The Medicare & You Handbook is widely read by beneficiaries who often use it as their sole or primary source of information about Medicare. In contrast to advertising and other promotion by companies and their agents seeking to sell products in the Medicare marketplace, the official government Medicare Handbook should present accurate, unbiased and unvarnished information about the trade-offs between different Medicare coverage options – namely traditional Medicare versus Medicare Advantage (MA). Under the previous Administration, this was not the case.
Starting in the Fall of 2017, the Center for Medicare Advocacy (the Center) and other advocacy organizations began to highlight that, in a marked change from previous practice, the Trump Administration’s 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 report issued in September 2021, we included a catalogue of such bias in Medicare materials during that time.
Last year, we were encouraged by the current Administration’s efforts to begin to reverse this trend of bias towards MA in the 2022 Handbook, as discussed in this Center report. In our analysis of the Medicare & You 2022, we found that there were noted improvements in how access to care in MA plans is described, including removal of promotional or advertising sounding language describing MA, more accurately describing limited MA provider networks and the actual scope of potential coverage of extra/supplemental benefits not covered under traditional Medicare. We also urged CMS to focus on further refining language surrounding issues such as MA out-of-pocket costs and plans’ use of prior authorization.
CMS recently released the 2023 edition of Medicare & You, available here. Based on our analysis of the 2023 version, we are pleased to report that the 2023 Handbook continues to improve with respect to eliminating bias towards MA by more accurately describing MA, including with respect to issues the Center flagged in the 2022 version. These changes help to restore the Handbook as an objective resource with accurate and unbiased information for Medicare beneficiaries.
2023 Medicare & You Handbook
Our analysis of the new Handbook, below, focuses on several areas we identified in both last year’s version and the draft 2023 version which we and other stakeholders had an opportunity to review earlier this year – specifically prior authorization, out-of-pocket costs, and extra benefits. As noted in our previous analyses, the charts comparing Medicare Advantage and traditional 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.
As we noted in our analysis of the 2021 version of the Handbook, 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. It is also the official government guide to the Medicare program, so clear articulation of the program in an objective and accurate manner is crucial. Changes and distinctions in language that may, at first glance, appear to be subtle, can significantly alter the meaning and interpretation of certain concepts. As noted below, we appreciate CMS’ attention to such nuance in the 2023 edition.
- Prior Authorization
As discussed in previous CMA Alerts, prior authorization and other utilization management tools can serve as significant barriers to care that both current and prospective Medicare Advantage enrollees are often unaware of until they need to access services. As noted in an August 2022 report by the Kaiser Family Foundation, “[n]early all Medicare Advantage enrollees are in plans that require prior authorization for some services.” The report notes that prior authorization:
is most often required for relatively expensive services, such as Part B drugs (99%), skilled nursing facility stays (98%), and inpatient hospital stays (acute: 98%; psychiatric: 94%), and is rarely required for preventive services (6%). Prior authorization is also required for the majority of enrollees for some extra benefits (in plans that offer these benefits), including comprehensive dental services, hearing and eye exams, and transportation. The number of enrollees in plans that require prior authorization for one or more services stayed the same from 2021 to 2022. 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.
Further, reports issued by the Department of Health & Human Services Office of Inspector General (OIG) in 2018 and 2022, found “widespread and persistent problems related to denials of care and payment in Medicare Advantage’ plans” including: high rates of MA plans overturning their own denials, coupled with few beneficiaries actually appealing denials; and plans’ use of clinical criteria that are more restrictive than allowed under Medicare rules (see CMA Alert cited above for further discussion).
In the draft version of the 2023 Handbook, CMS described prior authorization in several places as: “In some cases, you may need to get approval from your plan before it covers certain drugs or services.” The Center asserted in our review of the draft 2023 version that given the prevalence of prior authorization in MA plans, particularly for costly services, this description was misleading and “some” should be changed to “many.”
We appreciate that CMS followed this suggestion. For example, in the comparison chart on page 10, it now reads “In many cases, you may need to get approval from your plan before it covers certain drugs or services” (emphasis added). Similarly, in a chart on page 12, the Handbook states that “In many cases, you have to get a service or supply approved ahead of time for the plan to cover it” (emphasis added). Further, on page 61 it states “In many cases, you may need to get approval from your plan before it covers certain drugs or services” (emphasis added). These subtle, but important, changes more accurately highlight plans’ use of prior authorization.
