How do Medicare Advantage insurers craft population-specific health plans?

Population-specific plans

Insurance companies like SCAN Health Plan and Alignment Health have launched Medicare Advantage plans targeting historically marginalized populations.

SCAN Inspired markets itself as a health maintenance organization (HMO) plan designed by women for women. The plan is offered in Orange County and Los Angeles County in California.

Beneficiaries have access to a care professional who ensures they receive personalized care tailored to their health needs, referred to as a Women’s Health Coach. Beneficiaries with this plan can also receive care at Women’s Centers of Excellence in SCAN’s network, specializing in cardiac care, breast health, pelvic health, and other areas unique to women.

Additionally, SCAN Inspired offers a fitness benefit, zero-dollar estrogen therapy, weight management program reimbursement, and targeted wellness events.

SCAN also introduced an HMO plan for beneficiaries who identify as part of the LGBTQ+ community. The SCAN Affirm plan is a collaboration with a digital health platform and offers beneficiaries care navigation services for a range of healthcare and non-healthcare needs. In addition, members receive lower co-pays on specialty tier drugs, including HIV treatments and gender-affirming hormone treatment.

SCAN Affirm beneficiaries can access virtual behavioral healthcare services, companion care services, and legal services reimbursement.

Alignment Health has focused on plans directed toward specific racial and ethnic minority groups. For example, the payer offers a Medicare Advantage plan designed to serve Hispanic adults. The ONE, or el ÚNICO plan is available in Arizona, California, and Nevada and has a Spanish-speaking provider network, Spanish-speaking service agents, and in-language member materials.

Alignment Health also has the Harmony HMO Plan, which is targeted toward Asian American and Pacific Islander beneficiaries. The plan includes community network providers who offer culture-based alternative treatments and speak native languages. Beneficiaries can access traditional Eastern medicine disciplines like acupuncture and chiropractic services at no additional cost.

Identifying beneficiaries for population-specific plans

Before payers can establish population-specific plans, they must decide which populations to target. Data and analytics strategies are a key part of this step. Collecting data on beneficiaries can help plans identify important needs among their populations.

For example, payers may turn to data from NORC at the University of Chicago. NORC conducts the Medicare Current Beneficiary Survey (MCBS) continuously to gather data that goes beyond what administrative records can provide. The survey collects information directly from beneficiaries and links responses to administrative claims. The survey also gathers data on payment sources for healthcare costs and has a rotating panel representing the Medicare population.

MCBS includes data for all Medicare beneficiaries, including Medicare Advantage members. Health plans can use the survey results to gain insights into beneficiaries’ demographics, self-reported health status, access to care, and satisfaction with care. From there, plans can use the data to narrow down the populations that require targeted assistance in the form of population-specific health plans.

Medicare Advantage plans are also required to report certain enrollment, utilization, payment, and supplemental benefit data to CMS. Since plans already must collect this data, they can use it to inform new plan initiatives directed toward specific populations.

Plans can also choose to conduct their own surveys or assessments on their beneficiaries to better understand their needs.

Once plans have the data they need, analytics models can help them interpret it and project what populations would benefit from targeted health plans. For example, risk stratification models can assess demographic data, health status, and healthcare use to identify beneficiaries at risk for certain health conditions or would benefit from population-specific care.

Choosing which benefits to include

After identifying which populations would benefit from population-specific health plans, the next step is deciding what types of services to offer. Data collection could also be useful for choosing benefits to include in the plans. Plans could deploy additional surveys, this time focusing just on the population on which the plan is centered.

Additionally, Medicare Advantage plans can collaborate with healthcare providers in their networks and community-based organizations to develop benefits. Providers may know from firsthand experience what would be beneficial for their patients, while community organizations can assist with launching programs or offering resources that address healthcare needs and social determinants of health.

Implementing a continuous feedback strategy can help plans ensure that the benefits they choose are having the intended effects on beneficiaries. Ongoing evaluations can also help measure beneficiary satisfaction with the plan and generate ideas for future benefits.

It remains to be seen whether population-specific health plans are improving population health. Future data on these beneficiaries may help stakeholders decide if these Medicare Advantage plans are worth exploring and expanding on or if they will peter out.