《Milliman：2025年美國聯邦醫療保險優勢計劃研究報告：行業變革與挑戰應對（英文版）（29頁）.pdf》由會員分享，可在線閱讀，更多相關《Milliman：2025年美國聯邦醫療保險優勢計劃研究報告：行業變革與挑戰應對（英文版）（29頁）.pdf（29頁珍藏版）》請在三個皮匠報告上搜索。

1、Milliman Medicare Webinar SeriesA year of change:State of the 2025 Medicare Advantage industryFebruary 12,2025PresentersJordan CatesFSA,CERA,MAAAConsulting A Mark FranklinASA,MAAAAssociate A Julia FriedmanFSA,MAAAPrincipal&Consulting A Joanne FontanaFSA,MAAAPrincipal&Consulting A 2025 MA-PD Headwind

2、s4MA-PD Headwinds MA Revenue BenchmarksSource:2020 2025 Rate Announcements and 2026 Advance Notice released by CMS.2025 nationwide benchmark trend remains at a lower level than recent yearsSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|2025 MA-PD HEADWINDS Nationwide benchmark trends

3、 decreased in payment years 2024 and 2025.Driven by Medicare FFS costs as well as a technical adjustment to the calculation methodology which is phased in over three years(2024 2026).Actual benchmark trends can vary significantly by county.5MA-PD Headwinds Risk ScoresSource:https:/ 2024 Part C CMS-H

4、CC Model which is phased in from 2024 2026 generally results in lower risk scoresSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|2025 MA-PD HEADWINDS 2024 Part C CMS-HCC risk score model introduced with substantial clinical revisions.CMS estimates the combined impact of new model phas

5、e-in and annual normalization factor updates to be-2.2%in 2024,-2.5%in 2025,and-3.0%in 2026.Milliman study estimated the fully implemented impact of the new model to be-3.5%to risk scores on average.Impacts of the 2024 model can vary significantly by MAO and plan type.-3.10%-1.60%-5.80%-11.10%-1.80%

6、-12.00%-10.00%-8.00%-6.00%-4.00%-2.00%0.00%GeneralEnrollmentEGWPD-SNPC-SNPI-SNPChange in Risk ScoreHigh Level Impacts of Fully Implemented 2024 Risk Score Model,Based on 2019 Diagnoses6MA-PD Headwinds Star RatingsSource:2021 2024 Star ratings published by CMSOverall average Star ratings decreased fo

7、r a second straight yearSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|2025 MA-PD HEADWINDS Critical component of MA revenue,impacting quality bonus payments and MA rebate revenue.Average Star ratings decreased on average in payment year 2024 as adjustments made for the COVID-19 PHE

8、expired.Payment year 2025 saw another decrease in average Star ratings driven by methodological changes to the Star rating calculation.More changes are on the way.7MA-PD Headwinds Composite MA Payment Rate ChangeNote:Limited to benchmark changes,Star rating impacts,and risk score model and normaliza

9、tion impacts estimated in the 2020-2025 Rate Announcements and 2026 Advance Notice.Does not include other potential impacts to MA revenue such as MA coding trend.Combined impact of benchmark change,Star ratings,and risk score model pushed expected rate change negativeSTATE OF THE 2025 MEDICARE ADVAN

10、TAGE INDUSTRY:A YEAR OF CHANGE|2025 MA-PD HEADWINDS8MA-PD Headwinds Part D Plan LiabilitySource:https:/ IRA brought changes to the Part D benefit design that increased plan liabilitySTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|2025 MA-PD HEADWINDS Significant changes to Part D plan

11、 design including removal of the coverage gap phase,implementation of a maximum out-of-pocket,and reduction of federal reinsurance,among others.Increase in plan liability,particularly for highest-cost patients.Majority of plan revenue shifts to risk-adjusted direct subsidy.Impact will vary by plan a

12、nd could be negative,positive,or neutral.75%Plan Liability25%Member Coinsurance25%Member Coinsurance10%Manufacturer Liability*65%Plan LiabilityDeductible PhaseInitial Coverage PhaseApplicable*Non-Applicable100%Member Coinsurance60%Plan Liability40%GovernmentReinsurance60%Plan LiabilityCatastrophic P

