It is critical that Medicare beneficiaries know all of their options when it comes to their health coverage. Currently a Medicare beneficiary can receive her coverage through Original (sometimes called “traditional”) Medicare or can enroll in a Medicare Advantage (MA) plan. With each of these options comes advantages and disadvantages and it is only with clear, unbiased information that a Medicare beneficiary can truly make an informed decision. The Center for Medicare Advocacy (the Center) has helped thousands of Medicare beneficiaries and has witnessed the harm caused by individuals not having the necessary information or relying on incorrect information to make sure they have appropriate coverage. Any entity that distributes information about Medicare beneficiary coverage choices, particularly the Centers for Medicare & Medicaid Services (CMS), must communicate information in a way so that enrollees know and understand all of their options.
CMS recently posted the Medicare & You 2021 handbook on their website. The handbook is described as “[t]he official U.S. government Medicare handbook.” Given this, beneficiaries can infer that the handbook is a neutral catalogue of accurate information with the objective of guiding beneficiaries in making decisions about their care. Therefore, any bias towards one choice or another can undermine the trust beneficiaries have in government-supplied information.
The Center for Medicare Advocacy reviewed the new handbook with an eye toward assessing the balance of information provided about Original Medicare vs. Medicare Advantage, and the accuracy of information regarding coverage. Similar to what we found in our review of the 2020 handbook in our September 2019 Weekly Alert published last year, in short, while there have been general improvements in the handbook, bias towards Medicare Advantage remains, and in some ways, has gotten worse. Enrollment in MA plans is promoted at the same time that important restrictions and challenges faced when enrolling in an MA plan are downplayed or omitted.
Language matters, especially in a document that is widely read by beneficiaries who may use this as their sole or primary source of information about Medicare. Changes and distinctions in language that may, at first glance, appear to be subtle, can significantly alter the meaning and interpretation of certain concepts. Below we outline our concerns with how the handbook treats Medicare coverage options in a way that is not balanced or neutral, as it should be.
As outlined in last year’s Alert analyzing the 2020 handbook, since Fall 2017, the Center has expressed concerns about bias towards Medicare Advantage in CMS materials. The 2018 Medicare & You handbook, along with outreach and enrollment documents, encouraged beneficiaries to choose a private Medicare plan over Original Medicare instead of more objectively presenting all enrollment options (see, e.g., here and here). When the draft 2019 Medicare & You handbook was released in May 2018 for stakeholder input, the Center and other beneficiary advocates were alarmed at glaring inaccuracies in the document, which, among other things, continued to steer beneficiaries toward MA plans. As discussed in a previous CMA Alert, the Center joined Justice in Aging and the Medicare Rights Center in writing to CMS about concerns with the draft handbook.
As our organizations asserted at the time, rather than presenting information in an objective and unbiased way, the draft handbook’s information about Original Medicare and Medicare Advantage (MA) distorted and mischaracterized facts in serious ways.
In the final version of the 2019 handbook, as discussed in a previous CMA Alert, CMS addressed the most serious inaccuracies and omissions. More could have been done, however, to ensure a neutral and balanced perspective. Further, while some revisions were made to the 2019 Medicare & You handbook that improved the information comparing Original Medicare with MA, the Center and others remained concerned about other administration efforts to steer people toward MA plans. Similarly, as noted in our assessment of the 2020 handbook, there were still shortcomings concerning the accuracy and balance in describing differences between Original Medicare and MA.
Since the issuance of the 2020 handbook, the current Administration has made it even more clear that bias in favor of Medicare Advantage is to be tolerated, if not outright encouraged. On October 3, 2019, President Trump issued his “Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors”. Section 3 of the EO states that within a year, the Secretary is directed to, among other things, “ensure that, to the extent permitted by law, FFS [aka traditional, or Original] Medicare is not advantaged or promoted over MA with respect to its administration.” (For the Center’s analysis of the EO, including additional statements made by the Secretary of Health and Human Services that make this bias abundantly clear, see this previous Alert.)
In some ways, the Medicare & You handbook is getting better about providing people with necessary information. For instance, it is better about highlighting the imbalance in access to Medigap plans vs. MA plans, including the dangers of dropping Medigap coverage and the limitations in rights to get it back. It is also better about addressing the so-called improvement standard myth in certain care settings (however, without mentioning the Center’s Jimmo case).
