As Medicare’s annual enrollment period proceeds through December 7th, during which beneficiaries can make changes to their Medicare Advantage (MA) and/or Part D coverage, Medicare beneficiaries continue to be bombarded with advertisements and sales pitches, which aim to steer people towards MA plans.
Similar to last year’s Annual Enrollment Period, there continues to be a notable and welcome shift in media coverage of MA plans. Such coverage is no longer unquestioning in its description of Medicare enrollment options, but rather more balanced coverage that explores both the drawbacks as well as the benefits of enrollment in MA plans. As we outlined last year’s “Special Report: Recent Articles and Reports Shed Light on Medicare Advantage Issues” (Oct. 31, 2022), while the deck is still firmly stacked in favor of Medicare Advantage plans and the insurance providers who wish to sell them, we continue to see an increase in news coverage about Medicare, Medicare Advantage, and needed improvements that is more objective, and neutral. We highlight some of these articles, and the issues they raise, below.
More Objective Media Stories re: Coverage Choices
Every year during the Annual Enrollment Period, many media outlets try to educate their readers, listeners or watchers about their Medicare options. As we noted last year, overall these pieces seem to be getting more thorough in their analyses of trade-offs between different options, namely Medicare Advantage v. traditional Medicare. Such articles highlight considerations that MA plan advertising most certainly leaves out, including extensive use of prior authorization, limited provider networks, and limited rights to purchase Medigap plans
One example is the Wall Street Journal’s article “How to Avoid the Costly Pitfalls People Make With Medicare” by Anna Wilde Matthews (Oct 17, 2023), which opens with the statement: “Seniors choosing Medicare coverage often fall into hidden, costly traps that can leave them stranded—and unable to get the healthcare they want. But there are ways to avoid the pitfalls, if you know how.”
The article chronicles the struggles of an MA enrollee who had difficulty seeing his desired providers, and his subsequent struggles trying to purchase a Medigap when he returned to traditional Medicare. The article goes on to highlight common Medicare enrollment pitfalls, including the “Medigap trap” (the limitation on rights to enroll in such plans); “Wrong doctors” (limited MA provider networks); “Paperwork problems” (barriers created by MA prior authorization); “Drug deficits” (the need to review Part D or MA-PD plan formularies each year); and “Biased advice” (beware of ads and toll-free hotlines that look official – instead seek assistance from SHIPs or other unbiased sources).
Two recent New York Times articles similarly delve into such trade-offs. The article titled “Medicare Enrollment Guide: 2024 Edition” by Paula Span (updated Oct 16, 2023) has a section called “What are the downsides to Medicare Advantage?” which includes a discussion of prior authorization and provider networks, and another section highlighting traditional Medicare, which the article notes “also provides somewhat better access to high-quality hospitals and nursing homes.” The article also states: “In general, patients with high needs — people who were frail, limited in activities of daily living or had chronic conditions — were more apt to switch to traditional Medicare than those who were not facing such intense medical demands.”
The second New York Times article titled “How to Cut Through the Ad Blitz During Medicare’s Open Enrollment” by Mark Miller (Oct 14, 2023) analysis of a recent KFF report (discussed in a recent CMA Alert (Sept. 28, 2023)). Miller notes that:
It’s also possible to switch between Medicare Advantage and traditional fee-for-service Medicare during the fall period. Advantage plans offer lower upfront premium costs because of their all-in-one design, but they generally confine you to in-network providers, whom they are free to add and drop. And this year, some hospitals and health systems are dropping Advantage plans, citing problems with denials of care and slow payment.
Miller also describes the limitations in picking up a Medigap policy after being in MA for a time. Promotes the SHIP network.
NPR posted an article describing Medicare choices in the midst of a marketing onslaught in an article titled “Medicare shoppers often face a barrage of unsolicited calls and aggressive ads” by Leslie Walker and Dan Gorenstein (Oct 16, 2023). The authors state:
Research shows that picking a flawed plan can waste seniors’ often limited income, and even lead people to get lower quality care or leave lifesaving prescriptions unfilled. Some of the enrollment choices people make can also be hard and expensive to undo down the road. […] just like with advertisers, people cannot assume brokers are painting a full, unvarnished picture of their coverage options. The details of Medicare Advantage plans are especially important for consumers to understand since they can restrict people’s access to certain doctors and drugs more than traditional Medicare coverage does.
The Washington Post published an article titled “Deciphering the ABCs of Medicare open enrollment” by Michelle Singletary (Oct 13, 2023) which includes a heading titled “Don’t believe the hype of Medicare Advantage commercials” and includes the warning: “But be skeptical about lofty promises” and relays the comments of a reader: “When I first enrolled in Medicare, I selected a Medicare Advantage plan because it seemed less expensive than traditional Medicare,” Richard Timmins of Freeland, Wash., said in an email.
