Payer Roundup—Elevance Health wins reversal of star ratings decision; Humana expands partnership

Below is a roundup of payer-centric news for the week of March 4, 2024.

Elevance Health wins star ratings complaint

Four Elevance Health Medicare Advantage (MA) contracts will have better-than-expected star ratings for 2024, the company announced this week in a Securities and Exchange Commission filing (PDF).

The Centers for Medicare & Medicaid Services (CMS) is updating the ratings after the company objected to what it deemed as unfair results.

The decision returns approximately $190 million to Elevance. The company believed regulators put too much emphasis on a secret shopper call in March 2023 that Elevance never received, Bloomberg and others reported.

Elevance now has nearly half of its MA members in plans with at least four stars for payment year 2025.

"Others may find inspiration from Elevance's actions, potentially using it as a playbook for future disputes," said Jessica Assefa, chief quality officer for ATRIO Health Plans, in a LinkedIn post.

The insurer said in October it was expecting to get dinged $500 million in quality bonus revenue after the star ratings decline before suing CMS in January and calling methodology changes to MA unlawful.

Humana, Strive Health expand partnership

Humana and Strive Health are adding Illinois, Michigan and parts of North Carolina to their value-based kidney care arrangement.

Members of the Humana Medicare Advantage HMO and PPO plans with kidney disease will receive access to Strive's clinical care team for improved medication management, dialysis access planning and transplant coordination, according to a news release. Previously, the agreement only applied to Kentucky and Indiana, Fierce Healthcare reported in 2020.

“Humana has a proven track record of providing innovative care delivery models,” said Will Stokes, co-founder and chief growth officer of Strive Health, in a statement. “Our expanded partnership will allow us to serve thousands of patients through a value-based approach to kidney care and further our mission to deliver compassionate kidney care through data-driven insights, high-touch care and prevention.”

Feds slammed for not enforcing accumulators

Payers are ignoring regulations requiring insurers to only use accumulators when a drug has a generic equivalent, The AIDS Institute said in a new report (PDF).

Copay accumulator adjustment policies are used by insurers and pharmacy benefit managers to collect copayments made by enrollees that do not count toward a person's deductible or out-of-pocket limit. This hurts patients with chronic illnesses requiring expensive specialty prescription drugs with no generic equivalent.

In October, patient advocacy groups won a ruling that declared insurers and PBMs in all 50 states could not continue this practice.

But The AIDS Institute found that two-thirds of plans include copay accumulators in the 32 states that do not have state regulations banning accumulators. Each state was scored, and 20 states earned a grade of "D" or "F" based on how common plans within the state include accumulators.

The organization backs the HELP Copays Act to end this workaround.

"Federal and state policymakers can address this issue by enforcing the current regulation prohibiting this practice, or by enacting legislation to protect access to care for people living with chronic illness who have health insurance," the report reads.

Planned Parenthood cannot be defunded: court

The 4th U.S. Circuit Court of Appeals ruled this week South Carolina cannot cut Medicaid funding to Planned Parenthood.

It is the third time a court has had to intervene in the state's attempts to defund the organization because it provides abortions. Medicaid recipients will still be able to access preventive services, as allowed under federal law.

“The patients who come to Planned Parenthood health centers for care aren’t doing so to make a political statement," said Jenny Black, CEO of Planned Parenthood South Atlantic, in a news release. "They come to us because we are the provider they know and trust for compassionate, quality, affordable care. Every year, Planned Parenthood South Atlantic serves thousands of South Carolinians, providing lifesaving health care that includes breast and cervical cancer screenings, birth control, and STI testing and treatment."

ACHP receives diabetes research grant

The Alliance of Community Health Plans announced Wednesday a $1.5 million, 18-month research grant to improve diabetes outcomes by 2030.

Funds will go toward utilization of continuous glucose monitoring (CGM), according to a news release. The company will partner with HealthPartners Institute International Diabetes Center. CGM monitors track glucose levels and eliminate "the need for inconvenient finger pricks."

“CGM is an incredibly underutilized technology with the potential to improve lives, while—we predict—saving our health care system significant financial resources,” said Ceci Connolly, ACHP president and CEO. “Given this, it’s crucial for us to explore opportunities to address the coverage and utilization barriers to CGM.