This Alert, though, focuses on our assessment of the 2021 Medicare & You handbook and bias in favor of the Medicare Advantage program. Unfortunately, such bias remains, and in some instances, has become worse. Below we discuss: General, Ongoing “Plan” bias in the handbook; review the book’s Comparison Charts and Scales; and touch on how the handbook treats certain subject areas – Restricted Access to Providers, Beneficiary Costs, Covered and Supplemental Benefits, and Access to Care.
General, Ongoing “Plan” Bias
As noted in our Alert last year about the 2020 handbook, as with any summary of complex information, there is a risk that oversimplification or shortcuts can lead to incomplete or misleading information. Given recent CMS history, as outlined above, there is a concern that information about MA plans would be presented in the most favorable light, and any downsides of MA would be minimized.
Throughout CMS education and outreach materials, in recent years there has been a focus on “plans”, often inferring that a Medicare “plan” is the only or best option for individuals. This undermines the option of Original Medicare, and assumes that private MA plans are the default option. While people with Original Medicare may have stand-alone Part D plans, which they would be advised to review every year, CMS language has often blurred the distinction between MA and Part D plans and refer to them as “health and drug” plans or other characterizations that imply that they are either one and the same, or that a combination of both (a Medicare-Advantage Prescription Drug, or MA-PD) is the best choice.
As the Center has argued previously, CMS should make clear in its materials that people with Original Medicare can stay put if they wish, and people enrolled in MA can consider the option of returning to Original Medicare. Instead, information coming from CMS focuses almost exclusively on “plans” and “plan choices” with little or no reference to Original Medicare as an option.
Although CMS has not yet begun its education and outreach campaign via email for the 2020 enrollment period, last year, such emails tended to focus only on “plans.” For example, one opened:
“Happy with your current 2019 Medicare coverage? Plans — and your health care needs — may change from year to year, so it’s still important to take a few minutes and shop around during Medicare Open Enrollment.” [And, after touting the new Medicare Plan Finder, concluded:] “If you’re happy with the coverage you have now, and your plan is still being offered next year, you don’t need to do anything further. But if you find a plan that better meets your needs for 2020, you can easily enroll online until December 7.”
In recent years, CMS outreach and enrollment materials have framed Medicare coverage choices as being all about “plans” without making adequate distinctions between drug coverage and other types of coverage, and has actively promoted enrollment in MA plans.
General messaging in the Medicare & You handbook is no different. At the outset of the 2021 handbook, under “What’s New” on page 2, there is a prompt to “Get help with your Medicare coverage choices – Visit Medicare.gov/plan-compare to shop for and compare health and drug plans that meet your needs. You can also enter your drugs to get more accurate costs for plans in your area.” This implies that, in addition to Part D plan changes, people in traditional Medicare should get help with their coverage choices, which includes “health plans”.
In the “Get Started” section on page 4, the handbook suggests, under “If you already have Medicare” to “Review your Medicare health and drug coverage and make changes if it no longer meets your needs, or if you could lower your out-of-pocket costs. You don’t need to sign up for Medicare each year, but you should still review your options.” If Original Medicare is your “health coverage” you are advised to review it and explore other, cheaper options. The annual exercise for those in Original Medicare is encouraged to be expanded beyond merely reviewing Part D plans.
Similarly, on the same page, under “Mark your calendar ….” it notes that during the Annual Enrollment Period (AEP) one can “Change your Medicare health or drug coverage for 2021, if you decide to. This includes changing to Original Medicare, or joining or changing a Medicare Advantage Plan.” While at least Original Medicare is listed as an option – which, as noted above, some AEP materials in recent years have omitted altogether — the language suggests that, as a default, someone is enrolled in a private MA plan (or should be).
Elsewhere in the 2021 handbook, e.g., under “Who has to sign up for Part A/and or Part B” on page 16, a text box is titled “Once you’re enrolled in Medicare you’re not done yet” and states that “People get coverage in different ways. You’ll need to review all of your Medicare coverage options and find what best meets your needs. See pages 6–8 for more information.” In comments to CMS on the draft version, we stated that the phrase “…you’re not done yet” – implies that a new beneficiary must enroll in something else. While this may be true for individuals in Original Medicare who need Part D drug coverage, the prompt is overly broad and does not account for people with Medicaid, retiree coverage, etc. Our suggestion was that if not deleted, this direction should be tempered, such as “there is more to explore, including whether you might need any additional coverage.” CMS left the language as is.
