Center for Medicare Advocacy

Advancing Access to Medicare and Healthcare

CMA Alert – November 14, 2019

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  1. Medicare is Being Privatized. Where is the Outcry?
  2. Medicare Advantage Plans Impede Access to Care: Case Study #1
  3. Support for Medicare Oral Health Benefits
  4. 2020 Medicare Cost-Sharing Rates Released

Medicare is Being Privatized. Where is the Outcry?

For years, the Center for Medicare Advocacy has warned of wasteful overspending on private Medicare Advantage (MA) plans, the limitations on access to physicians and health care provided by MA, and the difficulties in obtaining the same coverage from the plans as is available in real Medicare. (See Case Study below.)

Despite these efforts, Medicare Advantage continues to be touted by the Administration and myriad advertising campaigns.  Private Medicare Advantage is promoted and invested in far more than real Medicare; beneficiaries and the Medicare program are harmed as a result.

So why does it feel like nobody else has noticed?

This is the central question asked in an excellent piece from Trudy Lieberman last week, in which Lieberman examines an October LA Times Column analyzing the recent Executive Order that rolled back protections in private Medicare Advantage, and increased efforts to push people into those plans. The Center for Medicare Advocacy also responded in detail to the Order.

That column focused on the disparity between the President’s public comments – “Nobody will lay a hand on your Medicare benefits” – versus the Administration’s actions, particularly the Executive Order, which are referred to as “pushing Medicare Advantage assiduously in a way that may lure in seniors for whom these plans are the wrong choice.” Lieberman acknowledges that it is clear that the Administration is “proposing to privatize Medicare” but follows up by raising the troubling fact that:

“There was scant analysis of what the order would do and how it will impact those now on Medicare and those yet to come. The press, for the most part, was AWOL. That’s despite the fact that the changes would affect the kind of coverage beneficiaries would get now and in the future.”

Health care has become a key issue this election season, and some candidates are promoting versions of “Medicare for All” – whether that means Medicare or something new.  However, there needs to be a renewed focus on the threats to the real Medicare program right now. Slowly but surely the program that has supported older people and people with disabilities for decades is being fragmented and sold off to private insurance companies.

Where is the outcry?

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Medicare Advantage Plans Impede Access to Care: Case Study #1

Medicare’s annual open enrollment period (October 15 – December 7), is time for beneficiaries to take stock of their Medicare options for the upcoming calendar year – whether to choose real Medicare (original/traditional) or a private insurance Medicare Advantage (MA) plan.

The Center for Medicare Advocacy (the Center) has developed information, materials, and educational webinars to promote informed choice by beneficiaries. We have heard from a number of beneficiaries, advocates, and providers about their MA experiences. Today we launch a series to highlight one of those first-hand reports. In upcoming CMA Alerts, we will write about other beneficiary, advocate, and provider experiences – all cautionary tales about Medicare Advantage.

We invite you to join this discussion by sending us your MA plan experiences to MedicareAdvantage@MedicareAdvocacy.org.

Case Study 1: MA Plan Prior Authorization Requirements Cause Problems in a Skilled Nursing Facility (SNF) Leading to Patient Re-Hospitalizations[1]

The SNF referenced here is a highly rated, privately owned, non-profit facility with almost 100 beds. The SNF serves traditional Medicare patients for an average of 14 to 21 days per admission. Typically, as long as the SNF documents that a patient has received necessary daily skilled care in the SNF after at least a 3-day inpatient hospital stay, Medicare covers the cost.

In addition to traditional Medicare, the SNF serves patients enrolled in multiple MA plans, but each MA plan typically authorizes SNF patient services for only 7 days, which is half to a third of the time an original Medicare patient stays in the SNF. During the 7 day MA plan authorized stay, each MA plan requires the SNF to provide extensive justification for continued services by giving documentation to the MA plan every 3 days for review.

Even when the MA plans allow a patient to receive 7 days of services, and the SNF then provides justification for MA plan patients to remain in the SNF longer than 7 days, multiple appeals to MA plans rarely result in additional authorized days. The SNF finds an occasional authorization by an MA plan beyond 7 days is clinically random – a patient they believe clearly needs continued services is denied, while a patient who is doing relatively better may be approved for several additional days. Further appeals for additional days, made to a Medicare Independent (medical) Review Entity (IRE, in this case KEPRO) are also frequently denied. Even when approved, MA plans do not always pay the SNF. One appeal to a Medicare Administrative Law Judge for a patient who was in the SNF from January 5, 2019 through January 31, 2019, was approved. On June 6, 2019, the judge ordered the MA plan to pay the SNF for the entire January stay. The MA plan has not paid the SNF for the approved services.

Last week 3 MA plan patients were discharged from the SNF although the SNF believed each patient was discharged prematurely. Each patient had only been authorized for 7 days of services at the SNF. Appeals for additional days in the SNF were unsuccessful. Without access to medically skilled care, all 3 patients have since been re-admitted to acute care hospitals.

The SNF is grappling with how to best provide care to MA plan patients. CMA has advised continued Medicare appeals by the SNF when it believes discharges are medically premature and continue to be Medicare coverable.

MA plans should not be allowed to override the expertise of the treating physician and the SNF at the expense of the patient’s health. MA plans should not be allowed to use prior authorization as a vehicle to deny necessary care.

Next Case

Case #2: Family History of Colon Cancer Should Increase the Frequency of Colonoscopies, but Ultimately the MA Plan, not the Treating Doctor, May Determine When Procedures Will Occur

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[1] Factual recount as reported to CMA on October 29, 2019. The names of the beneficiaries, provider, and MA plans have been withheld for privacy purposes.

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Support for Medicare Oral Health Benefits

The Center for Medicare Advocacy is pleased that oral health in Medicare is gaining attention and focus, as evidenced by the number of Congressional bills introduced this year that would add dental benefits to the Medicare program. Among them are the Medicare Dental Benefit Act of 2019 (S.22/H.R. 2951), the Medicare and Medicaid Dental, Vision, and Hearing Benefit Act of 2019 (S. 1423), and the Medicare Dental, Vision, and Hearing Benefit Act of 2019 (H.R. 1393). The Center believes the Medicare Dental Act of 2019 (H.R. 4650) would be an important step toward providing comprehensive oral health coverage for all Medicare beneficiaries. The addition of a comprehensive dental/oral health benefit would go a long way to improve the overall health and well-being of older persons and people with disabilities. It is among the top changes that beneficiaries wish to see in the Medicare program.

In the interim, a broad coalition of medical associations and societies, public health and disease organizations, and consumer and patient advocacy groups, has also been urging the Medicare agency to expand its policy to cover medically necessary oral/dental treatments. Unresolved oral disease may, for example, actually prevent or delay treatment, or seriously complicate outcomes for patients who require kidney transplants or treatment for leukemia/lymphoma or head and neck cancer, as well as for those needing joint replacements or who have uncontrolled diabetes.  The difficulty of affording dental and oral health care, experienced by most Medicare beneficiaries, may thus hinder management of major underlying health conditions. There has been a growing recognition for many years now that the glaring lack of coverage in this area must be addressed.

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2020 Medicare Cost-Sharing Rates Released

On November 8, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.

Each year, Medicare premiums, deductibles, and copayment rates are adjusted according to the Social Security Act. For 2020, the cost-sharing amounts for both Medicare Part A and Medicare Part B are higher than the 2019 amounts.

Since 2007, a beneficiary’s Part B monthly premium has been based on his or her income. Increased income-related monthly adjustment amounts (IRMAA) affect roughly 7 percent of people with Medicare Part B. The Part B total premiums for high income beneficiaries have also increased for 2020.

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