Medicare Advantage problems are getting worse, not better, lawmakers say

Author(s):

Richard Payerchin

Key Takeaways

Lawmakers express concern over worsening Medicare Advantage issues, despite regulatory efforts to improve the system.
Excessive prior authorizations and misleading marketing practices are highlighted as significant problems within Medicare Advantage plans.
High commission spending pressures brokers, leading to limited plan options for beneficiaries, potentially risking their health needs.
Lawmakers urge CMS to enhance oversight, enforce stricter regulations, and improve transparency in prior authorization and marketing practices.

Senator, representatives send letter asking CMS to increase oversight.

medicare advantage concept: © wladimir1804 - stock.adobe.com

Problems in Medicare Advantage (MA) are getting worse, not better, despite the best efforts of federal regulators, according to three national lawmakers.

Sen. Ron Wyden (D-Oregon), chair of the Senate Finance Committee, joined with Rep. Richard E. Neal (D-Massachusetts), ranking member of the House Ways and Means Committee, and Rep. Frank Pallone (D-New Jersey), ranking member of the House Energy and Commerce Committee, on a joint letter to the U.S. Centers for Medicare & Medicaid Services (CMS).

Medicare leaders including CMS Administrator Chiquita Brooks-LaSure have enacted rules to improve Medicare Advantage, the legislators said. Those include clarifying when prior authorizations can be used and strengthening market regulations. There is improved coverage for behavioral health services and more culturally competent care, they said.

But constituents are reporting back.

“However, we continue to hear alarming reports from seniors and their families, beneficiary advocates, and health care providers that MA plans are falling short, and finding a good plan is too difficult,” said the letter this week to Brooks-LaSure.

Among the troubles:

MA plans use of prior authorizations has skyrocketed to 46 million requests in 2022. Plans are not following CMS rules, as evidenced by news reports and a congressional investigation. Enrollees have taken to calling it “deny first.” CMS should require MA plans to disclose prior authorization data and must increase oversight, the legislators said.
MA insurers use bait-and-switch marketing to beneficiaries and taxpayers. Seniors, people with disabilities and families need clear and correct information, but MA plans gloss over benefit details while emphasizing perks such as gym memberships. A Senate secret-shopper investigation sampled MA plans for in-network mental health providers and found 80% were “ghosts,” either not reachable, not taking new patients, or not in network, according to the lawmakers.
MA spends more than $6 billion on commissions, which pressures brokers to rush beneficiary appointments. That leads to focusing on only a few plans and not examining the full range of options. “For seniors and people with disabilities, enrolling in a plan that does not meet their health needs can put them at serious risk,” the lawmakers said in their letter. They also called for disclosures of marketing and commission payments.

“We call on CMS to use every regulatory, oversight, and enforcement tool at the agency’s disposal to rein in rampant misuse of prior authorization, simplify the experience of choosing a Medicare plan, and put an end to rampant marketing abuses,” Wyden, Neal and Pallone’s letter said. They asked for a briefing on audits, oversight and enforcement by Dec. 15.