Such language outlined above perpetuates the framing of coverage choices as being all about “plans” without making adequate distinctions between drug coverage and other types of coverage. As discussed in the next sections, when CMS materials address Medicare Advantage plans vs. Original Medicare more directly, they fail to maintain appropriate balance.
Comparison Charts and Scales
The Medicare & You handbook, now at 124 pages, can be daunting to read, and one that may not be routinely read cover-to-cover by Medicare beneficiaries. Understanding that many people will not carefully study the entire manual, in recent years CMS has developed some summaries and shortcuts that attempt to provide basic information that might be helpful to readers.
In this vein, since 2018, CMS has included a new section toward the beginning of the handbook that attempts to summarize the different parts of Medicare as well as differences between traditional (referred to as “Original”) Medicare and the MA program. In the 2021 version, this information is on pages 6-8. There will be people who rely solely on these comparison charts rather than wade through the more detailed information about the respective coverage options further in the handbook. This is why it is critical that such information be accurate and balanced. As discussed below in sections devoted to analyzing how certain subjects are presented, unfortunately, this is not the case.
Instead of reading the entire handbook, some people will rely solely on comparison charts and other shortcuts rather than wade through the more detailed information about the respective coverage options further in the handbook. This is why it is critical that such information be accurate and balanced.
In another attempt to help individuals quickly compare Original Medicare with MA, CMS added a new feature to the 2020 handbook which is also included in the 2021 version. On page 8, CMS alerts readers to look for certain images “throughout this book to help you understand your Medicare coverage options” including an image of scales that “Shows comparisons between Original Medicare and Medicare Advantage”. There are seven such scales throughout the book.
As noted in our review of last year’s handbook, subject to the same concerns about oversimplification, or even outright steering towards MA plans, these scales can be more problematic than the comparison charts discussed above.
In both the draft and final 2021 handbook, at least four of the seven scales are “tipped” towards MA (in other words, the benefits of MA over traditional Medicare were highlighted) and in favor of Original Medicare only twice. More than just keeping “score” of how many times the scales tip one way or another (which a reader is unlikely to do), the final draft both bypassed opportunities to either highlight the advantages of Original Medicare, or add critical, clarifying information, and mischaracterized or over-sold some of the benefits attributed to MA plans.
Here are comments on the seven scales in the final version (and one that was removed):
- P. 20 – Health Savings Accounts – similar to the 2020 version, the scale following a discussion of health savings accounts (HSAs) suggests exploring Medicare Advantage Medical Savings Account (MSA) plans as an option for those who would like to get benefits through an HSA-like structure. Given that only approximately 5,600 people were enrolled in MSAs in 2019, out of 22 million people enrolled in MA plans overall (and over 64 million people with Medicare in 2019), it seems a stretch, at best, to use space to promote this very limited option that appears to be unpopular with both plan sponsors and beneficiaries. Despite our suggestion to CMS that this scale and text be removed, CMS left it in as is.
- P. 29 – MA Out-of-Pocket Costs – this scale favoring MA states: “Medicare Advantage Plans have a yearly limit on what you pay out-of-pocket for medical services. See page 60 to learn more and to find out what affects your Medicare Advantage Plan costs.” In comments to CMS about the draft handbook, we suggested that in order to provide balance in information concerning MA and Original Medicare, CMS should add something like “Certain types of supplemental coverage, such as Medigap plans, can also limit yearly out of pocket costs for those with Original Medicare. See page 71”. We also suggested adding language about the MA out-of-pocket limit, such as “Before this limit is reached, however, Medicare Advantage plans may charge more cost-sharing for certain services than is allowed under Original Medicare.” Neither suggestion was adopted.