13、haseApplicableNon-Applicable20%GovernmentReinsurance20%ManufacturerLiability*DeductibleMOOP2025 Defined Standard Benefit Design*Applicable is defined as drugs for which the manufacturer discount program applies;generally,brand drugs.*Specified and specified small manufacturers will have a reduced li

14、ability in 2025,ultimately grading to full liability by 2031.9Material challenges and market disruption will challenge MAOsRisk score coding practices also continue to face scrutiny,alongside the new Part C model becoming fully phased in for 2026.Utilization management(UM)is under fire given public

15、dialogue,which may impact ability to manage certain servicesDespite proposed MA payment rates going up in 2026,this continues to be a tough market with elevated trends across the industryAdministrative pressures are increasing CMS is implementing more oversight of marketing,benefit utilization,prior

16、 authorization,and encounter data activitiesSupplemental benefits are changing in a way we havent seen in many years,requiring data-driven introspective review to succeed Part D benefits changed materially,and carriers will need to evaluate emerging,disruptive strategies introduced in 2025Leadership

17、 in many MAOs are facing challenges on a multi-faceted frontSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|2025 MA-PD HEADWINDSPart C Benefit Changes11In 2025,the market pulled back on richness of plan offeringsOrganizations are reacting to margin headwinds by reducing the overall va

18、lue supplemental benefits provide“Table Stakes”benefits were not eliminated,but the richness of the offering was reduced Prevalence remains high Limits decreased in aggregate Cash-like benefits were most often reduced in value(OTC,Food cards,etc.)Reduction in offering of“low value”supplemental benef

19、its Items like RAT,Home-based Palliative Care,and Support for Caregivers TBC impacts remain top of mind Dental is the only major supplemental benefit which impacts TBC Some plans chose to reduce benefits with no impact on TBC,for example OTC richness was decreasedIn reviewing the landscape of Part C

20、 supplemental benefit offerings,the following statements applySTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGES12MA-PD Part C Benefit ChangesNational carriers mostly pursued leaner Part C benefit designs,with increases in In-Network MOOPs.Key Part C Benefit Trends

21、Many of the largest national carriers increased their In-Network MOOPs in 2025.The increase in MOOPs was accompanied by other benefit cuts,particularly in supplemental benefits,in 2025.MA headwinds and an uptick in utilization likely led to carriers making these changes.Average 2024 vs.2025 In-Netwo

22、rk MOOPsFor National Carrier General Enrollment Plans11The 2025 member-weighted averages are calculated prior to 2025 open enrollment,use September 2024 membership,and account for cross-walked plans.The 2024 member-weighted averages are calculated after 2024 open enrollment and use February 2024 mem

23、bership.1Source:Milliman MACVAT;https:/ took differing approaches to addressing benefit cuts in 2025,so a local market review is critical.STATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGES13Impacts on Revenue Pressures are being felt throughout the MA landscapeSour

24、ce:https:/ enrollment plans are reducing the value provided to members,as seen through the Milliman MACVAT lensKey InsightsAverage total value added,with significant growth from 2022 to 2023 and stability from 2023 to 2024,decreased almost$16 PMPM from 2024 to 2025.National carriers notably scaling

25、back benefits contributes to much of the decreases in benefit value and value added,given these comparisons are market averages.Multiple national organizations have discussed margin pressures on recent earnings calls and is likely driving the observed degradation of benefits.This substantial value a

26、dded decline in the MA market is driven by leaner MA plan benefit offerings in 2025 paired with level member(Part C+Part D)premiums$22.35$0.62($15.94)($2.79)($1.14)($0.44)$2.38$2.11$2.52$3.42($0.91)($7.98)$13.76($1.72)($10.92)($20.00)($15.00)($10.00)($5.00)$0.00$5.00$10.00$15.00$20.00$25.002022 to 2