“It was only when I needed care that I encountered the disadvantages of Medicare Advantage, limited networks, requirements for prior approval for almost everything, subsequent delays and denials, and denied payments.”
The article also mentions the restrictions on picking up a Medigap plan after being in a Medicare Advantage plan for more than a year.
Similarly, a KFF Health News article titled “Medicare Enrollees Can Switch Coverage Now. Here’s What’s New and What to Consider.” by Julie Appleby (Oct 16, 2023) references MA plans’ provider networks, and advises prospective enrollees to always check to see if desired providers contract with a given plan; gives a warning about trying to pick up a Medigap plan after leaving MA and returning to traditional Medicare and references SHIP programs.
Further Documentation of Ongoing MA Concerns
In addition to helping Medicare beneficiaries navigate their coverage options during the annual enrollment period, more journalists appear to be focusing on many of the challenges with accessing care in MA plans, including prior authorization and network adequacy, and the growing number of providers, including doctors’ groups and hospitals, that are leaving MA due to frustrations with prior authorization and lower pay.
For example, a recent NBC News article titled “‘Deny, deny, deny’: By rejecting claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs” by Gretchen Morgenson (Oct. 31, 2023) documents how “[p]roblems are emerging” with MA plans, including the submission of “inflated bills to Medicare” and notes MedPAC’s assertion that “it could not conclude Medicare Advantage plans “systematically provide better quality” over regular Medicare.” The articles states:
Even worse, because the plans routinely deny coverage for necessary care, they are threatening the existence of struggling rural hospitals nationwide, CEOs of facilities in six states told NBC News. While the number of older Americans who rely on Medicare Advantage in rural areas continues to rise, these denials force the hospitals to eat the increasing costs of care, causing some to close operations and leave residents without access to treatment.
Noting that “[i]f the government hoped Medicare Advantage plans would reduce the costs of care, that has not been the outcome”, the article highlights how state insurance commissioners “receive many complaints from customers saying they were sold Medicare Advantage plans without understanding their limitations” including being unaware that “their doctors are likely to change under the Medicare Advantage plans.”
While highlighting the high profits made by both health insurance companies and agents/brokers, the article states:
Meanwhile, CEOs of rural nonprofit hospital systems in Arkansas, Colorado, Mississippi, Missouri, South Dakota and Texas told NBC News that Medicare Advantage plans repeatedly refuse to reimburse them for the care they provide. Some 170 rural hospitals are at risk of closing in those six states alone, according to a report from the Center for Healthcare Quality and Payment Reform, a nonprofit advocacy organization.
Citing to a 2022 Office of Inspector General report finding that “the 15 top Medicare Advantage plans denied authorization for 13 percent of claims that had met Medicare rules” the article states that “[e]ven when the plans pay, they reimburse providers far less than traditional Medicare, rural hospital CEOs and doctors told NBC News. The plans are effectively rationing health care, these providers said.”
In an article on the same subject published by USA Today titled “Hospitals, doctors drop private Medicare plans over payment disputes” by Ken Alltucker (Oct. 27, 2023), the reporter chronicles a number of health systems that are no longer taking Medicare Advantage plans, and notes that:
Hospitals that are rejecting private Medicare plans say they don’t reimburse at the same levels as traditional Medicare, delay or deny care through prior authorizations or impose other limitations.
The article focuses on the impact to both providers and beneficiaries, noting that “[a]s health providers such as Scripps Health sever ties with some insurers, consumers are confronted with difficult decisions on how and where to get medical care. Some face the prospect of seeking out-of-network care that might cost more.”
MedPage Today has continued its focus on this issue in an article titled “UNC Health Publicly Threatens to Cancel UnitedHealthcare Contracts” by Cheryl Clark (Oct 13, 2023). Clark explains that the University of North Carolina (UNC) is warning patients and providers that it is on track to leave UnitedHealthcare’s commercial and Medicare Advantage plan networks. Clark quotes a letter from UNC Physicians to patients stating that “‘UnitedHealthcare improperly denies claims and causes unnecessary delays in patient care. This can negatively affect your well-being.’”
Clark concludes her article:
UNC’s threat follows what many think is the start of a national trend of health systems cancelling contracts with insurers who they think don’t play fair. Two weeks ago, two large and prestigious Scripps Health medical groups in San Diego announced they were not extending contracts in 2024 with nearly all of their MA plans, leaving 32,000 patients with a choice of leaving their doctors to search for one in another medical group that still accepts MA plans, or enrolling in traditional Medicare in hopes of being healthy enough to qualify for a supplemental plan.
Several other organizations in recent months have also announced an end to their MA contracts, citing similar reasons. It is unknown how many health systems plan to cancel their UnitedHealthcare commercial contracts for employer-sponsored plans.
Several other organizations in recent months have also announced an end to their MA contracts, citing similar reasons. It is unknown how many health systems plan to cancel their UnitedHealthcare commercial contracts for employer-sponsored plans.
