Skip to main content

Anthem, UnitedHealthcare MA Plans Sanctioned for Missing MLR Threshold

Analysis  |  By John Commins  
   September 20, 2021

When a Medicare Advantage plan fails for three straight years to meet the 85% threshold, CMS must suspend them from accepting new enrollees for the next contract year.

Four Medicare Advantage plans affiliated with UnitedHealthcare and Anthem, Inc. have been barred from enrolling new members until 2023 after failing to meet the 85% medical loss ratio threshold for paying benefits, the Centers for Medicare & Medicaid Services says.

The medical loss ratio, mandated by the Social Security Act, is applicable to all Medicare Advantage plans. When an MA plan fails for three straight years to meet that 85% threshold, CMS must suspend them from accepting new enrollees for the next contract year. 

The UHC plans affected by the suspensions are: UHC of the Midwest (MLR in 2020 of 84.5%), with a footprint in Missouri, Kansas, Nebraska, Iowa; UHC of New Mexico (MLR 84.9%); and UHC of Arkansas (MLR 79.8%). The enrollment suspensions affected about 80,000 of UHC's 7.5 million Medicare Advantage enrollees, the Minnetonka, Minnesota-based payer confirmed.

In a statement to the media, UHC said it "spends at least 85% of the premiums we take in on care for the people we serve."

"In a few markets, we were not able to do that because so many of our members deferred going to get care due to COVID-19. As a result, we can’t enroll any new members in a few local plans until 2023 when we expect care patterns to be at more normal levels," the payer said.

Existing members will not be affected by the suspension, UHC said, adding that it would "continue to offer alternative plan options for people who want to choose a new UnitedHealthcare plan in these select markets."

Also suspended was Indianapolis-based Anthem, Inc.'s MMM Healthcare, purchased as part of MMM Holdings LLC, in June from InovaCare. MMM Healthcare is Puerto Rico's largest MA plan, with more than 260,000 enrollees. CMS said the plan had a MLR of 77% in 2020.

In a statement to the media, Anthem stressed that the suspension "does not impact any of MMM Healthcare's other Medicare Advantage plans nor any other Anthem-affiliated health plan."

"Anthem will continue to invest in our health plans to ensure our members have access to high-quality healthcare services. We will also work with MMM Healthcare and CMS to address the agency’s concerns," Anthem said.

If the plans can document that they have achieved a medical loss ratio of at least 85% in 2021, they will be allowed to resume enrollments effective January 1, 2023.

Both payers may appeal the suspensions, but neither indicated that it would. 

“UnitedHealthcare spends at least 85% of the premiums we take in on care for the people we serve. In a few markets, we were not able to do that because so many of our members deferred going to get care due to COVID-19.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


KEY TAKEAWAYS

The UHC plans affected by the suspensions are: UHC of the Midwest (MLR in 2020 of 84.5%); UHC of New Mexico (MLR 84.9%); and UHC of Arkansas (MLR 79.8%).

The enrollment suspensions affected about 80,000 of UHC's 7.5 million Medicare Advantage enrollees, the Minnetonka, Minnesota-based payer confirmed.

Also suspended was Indianapolis-based Anthem, Inc.'s MMM Healthcare, purchased as part of MMM Holdings LLC, in June from InovaCare.

MMM Healthcare is Puerto Rico's largest MA plan, with more than 260,000 enrollees. CMS said the plan had a MLR of 77% in 2020.


Get the latest on healthcare leadership in your inbox.