- P. 48 – Telehealth – The scale states: “Medicare Advantage plans and providers who are part of certain Medicare Accountable Care Organizations (ACOs) may offer more telehealth benefits than Original Medicare. These benefits are available no matter where you’re located, and you may be able to use them at home instead of going to a health care facility. Check with your plan to see what telehealth benefits they offer. If your provider participates in an ACO, check with them to see what telehealth benefits may be available. For more information on Medicare Advantage Plans, see page 57. For more information on ACOs, see page 110.” On balance, it appears this language favors MA plans, since ACOs are not as widely available, and since the language concerning ACOs is rather limiting. In our comments to the draft language, we noted that since this scale references both MA and ACOs, which are part of Original Medicare, it does not really compare MA vs. Original Medicare. We suggested that instead this text be turned into a note rather than under a scale comparing the two programs, but CMS did not adopt this suggestion.
- P. 52 – Long-Term Care – the text in the scale states: “Special Needs Plans are a type of Medicare Advantage Plan that may be able to cover long-term care if you have Medicare and Medicaid. See page 66 to learn more. Also, some Medicare Advantage Plans may cover certain extra benefits, like adult day-care services. See page 58.” This scale favors MA plans, although eligibility for SNPs is limited and this language may over-promise the availability of such benefits.
- P. 56 – Provider Limitations in MA Plans – In a nod to Original Medicare, this scale references MA network provider limitations, but, as discussed below, it mischaracterizes access to providers in MA plans by referencing lower cost network restrictions rather than restrictions on access to providers.
- P. 58 – Compares Access to Care in Original Medicare vs. MA – “In most cases, you don’t need a referral to see a specialist if you have Original Medicare. See page 53. You can also see any provider you want that takes Medicare, anywhere in the U.S.” This scale appropriately points out these benefits to Original Medicare over MA plans.
- Note that CMS appropriately removed a comparative scale that appeared in the 2020 final and draft 2021 versions – On page 60, CMS followed our suggestion to change certain text from a comparative scale to instead flagging that it was “Important”: “If you already have Medigap and join a Medicare Advantage Plan, you can drop Medigap. Keep in mind that if you drop Medigap to join a Medicare Advantage Plan, you may not be able to get it back. See page 74” [emphasis in original]. Previously, this appeared as a comparative scale that favored MA plans, even though the ability to drop a Medigap plan and no longer pay premiums if one enrolls in an MA plan might be seen as a benefit, the inability to pick up a Medigap after dropping it is a disadvantage for those in an MA plan.
- P. 97 – MA Rights – CMS added a new scale that did not appear in the draft that, as discussed below, misleadingly suggests that the right for MA enrollees to request a coverage determination from their plan prior to obtaining a service or item is a benefit of MA enrollment that is unavailable in Original Medicare, rather than describing it as the prior authorization hurdle to care that it actually is.
These summaries, shortcuts and comparisons do a disservice to beneficiaries when they overplay the benefits of MA and underplay the drawbacks. As discussed in particular subject areas below, language in both the handbook summaries and more detailed explanations follow this trend.
Restricted Access to Providers
The fact that most MA plans use a model that, by design, restricts access to providers by establishing contracted provider networks, is a key to understanding how such plans work and is an important factor for prospective enrollees to consider. While roughly 30% of MA enrollees are in PPOs, which allow enrollees to see out-of-network providers (usually for a higher cost), according to the Kaiser Family Foundation, in 2019 nearly two-thirds (62%) of all Medicare Advantage enrollees are in HMOs (over 13.6 million people), which generally will only cover services provided by in-network providers. While HMO point-of-service (POS) plans do allow enrollees to go out-of-network for certain services, CMS enrollment data (Sept. 2020) show that approximately 2.01 million people are enrolled in such plans – roughly 15% of all MA HMO enrollees. This means that most plans will not cover services from providers outside the network. This is particularly important after CMS weakened MA plans’ network adequacy standards they must meet in a final rule issued earlier this year, as discussed in a previous Center Weekly Alert.
In several places in the handbook, CMS mischaracterizes access to providers in an MA plan by expressing the need to use network providers “for the lowest costs” rather than the fact that most plans don’t allow you to use out-of-network providers at all, let alone at the lowest cost.
In the 2020 version of the handbook at page 6, the Original Medicare v. MA comparison chart states: “In most cases, you’ll need to use doctors who are in the plan’s network.” In the 2021 version, however, “most” was changed to “many.” Although, at first glance, this might appear to be a minor semantic change, it diminishes the impact that the widespread prevalence of network restrictions in MA plans should have on a reader. “Most” raises awareness that something applies to a majority of situations; “many”, on the other hand, can more easily be dismissed as something that may or may not be applicable in a given scenario.