27、0232023 to 20242024 to 2025Part C Benefit ValuePart D Benefit ValuePart B Premium BuydownTotal Member Premium(C+D)Total Value AddedSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGES14Impacts on Revenue Pressures are being felt throughout the MA landscapeSource:http

28、s:/ are reducing the value provided to members,as seen through the Milliman MACVAT lensKey InsightsGrowth in D-SNP value added changed course considerably in 2025-from 2024 to 2025,the total value added of D-SNP MA plans shrunk by about$15 PMPM,mainly due to benefit degradations in the Part C(medica

29、l)benefit.Value added decreases are primarily driven by reductions to Part C supplemental benefits.Multiple national organizations have discussed margin pressures on recent earnings calls and is likely driving the observed degradation of benefits.Part D value added growth is slowing considerably.$27

30、.08$43.66($15.12)($0.03)$0.00$0.44$1.31$0.52$0.03$25.78$43.10($15.59)($20.00)($10.00)$0.00$10.00$20.00$30.00$40.00$50.002022 to 20232023 to 20242024 to 2025Part C Benefit ValuePart D Benefit ValuePart B Premium BuydownTotal Value AddedSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PA

31、RT C BENEFIT CHANGES15Part C Benefit Changes:Spotlight on DentalRapid expansion over past several years in:Proportion of people enrolled in plans with dental MSBScope of covered services of dental MSBDollar benefit limits for dental MSBSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|P

32、ART C BENEFIT CHANGESCoupled with:Dental highlighted as an important benefit in enrollmentIncreasing beneficiary awareness of dental benefitIncreasing provider awareness of dental benefitResult:significant increases in benefit utilization and cost16Part C Benefit Changes:Spotlight on DentalSource:20

33、24 Milliman MACVAT Proportion of Enrollment in MA Comprehensive Dental MSB Offering Various Covered ServicesSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGES Steady coverage of restorations(fillings)Dramatic upward trend in endodontics,periodontics,and prosthodont

34、ics through 2023,leveling off in 202417Part C Benefit Changes:Spotlight on DentalOrganizations are reacting to margin headwinds by reducing the overall value supplemental benefits provide.For dental,we see:Increased membership in preventive&diagnostic only plans(with no comprehensive dental)4%in 202

35、4,9%in 2025Comprehensive benefit may be offered as OSBMostly general enrollment plansContinued rationalization of comprehensive dental coverage Scope of covered services broadly at or below 2024 levels PBP category enhancements will enable better tracking in 2025 forwardFine-tuning plan details Cove

36、r only some services in PBP category(“checking the box”rather than covering everything)Frequency limitations Institute/reduce dollar benefit limits Prior authorization,other UM2025 First LookSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGESSource:2025 Milliman MAC

37、VAT 18Combined/Flex Benefits Continue to Increase for 2025 for all Plan Types Prevalence of these benefits increased into 2025 Allows plans to still get the“checkbox”of offering the benefit,but by combining it with other benefits of different types under a limit,MAOs may be able to reduce overall fi

38、nancial exposure Typically need to work with a vendor to facilitate Proposed 2026 rule discusses prohibiting MAOs from marketing the dollar value of benefits such as these offered through debit cards,as well as how the benefit is administeredPercent of Enrollees in Plans offering Flexible Benefit Ty

39、pesSource:2025 Milliman MACVAT,https:/public-inspection.federalregister.gov/2024-27939.pdfNote:Combined/Flex are defined here as packages offering a combination of multiple,unrelated,benefits under the same dollar limit,and exclude dental only packages(as shared dental limits need to be entered as a

40、 Combined/Flex package per CMS guidance).General EnrollmentD-SNP45%202449%202587%91%I-SNP59%63%76%93%C-SNPSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGES19Supplemental Benefit TrendsSource:2025 Milliman MACVAT Part B Premium Buydown General Enrollment Plans and

41、D-SNPsMA-PD plans offering to buydown Part B premiums have increased significantly from 2024 to 2025,driven largely by plans with buydowns of$3 or lessThe large increase in Part B buydowns in 2025 coincides with CMSs new rebate reallocation rules,likely leading more plans than usual to offer a small