- Out-of-Pocket Costs
As noted in our report last year, MA plans have the discretion to alter their cost-sharing as long as what they charge is actuarially equivalent to what an individual in traditional Medicare (without any supplemental insurance) would face. Cost-sharing is limited to the same limits in traditional Medicare for chemotherapy, kidney dialysis, and skilled nursing facility stays (except, as noted above, unlike traditional Medicare, MA plans can charge cost-sharing for the first 20 days). Further, MA plans are required to impose a maximum out-of-pocket cap (MOOP) for Part A and B covered services (according to the Kaiser Family Foundation, the average out-of-pocket limit (MOOP) for Medicare Advantage enrollees in 2022 is $4,972 for in-network services and $9,245 for both in-network and out-of-network services (PPOs)).
What is often lost in cost-benefit analyses regarding the choice between MA and traditional Medicare, as well as in educational materials such as the Medicare & You Handbook, is that despite the MOOP, people in MA plans can pay more for their care than those in traditional Medicare. For example, as noted in the same August 2022 Kaiser Family Foundation report, about half of all Medicare Advantage enrollees would incur higher costs than beneficiaries in traditional Medicare for a 7-day hospital stay.
Compared to the draft 2023 version, the language in the final Handbook makes improvements with respect to flagging this dynamic. For example, in the chart on page 11, text notes that in MA plans “Out-of-pocket costs vary—plans may have lower or higher out-of-pocket costs for certain services.” (Note: while we urged CMS to make this more explicit, such as “Medicare Advantage plans may charge more cost-sharing for certain services than is allowed under Original Medicare, and your out-of-pocket expenses in a Medicare Advantage plan might still be higher than in Original Medicare” – the final language is nonetheless an improvement.)
Similarly, in a chart on the same page, the Handbook does a better job of highlighting that one can have out-of-pocket costs capped through supplemental insurance in traditional Medicare; the text states that in traditional Medicare “There’s no yearly limit on what you pay out of pocket, unless you have supplemental coverage—like Medicare Supplement Insurance (Medigap).”
- Extra Benefits
While our report on last year’s Medicare & You noted improvement with respect to how the scope of MA coverage of extra or supplemental benefits is described, we noted that further improvement was necessarily concerning an explanation of the limitations of new, expanded supplemental benefits available in MA plans. The final 2023 Handbook could still be improved.
For example, in the comparison chart of MA v. traditional Medicare on page 12, the Center suggested in our feedback on the draft 2023 edition that CMS add information that clarifies that supplemental benefits are limited in scope and availability. For example, we suggested language like “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.” Instead, the final language reads: “Plans must cover all medically necessary services that Original Medicare covers. Plans may also offer some extra benefits that Original Medicare doesn’t cover—like vision, hearing, and dental services.”
With respect to the Handbook’s discussion of the new MA Special Supplemental Benefits for the Chronically Ill (SSBCI) at page 62, we suggested that when describing SSBCI, (e.g., in the second paragraph), it should be made clearer that not everyone will have access to all services offered; in addition, eligibility for SSBCI will not actually be determined until someone is enrolled in a plan and they are both confirmed to have a chronic condition and an individualized assessment has been made concerning whether the services for this individual have a reasonable expectation of improving or maintaining their health or overall function. Therefore, we suggested adding the phrase: “this means that not all of the services offered by the plan will be available to everyone who enrolls in the plan, and you might not find out if you qualify until you are actually enrolled in the plan.” Correspondingly, people should not be advised to check with a prospective plan to see if they qualify for such services because such determinations will not be able to be made prior to enrollment.
In the final language describing access to SSBCI, CMS partially followed these recommendations: “Plans can also tailor their benefit packages to offer additional benefits to certain chronically ill enrollees. These packages will provide benefits customized to treat specific conditions. Although you can check with a Medicare Advantage plan before you join to see if they offer these benefit packages, you’ll need to wait until you join the plan to see if you qualify.”
Along with the improvements made to last year’s version, we are encouraged by the edits to the 2023 Medicare & You Handbook. We hope this return to objectivity and trend away from bias in favor of Medicare Advantage continues in other Medicare outreach and enrollment materials. More broadly, we hope both Congress and CMS will work to address the growing imbalance between traditional Medicare and Medicare Advantage, and work to improve the Medicare program for all of its enrollees, not just those who choose, or are automatically enrolled, in private plans.