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Medicare Advantage ratings hurt insurers with dual-eligible members


WellCare is calling out the Centers for Medicare & Medicaid Services for creating unfair Medicare Advantage ratings that put insurers with a high proportion of dual-eligible members at a disadvantage.

The Florida-based insurer, whose membership is about 50 percent dual-eligible consumers, said the Medicare Advantage ratings system "unfairly penalizes plans focused on serving low-income, medically complex members," reported Health News Florida.

Because of the problems it sees with the ratings, WellCare wants CMS to adjust the system to account for challenges associated with treating dual-eligible consumers or create a separate system just for dual-eligible consumers, the insurer wrote in a whitepaper.

Without these changes, WellCare says, it faces multiple obstacles to obtain a 4-star rating, which is the minimum needed to quality for bonus payments. Right now, all WellCare Medicare Advantage plans are rated at 3 or 3 1/2 stars.

Plus, CMS continues to promote Medicare Advantage plans with at least 4 stars to consumers, who are increasingly enrolling in these "high-performing" plans, FierceHealthPayer previously reported.

"It's a little bit unfair to have a scoring system that doesn't account for the sociodemographic status of these [dual-eligible] members," Blair Todt, WellCare's chief strategy and development officer, told Health News Florida.

He added that although insurers can improve some measures that CMS uses to determine Medicare Advantage ratings, they have less control over measures involving patient compliance. For example, some dual-eligible members who are elderly or physically disabled have a hard time getting to doctor appointments or other facilities. Other dual eligibles are addicted to drugs and alcohol.

Todt said that WellCare has several steps in place to address dual-eligible members' specific needs, including transporting them to doctor offices, mailing prescriptions and employing case managers to check on their health. However, no insurer can actually force their members to take their medicine or improve their health.

To learn more:
- read the Health News Florida article
- here's the WellCare whitepaper (.pdf)

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