42、 Part B buydown66 plans offered in 2025 cover the full 2024 Part B premium,which decreased from 71 plans in 2024 that bid at the maximum allowable Part B premium buydownNationwide carriers have been driving the prevalence of Part B premium buydowns over the years0.1%0.1%0.2%37.5%0%5%10%15%20%25%30%3

43、5%40%$0.00$0.05$0.10$0.15$0.20$0.25$0.30$0.35$0.40$0.45$0.502022202320242025Average Part B Premium Buydown(PMPM)D-SNP Part B Premium Buydowns$4.82$7.19$9.31$11.83 6.9%9.0%10.8%31.2%0%5%10%15%20%25%30%35%$0.00$2.00$4.00$6.00$8.00$10.00$12.00$14.002022202320242025Average Part B Premium Buydown(PMPM)Ge

44、neral Enrollment Part B Premium BuydownsSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGES20How can MAOs position themselves well for 2026?Key supplemental benefit strategy considerations in light of competitive landscape changesUnderstand market implications of lo

45、oming 2026 changes:Key implications include:Drug price negotiationsStar rating methodology changesMid-year benefit notification impactsChange in member shopping habitsMarket reactions to competitor 2026 strategies Focus on local market implicationsDevelop rational and strategic benefit designs:Loomi

46、ng 2026 changes could prove a tailwind for some carriers Capitalize on opportunities to align or exceed competitors Understand how certain benefits are utilized in the marketAnalyze which benefit cuts or additions align with strategic direction:Perform member elasticity studies of certain benefit of

47、ferings Evaluate emerging 2025 population and identify selection risk Learn from national carriers 2024 financial performance and resulting 2025 benefit changesBe prepared for another year of Direct Subsidy and LIPSA uncertainty:Large 2025 market disruption may result in significant market share cha

48、nges by carrier Drug price negotiation impacts PDP bidding behavior response from demonstration program Be prepared for benefit options for both June and August bidsMilliman has tools,SMEs,and deep market expertise that can assist Clients in better understanding where there may be areas of opportuni

49、ty with respect to the above considerationsSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART C BENEFIT CHANGESPart D Benefit Changes22MA-PD Part D Benefit ChangesNational carriers mostly pursued leaner Part D benefit designs,with a large increase in deductibles for brand drugs.Key

50、Part D Benefit TrendsSeveral of the largest national carriers increased their Part D deductibles for brand and specialty drugs materially in 2025.Some national carriers also moved to brand drug coinsurance(T4 for Humana,T3/T4 for CVS,Elevance,and Centene).The Part D benefit design increases risk exp

51、osure for brand and specialty drug users,potentially driving these changes.New benefit accumulation logic causes members to pay much less than$2,000 if offering no deductible and brand drug copays.Average 2024 vs.2025 Part D Deductibles For National Carrier General Enrollment Plans11The 2025 member-

52、weighted averages are calculated prior to 2025 open enrollment,use September 2024 membership,and account for cross-walked plans.The 2024 member-weighted averages are calculated after 2024 open enrollment and use February 2024 membership.1Source:Milliman MACVAT;https:/ OF THE 2025 MEDICARE ADVANTAGE

53、INDUSTRY:A YEAR OF CHANGE|PART D BENEFIT CHANGES23Brand Tier strategy of copay vs.coinsurance Carrier Specific Commentary for most common tier structure on General Enrollment MAPD plans Moved both T3 and T4 to coinsurance in 2025 Maintained T3 on a copay structure,moved T4 to a coinsurance in 2025 M

54、oved T3 to coinsurance in 2025 Was only major MA-PD to move T4 to a coinsurance in 2024 Moved both T3 and T4 to coinsurance in 2025 Kept both T3 and T4 as copay in 2025 Kept both T3 and T4 as copay in 2025Key Insights Copay benefits keep members cost sharing predictable,and on brand medication,is of

55、ten lower out of pocket cost for the member than a coinsurance benefit Those moving to coinsurance on brand tiers are typically doing so in order to prioritize margin and/or to address selection concerns Those keeping copays on their brand tiers are typically doing so to limit member disruption and/

