Medicare Advantage

During a Sept. 20 KFF webinar, presenters and panelists seemed to agree on one thing: Regulations aimed at curbing misleading Medicare Advantage TV ads are a welcome fix for a mounting problem. Even an executive from the largest health insurance trade group acknowledged that “bad actors” in the MA marketing space need to be reined in — although he also stressed that most people are satisfied with their private Medicare plans. 

Meanwhile, CMS Administrator Chiquita Brooks-LaSure, who kicked off KFF’s hour-long virtual event, made it clear that the Biden administration is ratcheting up scrutiny of MA plans primarily in response to rising consumer complaints.  

As Medicare Advantage insurers prepare for the Oct. 1 start of Annual Election Period (AEP) marketing, they face an increased level of scrutiny as CMS implements various provisions aimed at curbing misleading and aggressive marketing practices. But new research suggests that some of the marketing misconduct of years past could rear its ugly head again this fall, prompting industry experts to question whether CMS should take additional steps or if action from Congress is needed.

Released on Sept. 12, the Commonwealth Fund’s survey of seniors’ experiences during the last week of the 2023 AEP tells the familiar tale of Medicare beneficiaries inundated with marketing messages during open enrollment. Nearly all seniors saw or received some form of plan marketing — ranging from phone calls to television advertisements — and more than three-quarters reported seeing television or online ads once daily. Additionally, 73% received phone calls at least once a week, and 30% reported receiving at least seven calls in a week. And despite CMS rules barring marketers from calling beneficiaries unless they’ve agreed to be contacted or requested the call, 74% of all respondents reported receiving an unsolicited call from a plan or plan representative.

The HHS Office of Inspector General will conduct a series of Medicare Advantage audits focused on diagnoses identified from unlinked chart reviews that resulted in higher risk-adjusted payments to MA organizations. For the risk adjustment program, CMS allows Medicare Advantage organizations to conduct chart reviews of enrollee medical record documentation to identify diagnosis codes that providers either did not originally give the MAO or provided in error. With unlinked chart reviews, MAOs do not have to include the specific date of service for previously unidentified diagnosis codes. In a 2021 report suggesting some MAOs were relying heavily on chart reviews and health risk assessments to achieve higher risk-adjusted payments, OIG previously recommended that CMS reassess whether it should allow unlinked chart reviews to be sole sources of diagnoses for risk-adjusted payments. The audit reports are expected to be released in 2026, according to a work plan summary posted this month.

As the Medicare Payment Advisory Commission (MedPAC) continues to consider ways Congress could achieve greater parity between traditional, fee-for-service (FFS) Medicare and Medicare Advantage, its September public meeting touched on several program aspects that are ripe for change. Three such areas — MA benefit standardization, access and quality, and encounter data — are slated to be addressed in separate chapters of its June 2024 report, MedPAC confirmed. Meanwhile, an analytical discussion on alternative methods of assessing MA coding intensity could lead the commission to conclude that MA plans are overpaid by even more than its current estimates, which are already disputed by the industry’s largest trade group.

Beneficiary switching from fee-for-service (FFS) Medicare to Medicare Advantage more than tripled between 2006 and 2022, contributing to the MA enrollment boom that’s taken shape over the past two decades, according to a study published this month in Health Affairs. MA enrollment has been “accelerating” since 2019, researchers said, and switchers from FFS to MA were the biggest driving force behind this trend.

The study authors broke down beneficiaries from CMS’s enrollment database into five categories: stayers, switchers to MA, switchers to FFS, beneficiaries who newly gained eligibility, and beneficiaries who lost eligibility (largely those who died during the year). While new enrollments among those who had recently turned 65 also contributed to MA enrollment growth, it was at a smaller scale than growth caused by switching activity among existing beneficiaries, researchers observed.

Economic instability, food insecurity, limited access to transportation and overall lack of support are seniors’ top barriers to staying healthy, according to new data from Alignment Health. Sponsored by the tech-enabled Medicare Advantage insurer, the second-annual Social Threats to Aging Well in America survey polled 2,601 seniors across Alignment’s six-state service area, asking them about their financial, physical and emotional needs — and how those needs are impacting their health. Their responses illuminate the types of supplemental benefits that could prove most valuable to seniors weighing their coverage options as the 2024 Annual Election Period approaches.

