Medicare Advantage Updates
1. New York Times Article Highlights Problems with Medicare Advantage Prior Authorization
A recent New York Times article titled “When ‘Prior Authorization’ Becomes a Medical Roadblock” by Paula Span (May 25, 2024), which references the work of the Center for Medicare Advocacy, states that:
Traditional Medicare rarely requires so-called prior authorization for services. But virtually all Medicare Advantage plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health.
Citing the Medicare Payment Advisory Commission (MedPAC) for the proposition that “Medicare Advantage has never saved money for the Medicare program”, and reports from the Office of Inspector General and KFF re: MA plans’ use of prior authorization, Span states that “Insurers can save money by restricting coverage; they’ve also learned that few beneficiaries challenge denials, even though they are entitled to and usually win when they do.”
2. Agent/Brokers Sue to Block Changes to their Payment for Selling Medicare Plans
As discussed in a recent Inside Health Policy articled titled “Brokers, TPMOs Sue Over Fixed Fee, Contract Restrictions In Final MA, Part D Reg” by Amy Lotven (May 23, 2024),
Groups representing agents and brokers and third-party marketing organizations (TPMOs) are asking a federal district court in Texas to block CMS from implementing provisions in the recently finalized Medicare Advantage and Part D rule that redefine how the industry is compensated by establishing a new fixed fee for enrollment and administrative services as well as restricting certain contracts, which the plaintiffs say violates the Administrative Procedure Act in multiple ways.
The article notes that “[t]he administration claims the rule will mitigate incentives to steer consumers into MA or Part D plans that may benefit a brokers’ financial interest over patients’ needs.” The Center for Medicare Advocacy strongly agrees with CMS’ intent behind this rule, and, as noted in our comments to the proposed rule that included these provisions, we urged the agency to go even further by making commissions for Medicare Advantage and Part D plans equal across the board with one uniform commission for Part D and MA products alike.
Medicaid Updates
Minnesota Blocks For-Profit Insurers from State Medicaid Program
As reported in a Minnesota Star-Tribune article titled “For-profit HMOs will, again, be blocked from Minnesota’s Medicaid program” by Christopher Snowbeck (May 28, 2024), the state’s legislature restored what until 2017 had been a 40-year ban on for-profit HMOs in Minnesota’s Medicaid program. As noted in the article, “UnitedHealthcare, which is the nation’s largest health insurer, is the only for-profit HMO currently in Minnesota Medicaid (known as Medical Assistance) and a related program called MinnesotaCare.”
May 30, 2024 – D. Lipschutz