As the Center for Medicare Advocacy (the Center) has highlighted in past years, during the Medicare Annual Election Period (AEP), when individuals can enroll in traditional Medicare and change or disenroll from Medicare Advantage (MA) and Part D plans, health insurance companies blanket the airwaves, internet and print to compete for attention and sell their products. These efforts inevitably paint Medicare Advantage in a light most favorable, highlight all of the plans’ new bells and whistles, and ignore most of the crucial considerations that prospective enrollees must weigh, including restricted networks, prior authorization for services, and other trade-offs of enrolling in an MA plan. This advertising onslaught, combined with the efforts of many agents and brokers primed – and financially driven – to sell MA products above all others, is clearly biased and bent toward pushing people to MA plans. As discussed in a recent CMA Alert (Sept. 28, 2023), recent reports from KFF and the Commonwealth Fund underscore the pitfalls of navigating Medicare enrollment choices. Unfortunately, there is no current counterweight to insurance industry advertising,.
These reports also highlight that few people rely on Medicare’s own materials to make their coverage decisions. Nonetheless, materials from the Medicare program itself, at the very least, should be straightforward and unbiased in their presentation of Medicare coverage options. As the we have previously written, starting in the Fall of 2017, in a marked change from previous practice, the Centers for Medicare & Medicaid Services’ (CMS) outreach and enrollment materials actively promoted enrollment in private Medicare Advantage (MA) plans, while downplaying the drawbacks of such plans, and omitting key information. At the same time, these materials – including revisions to several editions of Medicare & You, online comparison tools (including the Medicare Plan Finder and associated materials), and education and outreach materials – tended to downplay (or in the case of some email campaigns, entirely leave out), the option of traditional/Original Medicare. Instead of objectively presenting enrollment options, some of this material went as far as encouraging beneficiaries to choose a private MA plan over traditional Medicare. In an Addendum to a Center for Medicare Advocacy report issued in September 2021, we included a catalogue of such bias in Medicare materials at that time.
In the last few years, the Medicare agency’s own materials have begun to return to a more objective stance, but they still offer incomplete information and over-promotion of MA plans. For example, last year we noted some of these improvements as well as gaps that still needed to be filled in our “Special Report | Recent Articles and Reports Shed Light on Medicare Advantage Issues” (Oct. 31, 2022). As discussed below, there are further improvements this year in such materials, but much more is needed.
Medicare & You 2024
The Medicare & You Handbook is described on its cover page as the “official U.S. government Medicare Handbook” and is updated annually and mailed (or emailed) to all Medicare households. Along with a number of other stakeholders, the Center has provided feedback on drafts of annual updates to the book, and has focused, among other things, on the accuracy of information relating to coverage options in Medicare and bias toward the Medicare Advantage program. As noted in previous reviews of the Handbook, our concerns have included how some elements inherent to the MA program are described, including:
- Access to care limitations due to limited provider networks;
- Extensive use of prior authorization by MA plans;
- Out-of-pocket costs incurred prior to the out-of-pocket limit, and:
- Supplemental benefits that are unstandardized and might not be available to all enrollees in a given plan.
See, for example, our analysis of the 2023 Handbook in our CMA Alert (Sept. 28, 2022).
As noted in our previous analyses, the charts comparing Medicare Advantage and traditional/Original Medicare at the beginning of the Handbook are particularly important as that section of the book is what readers are most likely to pay attention to. Because of its brevity, that section is most susceptible to improper shortcuts or abbreviations of critical information. Further, changes and distinctions in language that may, at first glance, appear to be subtle, can significantly alter the meaning and interpretation of certain concepts, such as using the word “many” vs. “most.” The Handbook has significantly improved over the last few years with respect to a more objective presentation of information, but it still requires work. Below are some (but certainly not all) of our concerns about language in the 2024 Handbook.
Here are a few comments about the comparison charts at the beginning of the Handbook (at pp. 9-12):
- Under the “Your Medicare Options” chart on page 10 – “Medicare Advantage” column – the draft 2024 version said “In most cases, you can only use doctors who are in the plan’s network” – the final version changed “most” to “many” and did not include advocates’ suggestion that provider networks are usually limited to your local geographic area (although on p. 11 language does state that “In many cases, you can only use doctors and other providers who are in the plan’s network and service area (for non-emergency care) [emphasis in original]”. This “most” vs. “many” distinction is important – as of 2022, almost 60% of all MA enrollees were in HMOs that usually restrict access to only network providers (as opposed to roughly 40% who were in PPOs, that usually do allow access to out-of-network providers, but usually with higher cost-sharing).
- On page 10, under “Medicare Advantage” draft language for 2024 said “Plans may have lower out-of-pocket costs than Original Medicare, but may have an additional premium.” The final version followed suggestions of advocates that such language be changed to say “higher or lower” which is a more accurate description (see, e.g. ,Commonwealth Fund paper (Sept. 2023) re: little difference in affordability between MA and trad. Medicare).
