In an effort to foster informed decision-making by Medicare beneficiaries about their coverage options, the Center for Medicare Advocacy has long tried to highlight the trade-offs of enrolling in Medicare Advantage (MA) plans. In the past, media attention on MA plans was usually limited to the time period around the annual enrollment period, and often did not adequately inform people of some of the drawbacks of MA enrollment, including extensive use of prior authorization and limited provider networks. Over the last couple of years, as MA enrollment grew to now exceed over half of all Medicare beneficiaries, problems faced by many MA enrollees are getting harder to ignore. Thankfully, many journalists are providing a more complete picture for the public, including outside the annual enrollment period.
For example, the Washington Post’s “Health 202” blog recently posted “Medicare Advantage is popular, but some beneficiaries feel buyer’s remorse” by Sarah Jane Tribble (Jan. 23, 2024), which describes how enrollment in MA is “booming” then states:
But a little-known fact: Once you’re in a Medicare Advantage plan, you may not be able to get out.
The post goes on to describe the difficulty of later purchasing a Medigap (Medicare supplemental insurance) policy after being in an MA plan: “unless you sign up for Medigap soon after you’re first eligible, insurers can often deny coverage or charge steeper premiums based on preexisting conditions.” Tribble notes:
The inability of most Advantage enrollees to switch back to traditional Medicare has been a known concern for years in policy circles, said Tricia Neuman, executive director of KFF’s Program on Medicare Policy.
One solution under discussion, she said, is putting a limit on out-of-pocket spending under traditional Medicare. That would increase federal spending on the program and might offset the need to increase Medigap premiums when beneficiaries enroll.
The post also discusses another possible policy solution: allowing “beneficiaries to enroll in Medigap during specific enrollment periods each year without facing rejection for preexisting conditions”.
This Washington Post article is a follow up to a story by Tribble for NPR titled “Older Americans say they feel trapped in Medicare Advantage plans” (Jan. 7, 2024), which also discusses the difficulty of leaving MA plans and picking up a Medigap, and interviews an MA enrollee with melanoma who faced delays obtaining care, and who “thinks getting care using traditional Medicare would have been faster and easier”. This MA enrollee concluded that “You can get screwed if you’re on Medicare Advantage. The advantage kind of disappears once you need them.”
Another recent example of increased media scrutiny appeared in Newsweek in an article titled “Seniors Stuck in Medicare Advantage Nightmare: ‘Designed to Confuse’ Us” by Suzzane Blake (Jan. 16, 2024). Blake notes that “A growing number of Americans are finding insufficient coverage options or jaw-dropping medical bills after unknowingly signing up for Medicare Advantage.”
One broker quoted in the articled opined:
“Imagine foregoing your original Medicare you paid your entire life into for gym membership,” Brandon Selfors, a Medicare broker and the founder of Tampa-based Bridge Insurance. “Sounds ridiculous but that is over half of seniors in the U.S. who traded their birthright for a privatized plan.”
“These plans are pushed too quickly on seniors who only have seven months to make a potentially life-altering decision.”
The article also quotes a retired pharmacist from Missouri who “said she’s seen it time and time again. While elderly patients generally enjoy their Medicare Advantage plans while healthy, it takes a turn for the worse when their health begins to decline.”
Trade press or industry-specific media also continues to cover some of the challenges posed by MA plans for both providers and beneficiaries. For example, MedPage Today, which covers clinical news relevant to a range of medical specialties, recently published an article titled “MedPAC Report on Medicare Advantage Growth, High Costs Generates Kerfuffle” by Cheryl Clark (Jan. 16, 2024) with the subheading: “Commissioners reveal growing unease with MA practices: Not the “glowing success” everybody says”. The article references a report generated by the Medicare Payment Advisory Commission (MedPAC), noting that:
According to the report, 52% of beneficiaries — 31.6 million people — are now enrolled in MA plans, up from 26% in 2010, a fact that prompted many commissioners to note a “sense of urgency” that aspects of the MA program have gotten out of control.
The article states that the MedPAC report highlights:
growing concerns with the rapidly increasing amounts of Medicare funds now flowing to MA plans. The slides showed that MA plan “coding intensity” and “favorable selection” increased spending to MA plans — $82 billion in 2023 alone — above what Medicare paid for care to fee-for-service beneficiaries.
The article noted that while one MedPAC commissioner took issue with the report, several commissioners came to the report’s defense and:
Many also chimed in with a wide array of adjacent frustrations they’ve heard about MA from providers and patients dealing with narrow networks, prior authorization practices that delay or deny care, and extravagant broker commissions that result in steering confused seniors into plans without their understanding of what they might be giving up.
Highlighting recent research about MA networks, Health Payer Specialist published an article titled “Medicare Advantage Plans Restrict Access to Top Cancer Care” by Gale Scott (Jan. 22, 2024), which states:
Most MA plans do not have a top-rated center in their networks, a study by Brown University researchers finds. Even when there is, 41% of plans exclude that top center from their networks, David Meyers and colleagues note in a study, “Comparison of the Use of Top-Ranked Cancer Hospitals between Medicare Advantage and Traditional Medicare,” published in the American Journal of Managed Care.
The article further quotes the researchers: “‘It is important for MA enrollees to understand the consequences of choosing plans that restrict the network of care and access to high-quality providers, particularly for complex cancer care,’ the Brown researchers said.”
Tracking health insurance industry profits can reveal that when MA plans provide more care than they expected to, it can impact their bottom line. For example, a Fierce Healthcare article titled “Payer stocks skid as Humana slashes 2023 outlook amid elevated utilization” by Paige Minemyer (Jan 18, 2024) noted that “Amid a surge in utilization and disappointing results in the annual enrollment period, Humana lowered its outlook for 2023, according to a new filing.” The article noted: “Humana said in the filing that the utilization spike included higher-than-expected inpatient care use in November and December alongside a continued trend of rising utilization in outpatient services.”
The Medicare regulator – the Centers for Medicare & Medicaid Services (CMS) – has made strides in trying to address problems that MA enrollees face, including rampant prior authorization and marketing misconduct. As referenced above, there have been some congressional hearings focusing on some of these issues. However, in order to ensure that MA enrollees truly have access to affordable, medically necessary care, much more action is required by both CMS and Congress.
In the meantime, as discussed in a recent CMA Alert, people who began 2024 enrolled in a Medicare Advantage (MA) plan have an additional opportunity to switch MA plans or disenroll from an MA plan and enroll in traditional Medicare with a Part D prescription drug plan during the first 3 months of the calendar year –ending on March 31st.
For those who remain in an MA plan, as discussed in a separate CMA Alert, remember that existing rules require MA plans to “arrange for and cover any medically necessary covered benefit outside of the plan’s provider network, but at in-network cost sharing, when an in-network provider or benefit is unavailable or inadequate to meet an enrollee’s medical needs.”
January 24, 2024 – D. Lipschutz