Clover Health expanding Medicare Advantage footprint to new counties, states

Photo: Marko Geber/Getty Images

Clover Health has become the latest insurer to expand its Medicare Advantage footprint, and will push into 13 new counties across three states in 2023: Georgia, South Carolina and Tennessee.

Subject to approval from the Centers for Medicare and Medicaid Services, those eligible for Medicare in these new counties will be able to sign up for Clover's MA plans during the MA Annual Enrollment Period, which runs from October 15 to December 7, with coverage starting on January 1, 2023.

Clover currently offers its MA plans in 209 counties, covering about 85,000 members. The planned expansion will make its MA plans available in 220 counties across eight states: Alabama, Georgia, Mississippi, New Jersey, Pennsylvania, South Carolina, Tennessee and Texas.

However, Clover will be exiting two of its smaller markets, the counties of El Paso, Texas and Pima, Arizona. The company attributed this to a focus on "sustainable membership growth."

WHAT'S THE IMPACT?

In Georgia, Clover is aiming to replicate a growth strategy first attempted in New Jersey. In 2022, Clover nearly tripled its membership in Georgia by increasing the breadth of its provider network throughout the state with the addition of dozens of hospitals, health systems and provider partners across the region, aligning about 5,000 new primary care physicians and specialists with its MA network.

In 2023, subject to CMS approval, Clover plans will be available to eligible individuals in 151 of the 159 counties in Georgia, which together contain a market opportunity of nearly 650,000 Medicare eligibles, the company said.

THE LARGER TREND

Clover Health's Medicare Advantage enrollment for 2022 has beaten expectations, increasing 25% over the previous year, the insurer said in January.

This outpaces the overall industry growth average of about 10% year-over-year. Clover began the year already above its 2022 average MA membership guidance of 82,000 lives.

In explaining the reasons behind the MA plan growth, president Andrew Toy credited benefit-rich health plans with low out-of-pocket costs and a philosophy of encouraging beneficiaries to engage with the healthcare system, and their PCP in particular.

Medicare Advantage plan payments are expected to get an 8.5% revenue increase for 2023, an increase over the 7.98% proposed in the February advance notice, CMS said in April. The 2023 growth rate is set at 4.88%, compared to the proposed 4.75% in the 2023 Advance Notice.

MA has been under some scrutiny as of late. Medicare Advantage Organizations sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the prior authorization requests met Medicare coverage rules, according to an April report by the Office of the Inspector General.

Examples of healthcare services involved in denials that met Medicare coverage rules included advanced imaging services such as MRIs and stays in post-acute facilities such as inpatient rehabilitation facilities.

Meanwhile, as enrollment in the Medicare Advantage program grows, so do concerns and uncertainty over the profits providers are reaping and whether "overpayment" is an issue. A report from the Brookings Institution indicates the five major insurers – UnitedHealthcare, Humana, Aetna, Kaiser Permanente and Elevance Health (formerly Anthem) – are padding their bottom lines by disguising profits as costs. 

The report points out that insurers are able to do this because profits accrued through related businesses are not regulated by medical loss ratio requirements.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com