Similarly, CMS has changed language in the “At a Glance” side-by-side comparison chart between Original Medicare and MA plans at page 7. In the 2020 version, it stated: “In most cases, you’ll need to use doctors who are in the plan’s network (for non-emergency or non-urgent care). Ask your doctor if they participate in any Medicare Advantage Plans” [emphasis in original].
This was how the language appeared in the draft 2021 version, but the current, final 2021 language is much diminished: “In many cases, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs. Some plans won’t cover services from providers outside the plan’s network and service area” [emphasis in original]. Not only did CMS change the language from “most” to “many” again, it added a qualifier that does not apply to most MA enrollees –in-network providers need to be seen “for the lowest costs.” Such advice only applies to PPO enrollees; for the majority of MA enrollees in HMOs, there is no coverage (outside emergency or urgent care – as noted by last year’s version). Most plans, not “some”, won’t cover services provided outside the network. Further, the updated language leaves off the critical advice that prospective (and even current) enrollees should ask their doctor if they participate in any MA plans, and whether they will continue to do so.
Even a comparative “scale” image included in the Original Medicare section – inserted seemingly to infer an instance in which Original Medicare is favorable to MA, has been altered in a misleading way. Both last year’s comparable scale (at p. 53) and the draft 2021 version stated: “If you have Original Medicare, you can see any provider you want that takes Medicare, anywhere in the U.S.” However, the current language at the scale (at p. 56) states: “If you have a Medicare Advantage Plan, in many cases, you’ll need to use doctors and other providers who are in the plan’s network and service area for the lowest costs.” As noted above, this language mischaracterizes access to providers in an MA plan by expressing the need to use network providers “for the lowest costs” rather than the fact that most plans don’t allow you to use out-of-network providers at all, let alone at the lowest cost. HMOs generally will not cover services out of network (unless urgent or emergent); to leave the text as is implies that everyone in an MA plan can have out-of-network coverage, but need only be concerned about the network for purposes of lower costs.
In addition to the comparison charts and comparative scales, there is similar language in the lengthier descriptions of Original Medicare and MA further along in the handbook. For example, in the 2020 handbook under the Medicare Advantage section at p. 55, text states that “In most cases, you’ll need to use health care providers who participate in the plan’s network. However, many plans offer out-of-network coverage, but sometimes at a higher cost.” But in the same section in the 2021 version (now at p. 57), CMS made the same revisions described above so that the text now reads: “In many cases, you’ll need to use health care providers who participate in the plan’s network and service area for the lowest costs. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services, to help protect you from unexpected costs. Some plans offer out-of-network coverage, but sometimes at a higher cost.” An official government publication has an obligation to the people it serves to accurately relay this information. Beneficiaries who are misled by this and opt for an MA plan, may be left with large out-of-pocket costs that they would not have in traditional Medicare.
These changes to the language and descriptions of access to providers water down the restrictions that the majority of MA enrollees in HMOs face. If anything, CMS should err on the side of highlighting rather than downplaying such restrictions so that individuals can make better, informed decisions about how they wish to access their Medicare coverage.
In related information about access to providers, the handbook, on p. 8, discusses “Travel” but only focuses on international, rather than domestic travel, which is much more relevant to many more Medicare beneficiaries. One of the key distinctions between Original Medicare and MA plans is that the former allows access to providers across the country regardless of where an individual lives, whereas the latter usually restrict access to providers based upon designated service areas. In our comments to CMS concerning the draft version, we suggested that CMS revise this section to state “People with Original Medicare can get care anywhere in the U.S., however Original Medicare generally doesn’t cover care outside the U.S.”; similarly, under the “Medicare Advantage” field, we suggested that CMS revise language as follows: “Most Medicare Advantage plans require you to go to providers in limited, local networks. Also, plans don’t generally cover care outside the U.S.” CMS did not do this, and missed a key opportunity to educate people about MA restrictions on access to providers.