- Under “Coverage” and “Medicare Advantage” on page 12 – the Handbook states “Plans may offer some extra benefits that Original Medicare doesn’t cover – like certain vision, hearing, and dental services [emphasis in original].” CMS did not follow advocates’ suggestion to add information that clarifies that supplemental benefits are limited in scope and availability, such as “Plans may also offer extra benefits that Original Medicare doesn’t cover—like some vision, hearing, and dental services. Most extra benefits will be limited in scope. Some benefits are only available to people with certain health conditions.” Later in the Handbook, at p. 62, there is a more complete description of extra benefits, however it does not state that such benefits are not standardized and therefore can vary considerably. With respect to Special Supplemental Benefits for the Chronically Ill (SSBCI), which can be offered non-uniformly to only chronically-ill MA enrollees in a given plan, there is language that accurately says that plans can offer certain benefits only to “certain chronically-ill enrollees [and that] [a]lthough you can check with a Medicare Advantage plan before you join to find out if they offer these benefit packages, you’ll need to wait until you join the plan to find out if you quality.” (For more information about SSBCI, see these Center publications (2019): Advocates Guide and Consumer Guide.)
In the Medicare Advantage section of the Handbook (pp. 61-74) there is new, helpful language concerning changes in provider networks and a warning that they can change during the year (see pp. 62-63). Given increasing concerns about the adequacy of MA networks, including provider groups and hospitals that are no longer contracting with MA plans (see, e.g, this CMA Alert (Sept. 28, 2023) and article cited therein) there needs to be greater attention to situations in which network providers are not available. At p. 63, the Handbook does state: “When an in-network provider or benefit isn’t available or can’t meet your medical needs, most plans will help you get any medically necessary care outside the provider network (at in-network cost sharing).”
As noted in our Special Report describing new rules applicable to MA plans, CMS revised language in an existing regulation at 42 CFR §422.112(a)(3) that requires an MA organization to provide or arrange for necessary specialty care and arrange for specialty care outside of the plan’s provider network when network providers are unavailable or inadequate to meet an enrollee’s medical needs. In the preamble to the final rule, CMS clarified that this requirement is not limited to specialists, and that “[e]nrollees should not bear a financial burden because of the inadequacy of the MA plan’s network.” (p. 22175). Further, CMS revised the regulation accordingly to “ensure adequate access to medically necessary covered benefits for enrollees when the plan network is not sufficient by both arranging or covering the out-of-network benefits and only charging in-network cost sharing for those out-of-network benefits.” (p. 22175). Thus, the current language in Medicare & You is wholly inadequate – instead of stating that “most” plans will help people who cannot find care in-network, this should state that plans are obligated to do so, and this provision should be highlighted given growing concerns about access to care due to limited provider networks. More broadly, and beyond just the Handbook, CMS should publicize and educate MA enrollees and Medicare providers about this obligation and ensure that MA plans are compliant.
One area that has improved in the Handbook is more prominent references to MA prior authorization. For example, in the summary chart at p. 12, it states “In many cases, you may need to get approval from your plan before it covers certain services or supplies.” While this might not capture just how widespread prior authorization is — according to KFF (Aug 2023), “nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services in 2023” and “[p]rior authorization is most often required for relatively expensive services” – or the scope of inappropriate denials (see, e.g. Office of Inspector General studies referenced here) including the growing use of AI or algorithmic tools to deny care (see, e.g. here) – prior authorization is at least mentioned. As discussed below, this is contrasted with the overwhelming lack of prior authorization warnings on the Medicare website.
Medicare.gov and Medicare Plan Finder
Last year, we noted that on the www.medicare.gov website, many of the improvements made to Medicare & You had been incorporated in the comparison information and charts, but there was also key information missing. A year later, it is still missing. Most notably, it is difficult to find any mention of MA prior authorization on the Medicare website.
For example, on the medicare.gov website, if one selects “Basics – Get started with Medicare -Medicare basics -Parts of Medicare one ends up here. The chart titled “Your Medicare Options” uses language almost identical to the Handbook, but inexplicably omits key information from a similar chart from the Medicare & You Handbook (at p. 10) – specifically, a key statement about MA plan prior authorization is missing: “In many cases, you may need to get approval from your plan before it covers certain drugs or services.” Also, the chart states that “Plans may have lower out-of-pocket costs than Original Medicare” instead of the “higher or lower” as included in the Handbook.
Similarly, if one chooses to “Find health & drug plans” on the homepage of the website, and type in a zip code, you are prompted to select the type of plan you want. If you select “Which type of plan should I choose?” and then select “I want to compare coverage options before I see plans” the medicare.gov website takes you here, where the information is much more abbreviated. Under “Your Medicare coverage options,” the “Medicare Advantage Plan” box mentions neither limited provider networks nor prior authorization. When following the Medicare Advantage link to a longer summary page, there is still no mention of prior authorization.
A more detailed description at Your health plan options similarly omits any reference to prior authorization. This is also the case when one selects the link “What should I know about Medicare Advantage plans?” although there is helpful language about networks that does not seem to be reflected elsewhere: “Providers can join or leave a plan’s network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider.”
At the very least, Medicare must ensure consistency in information between the Handbook and the website, and should not omit key information from either platform. Failure to prominently mention prior authorization, let alone failure to mention it at all, is a glaring oversight.
