by Jeff Lagasse, Editor, Healthcare Finance News
The Centers for Medicare and Medicaid Services is looking for ways to make Medicare Advantage better. The agency has released a Request for Information seeking public comment on the popular offering, and is seeking input on ways to make it more equitable, affordable and sustainable.
CMS Administrator Chiquita Brooks-LaSure framed the request as part of the agency’s push to advance health equity and expand care access, calling Medicare Advantage plans “essential partners in this work.”
The agency made the request as part of its Strategic Pillars, which prioritize increased engagement with various partners and communities during policy development and implementation.
CMS Deputy Administrator and Director of the Center for Medicare Dr. Meena Seshamani said via statement, “It’s important that CMS engage as many stakeholders as possible to achieve our collective vision of equity, access, quality and affordability.”
Feedback from plans, providers, beneficiary advocates, states, employers and unions, and others will help inform policy development, CMS said.
WHAT’S THE IMPACT
In the Medicare Advantage program – also known as Medicare Part C – Medicare contracts with private insurers that must offer all traditional Medicare services to people with Medicare, and may offer added supplemental benefits, such as vision or dental benefits. Most Medicare Advantage Plans also include prescription drug coverage (Part D).
While the program has proven to be hugely popular among consumers, and insurers are increasingly muscling into the space, there have been criticisms. Some industry experts, for instance, point out that while premiums are lower and sometimes free in MA plans, some beneficiaries with health issues end up paying more over time; as they age and health problems accumulate, care costs them more out of pocket.
Another criticism hinges on prior authorizations. A report published this year by the Office of the Inspector General found that Medicare Advantage Organizations (MAOs) sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the prior authorization requests met Medicare coverage rules.
Examples of healthcare services involved in denials that met Medicare coverage rules included advanced imaging services such as MRIs and stays in postacute facilities such as inpatient rehabilitation facilities.
A separate survey conducted by eHealth in June found that 13% of Medicare Advantage enrollees had a claim or pre-authorization request denied. Those who experienced a self-reported denial of coverage included many who were declined for benefits, such as dental and vision care, which Medicare usually doesn’t cover.
However, 15% of those who had a claim or pre-authorization request initially denied said it was eventually paid by their insurer
THE LARGER TREND
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.
Still, insurers are expanding their Medicare Advantage offerings at a decent clip, with Humana announcing last fall it would debut a new Medicare Advantage preferred provider organization (PPO) plan in 37 rural counties in North Carolina in response to market demand in the eastern part of the state.
Around the same time, UnitedHealthcare, which already has significant market control with its MA plans, said it will strengthen its foothold in the space by expanding its MA plans in 2022, adding a potential 3.1 million members and reaching 94% of Medicare-eligible consumers in the U.S.
Medicare Advantage plan payments are expected to get an 8.5% revenue increase for 2023. This is an increase over the 7.98% proposed in the February advance notice. The 2023 growth rate is set at 4.88%.