The Center made a similar suggestion to revise the discussion of “Travel” on p. 49 to add a section that describes travel within the U.S., highlighting that those in Original Medicare can see providers across the country whereas most Medicare Advantage plans usually limit non-emergency or urgent coverage to a network of providers within a geographic area. While there is a helpful comparative scale at p. 58 concerning access to providers in Original Medicare, we suggested that CMS add a similar scale here comparing Original Medicare and MA that articulates this, but CMS did not adopt this suggestion.
Similar to 2020, there is text in the comparison charts on p. 6 that says “Plans may have lower out-of-pocket costs than Original Medicare.” A separate box below on the page reiterates this point: “Some plans also include: Lower out-of-pocket costs.” The reverse point that costs in Original Medicare might be lower than those in MA is not made, although the reality is decidedly mixed.
Since 2011, MA plans have been required to provide a maximum out-of-pocket (MOOP) limit for Part A and B services not to exceed $6,700 (for in-network services) or $10,000 (for in-network and out-of-network combined) in 2020 (note these amounts will increase in 2021 as individuals with ESRD are allowed to enroll in MA plans). According to the Kaiser Family Foundation, in 2020, MA enrollees’ average MOOP for in-network services is $4,925 (HMOs and PPOs) and $8,828 for out-of-network services (PPOs). Even with a MOOP applicable to MA enrollees, whether or not someone faces lower costs in an MA plan is far more nuanced. For example, an April 2020 Kaiser Family Foundation report analyzing Medicare beneficiary out-of-pocket costs found that “[o]verall, a larger percentage of beneficiaries enrolled in Medicare Advantage plans reported problems getting care due to cost or paying medical bills than beneficiaries in traditional Medicare, even after controlling for income and health status.”
Further, costs can vary considerably in an MA plan, including based on the duration of care needed. For example, another report by the Kaiser Family Foundation notes that in 2020, virtually all MA enrollees would pay less than those in traditional Medicare for the Part A hospital deductible ($1,408 in 2020) for an inpatient stay of three days. When looking at cost-sharing for hospital stays beyond three days, however, costs in a MA plan can significantly increase: for stays of five days, half of MA enrollees would be required to pay more than the beneficiaries in traditional Medicare; for a seven-day inpatient stay, nearly two-thirds (64%) of MA enrollees are in a plan that requires higher cost-sharing than the Part A deductible; and for a ten-day inpatient stay, more than seven in ten (72%) are in a plan that requires higher cost-sharing.
Thus, beneficiaries with high or unexpected healthcare costs could face significant out-of-pocket costs in MA plans. In fact, those with Original Medicare with a Medicare Supplement (Medigap) may experience lower costs or be better protected for out-of-pocket health care expenses than those in MA plans, even with a MOOP. According to one insurance agency selling Medigap plans, the national average cost of a Medigap G plan for a 65 year old in 2020 is $143.46 in premiums per month (or $1,721.52 per year). This amount is well below both the average and maximum MOOP amounts referenced above.
The handbook promotes MA plans as an opportunity to have lower out-of-pocket costs than those in Original Medicare, but downplays variables that could make the opposite true.
Elsewhere in the handbook CMS did make some improvements that will help with informed decision-making, such as in the “Original Medicare” sections on pp 53-4. For example, under “Should I get a supplement?” at p. 53 the handbook added in Medicaid and military coverage so that the text reads: “You may already have Medicaid, military, or employer or union coverage that may pay costs that Original Medicare doesn’t. If not, you may want to buy a Medicare Supplement Insurance (Medigap) policy if you’re eligible. See pages 71–74.” Similarly, under the “What Else Should I Know?” section on p. 54, CMS added in language about other insurance in addition to Original Medicare that can cap out-of-pocket expenses, so the text now reads: “There’s no yearly limit for what you pay out of pocket unless you have other insurance (like Medigap, Medicaid, or employee or union coverage).”
In other places, CMS missed opportunities to further flush out important information. For example, under “Paying for Long-Term Care” on p. 52, the text notes that “Medicare and most health insurance, including Medicare Supplement Insurance (Medigap), don’t pay for this type of care, sometimes called ‘custodial care.’” CMS did not take our suggestion to include Medicare Advantage along with Medigaps as a type of insurance that does not cover long-term care. In addition, in the MA section under “What do I pay?” on p. 60, CMS did not follow our suggestion to add to the fourth bullet that “Medicare Advantage Plans can charge more than Original Medicare for certain services, such as co-pays for home health services” and note that, with respect to services that MA plans are prohibited from charging more than Original Medicare for certain services, that the limitation on dialysis cost-sharing should be highlighted here, and/or reprinted in the section above re: individuals with ESRD joining MA plans in 2021.