56、or to achieve growthSource:2025 Milliman MACVAT,Medicare Advantage under pressure:How MA-PD plans are responding in 2025STATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART D BENEFIT CHANGES242025 D-SNP VBID Participation(Rx$0 or reduced Part D Cost-sharing)Takeaways All major nationa

57、l carriers had broad participation in 2024,continuing into 2025 Elevances participation rose from 74%in 2024 to 80%in 2025 Participation across the market has grown significantly since 2022 Reduced LIS Part D Cost-Sharing under VBID continued to be“table stakes”for 2025 D-SNP offeringsNote:September

58、 2024 membership cross-walked to 2025 based on the 2025 crosswalk file available from CMS,excluding membership for terminated plansMeasured by lives in participating plansAll OtherCignaCenteneElevanceCVSHumanaUnitedLIS VBIDNon-VBID99%93%98%80%92%57%89%STATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A

59、YEAR OF CHANGE|PART D BENEFIT CHANGES25Relative to 2024,the number of PDPs decreased for 2025,and premium increases were curbed by wide participation in the premium demonstration programNote:Premiums weighted on membership as of September 2024.LI lives are based on the March 2024 LIS membership file

60、Number of PDPs decreases relative to 2024Mutual of Omaha,a nationwide carrier,and three other regional carriers exit the individual PDP market,terminating all plans consisting of about 220,000 membersCVS/Aetna crosswalks both enhanced plans into its basic planUnited crosswalks their second enhanced

61、plan into their first enhanced plan,but retains the AARP Preferred plan nameLIB plans missing benchmark in 2025 contain fewer LI lives than prior years(462K members)63%of potential reassignments are due to United losing eligibility for 9 plans20%of potential reassignments are due to Cigna losing eli

62、gibility for 4 plansWellcare remains under benchmark in nearly all regionsClear Spring Healths forthcoming PDP contract termination will likely lead to additional reassignments(up to 280k LI lives)PDP premiums increase nationwide about$3 on average(7%)from 2024 to 2025Smaller increase than from 2023

63、 to 2024(21%)The voluntary PDP premium stabilization demonstration limits a plans total premium increase year over year to$35Typically,average premium change will decrease after open enrollment as members migrate to lower premium plansSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PA

64、RT D BENEFIT CHANGES26How can MAOs position themselves well for 2026?Key Part D benefit strategy considerations in light of competitive landscape changesEvaluate landscape of brand copays vs.coinsurance:Locally assess the changes in brand cost sharing and deductible levels by competitors Determine i

65、mpact of coinsurance switch to enrollment changes Understand Part C benefit changes amongst competitors retaining a brand copayConsider strategic reactions to loss of$0 LIS VBID:DSNP carriers may strategize new means of offering attractive Part D benefits Predict DSNP member reactions considering lo

66、ss of Part C and D VBIDAnalyze emerging 2025 Part D experience:The 2025 Part D design opened the door for increased selection risk Monitor and evaluate implications of elevated utilization Recognize PDP market disruption and resulting MAPD enrollment transitionsProactively develop a strategy around

67、negotiated drugs:Compare current formulary coverage of 2026 negotiated drugs Evaluate 2026 risk position of elevated utilization on negotiated drugs Strategically think ahead when developing 2026 formulary to consider implications of 2027 negotiationsMilliman has tools,SMEs,and deep market expertise

68、 that can assist Clients in better understanding where there may be areas of opportunity with respect to the above considerationsSTATE OF THE 2025 MEDICARE ADVANTAGE INDUSTRY:A YEAR OF CHANGE|PART D BENEFIT CHANGESQ&A28Thank youJordan C Joanne F Mark F Julia F 29Caveats and LimitationsThese presenta

69、tion slides are for discussion purposes only.They should not be relied upon without benefit of the discussion that accompanied them.They are not to be distributed without approval by Milliman.This presentation and Q&A is not intended to be an actuarial opinion or advice,nor is it intended to be legal advice.Any statements made during the presentation and subsequent Q&A shall not be a representation of Milliman or its views or opinions,but only those of the presenter.