Email Campaign
In our report last year, we expressed concern about CMS’ email campaign during the AEP which was very “plan” focused – for example, a generic email sent on October 27, 2022 titled “What to consider when choosing your 2023 Medicare plan” encourages recipients to compare plans and then recommends factors to consider – most of which apply only to Medicare Advantage plans – and implies that one is already (or should be) in an MA plan, not traditional Medicare. Medicare also sent targeted emails to individuals, using their name and zip code. For example, in late October 2022, Medicare sent an email to a beneficiary, “Jane “ with the title “Jane, see how many Medicare Advantage Plans are available in your area.”
We expressed concern that these emails further placed the Medicare program’s thumb on the scale in favor of enrollment in MA, and that instead CMS should actively promote traditional Medicare. So far this year, before the start of the AEP on October 15, emails we have reviewed have improved, but are still lacking.
One CMS email titled “Get Ready for Medicare Open Enrollment! Prepare by Previewing 2024 Plans Now!” sent on Sept. 29, 2023 is more typical of prior years’ communications, referencing comparison of “options for health and drug coverage” without referencing traditional/Original Medicare.
Another CMS email titled “Open Enrollment sneak peak” sent on Sept. 29, 2023, advised recipients that the Open Enrollment period is “your chance to review or change your prescription drug and health coverage for next year. Get a head start by previewing your 2024 options to see if there’s a better fit for your needs and budget.”
In a considerable improvement over previous years, the email goes on to specifically reference traditional/Original Medicare, which had been absent in previous similar communications:
“You have 2 main ways to get your Medicare coverage — Original Medicare or Medicare Advantage (Medicare-approved plans from private companies). It’s important to understand the differences between these 2 options, so consider these 7 things when choosing coverage.”
When following the “consider these 7 things” link, however, the information found on the Medicare website again fails to mention Medicare Advantage prior authorization at all. (Note that as of Sept. 29, 2023, the same website also said that that Medicare Advantage “may be more cost effective for you” but this language has since been removed.)
The email also stresses the importance of “unbiased” information, which is a good warning about misleading advertising and high-pressure sales tactics, but misses an opportunity to refer people to SHIP programs:
“Note: You may be seeing and hearing a lot of information about Medicare plans. Start at Medicare.gov, your official source for unbiased Medicare information, to find the type of coverage that best meets your needs.”
Fortunately, another CMS email titled “Medicare 101: What to know for Open Enrollment” sent on October 4, 2023, both referenced traditional/Original Medicare as an option, and referred people to 1-800-MEDICARE and the SHIP program (including a link to www.shiphelp.org).
However, similar to other online information, a link in the email after referencing Original Medicare and Medicare Advantage “differences between the 2 options” takes you to a medicare.gov webpage that fails to mention Medicare Advantage prior authorization. When discussing Original Medicare, there is also an insufficient warning about the option of picking up a Medigap plan: “If you don’t get Medicare drug coverage or Medigap when you’re first eligible, you may have to pay more to get this coverage later.” Instead, it should state that in most geographic areas, you might not be able to get a Medigap plan at all. The MA language also says “Plans may have lower out-of-pocket costs than Original Medicare” without the clarifying language of Medicare & You stating that costs could be higher or lower.
Conclusion
In the current Medicare environment, dominated by private plans, it is difficult for materials generated by the Medicare program to meaningfully compete for attention. The public is simply inundated by the onslaught of Medicare advertisements and marketing, 85% of which promotes Medicare Advantage plans, and, as noted by KFF (2023), “rarely mention[ ] traditional Medicare, or potential limitations with plan coverage, such as provider networks or prior authorization requirements, leaving beneficiaries with an incomplete view of their coverage options and the tradeoffs among them.”
There are many policy options available to both Congress and CMS to begin to right the imbalance between traditional Medicare and Medicare Advantage, ranging from reining in and redistributing overpayments to MA plans to the benefit of all Medicare beneficiaries by covering more benefits and adding an out-of-pocket cap, equalizing freedom of choice in coverage by expanding Medigap rights, addressing agent/broker commissions that incentivize MA enrollment over all other products, requiring more disclosure of information by MA plans concerning denials and appeals (and other issues), closing loopholes in marketing rules and increasing oversight of MA plans to make sure that people who do choose MA have adequate access to care.
When it comes to providing information about Medicare coverage options, the solutions are more straightforward. The Medicare program has an obligation to present objective and unbiased information about beneficiaries’ coverage options. First, the information must be accurate; as described above, there is still work to do in this area. Second, the Medicare program is under no obligation to do the bidding of the insurance industry. Instead of promoting all of the “health and drug plan” options available during open enrollment, there should be a concerted effort on the part of the Medicare program to at least equally promote and support traditional/Original Medicare. Further, the services of the unbiased and objective State Health Information and Assistance Programs (SHIPs) must be promoted and better funded. Medicare beneficiaries deserve a more robust counterweight to the massive financial incentives and resources of the insurance industry.
October 5, 2023 – D. Lipschutz