Covered and Supplemental Benefits
In general, MA plans must cover what is covered under Parts A and B of Medicare. One thing that sets MA plans apart from Original Medicare is that they can offer benefits that are not covered in Original Medicare, using rebate dollars based upon the plan’s bid or charging extra premiums for such coverage. While most MA plans do offer some additional, or supplemental coverage, the scope of such coverage is often limited (e.g., restricted number of visits, dollar cap, etc.). Often, CMS materials over-sell the value of extra benefits MA plans offer.
On the one hand, CMS has tempered expectations in some places. For example, the 2021 handbook, in the comparison chart at p. 8 states: “Plans must cover all of the medically necessary services that Original Medicare covers. Most plans offer extra benefits that Original Medicare doesn’t cover—like some vision, hearing, dental, routine exams, and more. Plans can now cover more of these benefi[t]s (see page 57)” [sic; emphasis in original]. CMS did add the qualifying language “some” in front of “vision, hearing, dental” because such coverage is often, indeed, limited in scope.
On the other hand, while language on p. 58 describing “Extra Benefits” available in MA plans similarly includes the qualifying “some” before “vision, hearing, dental”, etc., CMS fails to appropriately temper expectations with respect to the new flexibilities MA plans have to offer supplemental benefits, including the Special Supplemental Benefits for the Chronically Ill (SSBCI). The text goes on to state: “Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations.”
Provision of such services is entirely voluntary and at the discretion of a given MA plan. Without language further limiting the potential extra benefits, including SSBCI, this oversells how many plans are offering such benefits, and the scope of such benefits (which can be, we find, very limited; see, e.g., Center for Medicare Advocacy issue brief Medicare and Family Caregivers (June 2020) with an example of limited availability and scope of in-home support offered by MA plans in Los Angeles county in 2020). Further, CMS did not follow suggestions that people should not be advised to check with a prospective plan to see if they qualify for such services because eligibility will not actually be determined until someone is enrolled in a plan and they are confirmed to have both a chronic condition and an individualized assessment. The assessment will determine whether the services for this individual have a reasonable expectation of improving or maintaining their health or overall function (see, e.g., the Center’s Issue Brief: New Medicare Advantage Supplemental Benefits: An Advocates’ Guide to Navigating the New Landscape (October 2019)).
Access to Care
In addition to restricting enrollees’ choice of providers, another hallmark of managed care plans is – “managing care.” This often involves restricting services enrollees can receive and from whom, often in the form of prior authorization requirements or other utilization management tools.
As noted by the Kaiser Family Foundation in an April 2020 issue brief, virtually all MA enrollees are subject to some form of prior authorization:
Medicare Advantage plans can require enrollees to receive prior authorization before a service will be covered, and nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services in 2020. Prior authorization is most often required for relatively expensive services, such as inpatient hospital stays, skilled nursing facility stays, and Part B drugs, and is infrequently required for preventive services. The number of enrollees in plans that require prior authorization for one or more services increased from 2019 to 2020, from 79% in 2019 to 99% in 2020. In contrast to Medicare Advantage plans, traditional Medicare does not generally require prior authorization for services, and does not require step therapy for Part B drugs.
Such use of prior authorization often serves as a barrier to accessing care. For example, a 2018 Dept. of Health and Human Services Office of Inspector General (OIG) report found “‘widespread and persistent problems related to denials of care and payment in Medicare Advantage’ plans”. The report’s findings included: when beneficiaries and providers appealed preauthorization and payment denials, MA plans “overturned 75 percent of their own denials”; however, OIG found that “beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.”
As discussed in a previous CMA Alert addressing the report’s findings, OIG stated that MA plans: “may have an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits. High overturn rates when beneficiaries and providers appeal denials, and CMS audit findings about inappropriate denials, raise concerns that some beneficiaries and providers may not be getting services and payment that [MA plans] are required to provide.”