Similarly, an article posted by Becker’s Healthcare titled “Hospitals sour on Medicare Advantage: 8 things to know” by Jakob Emerson (Oct 17, 2023) notes that “With the Medicare open enrollment period underway, some seniors may have fewer provider choices in their respective regions as hospitals and health systems across the country increasingly cut ties with the Medicare Advantage program.”
NPR has also focused on the impact that MA plans have on rural hospitals in an article titled “Medicare Advantage keeps growing. Tiny, rural hospitals say that’s a huge problem” by Sarah Jane Tribble (Oct. 17, 2023). The article notes:
Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.
American Hospital Association Letter re: Prior Authorization
A compelling analysis of the problems of prior authorization is outlined in a letter by the American Hospital Association, as highlighted by Inside Health Policy in an article titled “Stakeholders Press CMS On MA Oversight As Agency Releases Star Ratings” by Bridget Early (Oct 16, 2023). The AHA letter to CMS (dated Oct. 13, 2023), according to Early, “raised concerns that certain MA organizations (MAOs) may not comply with the new regulations and called for rigorous oversight to ensure the enrollment process goes smoothly and any violations are quickly corrected.”
The AHA letter states: “hospitals and health systems nationwide are increasingly concerned about certain MAO [Medicare Advantage organization] policies that restrict or delay patient access to care, while adding cost and burden to the system. […] while the new rules are a critical step forward in advancing patient access and holding MAOs accountable for adhering to federal rules, we believe a heightened level of enforcement and oversight is needed to facilitate meaningful change. We urge the agency to conduct rigorous oversight to enforce the policies and safeguards included in the rule and to ensure that appropriate action is taken in response to any violations” [emphasis in original].
The letter goes on to outline AHA’s concerns about “reports from our members that certain MAOs may not comply with the new regulations. Specifically, as a result of interactions with MAO partners, hospital leaders have heard from some MAOs that they either do not plan to make any changes to their protocols as a result of the new rules or, in contrast, have made changes to their denial letter terminology or procedures in a way that appears to circumvent the intent of the new rules.”
Among the concerns raised are that plans seem to be side-stepping CMS rules regarding medical necessity determinations by characterizing plan reviews as focused on payment; AHA provides an example of language in a denial letter received by one of their members noting that “the use of language stating that denials of inpatient care are payment reviews and not level of care reviews, medical necessity audits or organizational determinations — even when the audit is explicitly evaluating whether the inpatient level of care as appropriate and results in the care delivered being downgraded to observation status and payment.”
AHA also highlights that “Hospitals and health systems that are contracted with MAOs have no streamlined mechanisms for providers to report suspected violations of federal rules to CMS or other appropriate oversight entities.”
The letter states: “To date, the non-interference clause has limited CMS involvement in many aspects of MAO compliance that are broadly considered contractual issues, as was the case in the preceding example. However, we increasingly believe this approach has allowed certain MAOs to circumvent CMS rules without accountability on issues that are not, in fact, contractual in nature, but directly and detrimentally affect patient care and access.”
Congressional Action
The scale of some of these problems have been so vast that Congress has had to take notice. As discussed in a previous CMA Alert (Oct 19, 2023), the Senate Finance Committee recently held a hearing entitled “Medicare Advantage Annual Enrollment: Cracking Down on Deceptive Practices and Improving Senior Experiences” on October 18, 2023.
Following the hearing, the Senate Finance Committee Democrats sent a letter to CMS on October 25, 2023, urging further action concerning deceptive Medicare Advantage marketing scams. The letter urges the agency to limit third-party marketing organizations (TPMOs) from selling individuals’ personal information; require MA plans to provide a broker’s identity when a beneficiary submits an enrollment related complaint through Medicare’s complaint tracking system; increase transparency around marketing spending in the MA program; and “review the agent and broker compensation model to ensure a level playing field for plan participants in the MA program.”
The Center for Medicare Advocacy agrees with these proposals, but more needs to be done by both Congress and CMS in order to meaningfully address MA marketing misconduct, as outlined in our submitted written testimony to the Committee, available here.
Some of these issues are also getting attention in the House of Representatives. On November 1, 2023, Energy & Commerce Committee Ranking Member Frank Pallone (D-NJ) joined with Ways & Means Committee Ranking Member Richard Neal (D-MA) in sending a letter to CMS “urging increased oversight and transparency of broker participation and compensation in the Medicare Advantage market.”
Conclusion While there is still no adequate counterweight to the staggering amount of Medicare Advantage advertising during the annual enrollment period and during the year that paints the MA program only in a favorable light, more journalists are trying to provide the public with a more full picture of the various trade-offs surrounding Medicare coverage choices in general, and some of the drawbacks to MA enrollment in particular. Congress is beginning to take notice of these issues, but it is long past time for policymakers to take concrete
November 2, 2023 – D. Lipschutz