CMS) expressing concern about the use of prior authorization in MA, and asking for agency guidance to ensure that these requirements do not create inappropriate barriers to care for people with Medicare. The effort was led by Rep. David P. Roe (R-TN-1) and Rep. Ami Bera (D-CA-7), and the Medicare Rights Center recently thanked them for their leadership.

We look forward to working with Congress, the Administration, and our organizational partners to strengthen these and other beneficiary protections within Original Medicare and MA, with the goal of improving the health and economic security of people with Medicare.

Read the KFF report.

Read our letter to Reps. Roe and Bera.

Read the Congressional Letter to CMS.

Read more about the differences between MA and Original Medicare.

Source

New CMS pay model targets
soaring drug prices

The Trump administration on Thursday accelerated its efforts to bring prescription drug prices under control.

Speaking at the Hubert Humphrey building, President Donald Trump announced a proposal that would shift Medicare Part B drugs to a level more closely aligned with prices in other countries. The CMS calls the program the International Pricing Index model. 

American taxpayers and patients are projected to save more than $17.2 billion over five years.

"In an era where the pharmaceutical industry is pricing drugs at levels approaching a million dollars—and jeopardizing the future of our safety-net programs—the time has come to fix the perverse incentives in the Medicare program that are fueling price increases," CMS Administrator Seema Verma said in a statement. 

The move from current payment levels to ones based on international prices would be phased in over a five-year period, would apply to 50% of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines such as infusions.

Read the full article here

Best Insurance Companies for
Medicare Advantage 2019

https://health.usnews.com/health-news/best-medicare-plans/best-insurance-companies-for-medicare-advantage-plans

U.S. News & World Report Announces the 2019 Best Insurance Companies for Medicare

U.S. News & World Report, the global authority in healthcare rankings, today released the 2019 Best Insurance Companies for Medicare Advantage and Prescription Drug Plans. The new ratings are a resource for Medicare beneficiaries and their families searching for the best coverage options during the annual open-enrollment period, which began October 15 and runs through December 7, 2018.

The Best Insurance Companies for Medicare Advantage (a state-by-state list) and Medicare Prescription Drug Plans (same thing in this article) highlights insurance companies that consistently offer highly rated health coverage to Medicare beneficiaries, who are typically age 65 or older.

"Medicare beneficiaries face many complex considerations when it comes to choosing the best health insurance plan, including monthly cost and in-network and out-of-network benefits," said Ben Harder, chief of health analysis for U.S. News. "Our easy-to-navigate online tools and straightforward ratings help consumers identify which plan is best for their specific needs."

Insurance companies were recognized if either their Medicare Advantage or their Part D plans received an average rating of 4.5 stars or higher across all plans in a given state. Companies that consistently offer highly rated Medicare Advantage plans in multiple states include Anthem Blue Cross and Blue Shield, Cigna-HealthSpring, HealthPartners, Kaiser Permanente, Martin's Point Generations Advantage, Medical Associates Health Plan, Inc., MVP HEALTH CARE, Providence Health Assurance, and Senior Preferred. For Part D Prescription Drug plans, 12 states have one insurer that made the U.S. News list, with Blue Cross Blue Shield being the single insurer in 11 of those 12 states.

U.S. News uses plan-ratings data from the Centers for Medicare & Medicaid Services (CMS) to populate its comparison tool and identify the Best Insurance Companies for Medicare Advantage and Prescription Drug Plans. CMS rates individual plans on a scale of 1 to 5 stars. The U.S. News methodology analyzes insurers in a given state with plans rated 3-stars or higher by CMS.

The Best Insurance Companies for Medicare Advantage and Prescription Drug Plans serve the broader U.S. News mission to provide trusted information and rankings that help Americans navigate complex health care decisions, including their choices of insurance plans, doctors, hospitals and nursing homes.

https://www.prnewswire.com/news-releases/us-news--world-report-announces-the-2019-best-insurance-companies-for-medicare-300736160.html

Politicians Hop Aboard ‘Medicare-For-All’ Train, Destination Unknown

Sen. Bernie Sanders (I-Vt.) speaks during a health care rally at the 2017 Convention of the California Nurses Association/National Nurses Organizing Committee on Sept. 22, 2017 in San Francisco. (Justin Sullivan/Getty Images)

After decades in the political wilderness, “Medicare-for-all” and single-payer health care are suddenly popular. The words appear in political advertisements and are cheered at campaign rallies — even in deep-red states. They are promoted by a growing number of high-profile Democratic candidates, like Alexandria Ocasio-Cortez in New York and Rep. Beto O’Rourke in Texas.

Republicans are concerned enough that this month President Donald Trump wrote a scathing op-ed essay that portrayed Medicare for all as a threat to older people and to American freedom.

It is not that. But what exactly these proposals mean to many of the people who say they support them remains unclear.

As a renegade candidate for the 2016 Democratic nomination for president, Sen. Bernie Sanders (I-Vt.) opened the door to such drastic reform. Now, with Republicans showing little aptitude for fixing an expensive, dysfunctional health system, more voters, doctors and politicians are walking through it.

More than 120 members of Congress have signed on as co-sponsors of a bill called the Expanded and Improved Medicare for All Act, up from 62 in 2016. And at least 70 have joined Capitol Hill’s new Medicare for All Caucus.

But some worry the terms “Medicare-for-all” and “single-payer” are at risk of becoming empty campaign slogans. In precise terms, Medicare-for-all means bringing all Americans under the government’s insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone’s medical bills. But few politicians are speaking precisely.

Celinda Lake, a Democratic pollster, said, “People read into ‘Medicare-for-all’ what they want to read into it.”

For every candidate with a clear proposal in mind, another uses the phrases as a proxy for voter frustration. The risk, some critics say, is that “Medicare-for-all” could become a Democratic version of the Republican “repeal and replace” slogan — a vote-getter that does not translate to political action because there is neither agreement about what it means nor a viable plan.

“If you’re on the left, you have to have something on health care to say at town halls,” said David Blumenthal, president of the Commonwealth Fund. “So you say this and move on. That’s part of the motivation.”

Dr. Carol Paris, the president of Physicians for a National Health Program, an advocacy group, said she has fielded a number of calls from candidates asking for tutorials on Medicare-for-all.

“I’m heartened, but not persuaded” that all the high-profile talk will result in any action, she said. She worries about what she called “faux ‘Medicare-for-all’ plans” that don’t live up to the mantra.

Continue to read the full article