Although the Medicare & You handbook isn’t necessarily the forum in which to cite OIG reports, the OIG results justify an obligation by CMS to provide individuals with information about restrictions to care and coverage in both Original Medicare and MA plans. It accomplishes this goal in some ways. For instance, on p. 58, there is a comparative scale – appropriately painting Original Medicare in a more favorable light in a section addressing MA plans – that states: “In most cases, you don’t need a referral to see a specialist if you have Original Medicare. See page 53. You can also see any provider you want that takes Medicare, anywhere in the U.S.”
CMS has an obligation to provide individuals with information about restrictions to care and coverage in both Original Medicare and MA plans. In the handbook, though, CMS misleadingly suggests that the right for MA enrollees to request a coverage determination from their plan prior to obtaining a service or item is a benefit of MA enrollment that is unavailable in Original Medicare, rather than describing it as the prior authorization hurdle to care that it actually is.
In the draft version of the 2021 handbook, CMS proposed, in a text box, the following language: “If you have a Medicare Advantage Plan, you may get an organization determination to see if a service, drug, or supply is covered. You also may get plan directed care. This is when a plan provider refers you for a service or to a provider outside the network without getting an organization determination in advance. See page 61.” Our comment to CMS concerning this language was as follows: “Medicare Advantage appeals, specifically the right to getting an organization determination, remains a source of so much confusion for Medicare Advantage enrollees, particularly since the appeals process for Medicare Advantage enrollees differs from those who have Original Medicare. This section should be expanded upon. Specifically people should be told they have a right to an organization determination and should call their plan to request one to see if a service, drug, or supply is covered. Also that they should follow the instructions on the organization determination to file a timely appeal.”
Instead of following this suggestion for language in the regular text of the handbook, which proposed addressing MA enrollee rights – specifically to mitigate against restrictions to care and coverage due to prior authorization requirements – in the final version CMS added a new comparative scale on page 97 in the “Know Your Rights” section that states: “If you have a Medicare Advantage Plan, you have the right to an organization determination to see if a service, drug, or supply is covered. Contact your plan to get one and follow the instructions to file a timely appeal. You also may get plan directed care. This is when a plan provider refers you for a service or to a provider outside the network without getting an organization determination in advance (see page 61).”
Although it is critical that this right be articulated, to do so in a comparative box that is meant to “help you understand your Medicare coverage options” and “Shows comparisons between Original Medicare and Medicare Advantage” without including further information is highly misleading. Here, without adding that in Original Medicare such prior approval is rarely needed, highlighting this enrollee right here suggests that this is in fact a benefit available only in MA plans – rather than a necessary safety measure to mitigate against MA plan restrictions.
Such presentation of information is reminiscent of how a previous draft of Medicare & You characterized prior authorization. As noted in the Background section above, the Center, along with Medicare Rights Center and Justice in Aging, wrote to CMS in May 2018 about concerns in the draft 2019 handbook. As stated in our joint letter about that draft:
Even more problematic is the treatment of prior authorization requirements in Medicare Advantage. On both page 6 and page 62, the Handbook attempts to paint this restriction on access to services as a benefit, rather than as what it is, a mandatory hurdle for Medicare Advantage members that is not required for individuals in Original Medicare. On page 62, the Handbook goes so far as to describe prior authorization as a “right” that people in Original Medicare “can’t get.” Describing a restriction as a “right” and then saying that people who are not subject to this restriction are disadvantaged twists the facts beyond recognition.
Thankfully, this characterization of prior authorization as a benefit did not make it into the final 2019 handbook. Unfortunately, although this issue was not even in the proposed 2021 handbook draft, it is now included in the final version.
The Medicare & You handbook is one of the primary ways that Medicare beneficiaries, their families, and those who assist them get their information about the Medicare program. It is critical that the information therein is accurate and unbiased so Medicare beneficiaries can make a fully informed choice about whether to choose Original Medicare or a private MA plan to receive their healthcare. Unfortunately, over the last several years, the handbook has been influenced by the same forces that have pushed other CMS materials away from balance and towards bias in favor of private MA plans.
In some ways, the handbook is improving, but more attention must be paid to ensuring neutrality with respect to how CMS disseminates information about coverage options – and how such coverage operates in practice. Bias in favor of the MA program must be scrubbed from all CMS materials, including the Medicare & You handbook.