Not having enough money for medical expenses was the most common overall obstacle to health, reported by 41% of survey respondents who anticipate any upcoming challenges. And about 20% of respondents cited financial instability as their top obstacle to health and wellness. One in 5 seniors said they’ve skipped out on needed medical care, and lack of funds was the No. 1 reason for doing so. In addition, 14% of seniors said they have outstanding medical debt, and 11% do not think they will be able to pay all of their medical bills in the coming year. When asked about supplemental benefits, nearly half (46%) of respondents said they would take advantage of assistance with rent, mortgage payments, and/or utility bills. Seniors also responded positively to fuel and grocery allowances.

To help overwhelmed seniors make better Medicare Advantage plan comparisons, the Medicare Payment Advisory Commission (MedPAC) nearly a year ago began discussing the concept of standardizing a limited number of common supplemental benefits in MA. During its September public meeting, MedPAC agreed to devote a chapter of its June 2024 report to standardizing select MA benefits, while several commissioners echoed previous sentiments about striking a balance between standardization and flexibility.

At its November 2022 public meeting, the independent congressional agency considered two different approaches: (1) standardizing a limited number of common supplemental benefits, such as dental, hearing and vision, and (2) standardizing Medicare Parts A and B services, whereby plans use a limited number of benefit packages. But some commissioners at the time expressed concern about potentially hampering MA plan innovation.

Executives from health insurance firms Centene Corp. and Humana Inc. on Sept. 6 pitched investors on rosy projections for the rest of the year at the 2023 Wells Fargo Healthcare Conference — despite ongoing Medicaid eligibility redeterminations and elevated utilization in Medicare Advantage, particularly around COVID-19 hospitalizations.

In remarks during the conference, Centene CEO Sarah London highlighted the spinoffs and balance sheet restructuring that she has orchestrated since taking over the firm in spring 2022. London said that Centene bought back $200 million of shares in August, and “expect[s] to exceed our original $1.5 billion share repurchase target in 2023.”

Since the January release of CMS’s controversial final rule on Risk Adjustment Data Validation (RADV) audits, all has remained quiet on the litigation front. But in a complaint filed in a federal court on Sept. 1, Humana Inc. opens old wounds regarding the years-long leadup to the final rule and invokes the Administrative Procedure Act (APA) in asking the court to vacate the rule. In doing so, it seeks to stop CMS from applying its new audit policy of seeking extrapolated recovery amounts.

Issued on Jan. 30, the final rule (88 Fed. Reg. 6643, Feb. 1, 2023) pertains to contract-level audits that CMS began conducting more than a decade ago to verify the accuracy of payments made to MA organizations and recover improper payments. In that rule, CMS codified its plans to begin extrapolating RADV audit findings with payment year 2018 — but not findings for payment years 2011 through 2017, as once proposed. And the agency confirmed it would not adopt a “fee-for-service adjuster” to account for any impact from unaudited diagnosis codes in FFS data that are used to calibrate the MA risk adjustment model.

Medicare Advantage members using post-acute care services are reporting less favorable outcomes than their fee-for-service counterparts, according to a new study published in JAMA Health Forum. Not only are outcomes worse, MA beneficiaries are also using fewer post-acute care services than those enrolled in traditional Medicare (TM), which study authors said could be linked to payers’ tight prior authorization (PA) requirements.

The study authors explained that prior research on this topic, which has generally shown favorable post-acute outcomes in MA, relied largely on administrative data, which can’t capture individual beneficiaries’ perception of quality or health status. That’s why they looked to self-reported data from the National Health and Aging Trends Study, focusing on seniors age 70 and older who lived in community settings (rather than nursing homes). “Examining self-reported patient outcomes is key to ensuring that the MA program adequately meets beneficiaries’ needs, particularly since there is evidence that MA enrollees are treated at lower-quality SNFs [skilled nursing facilities],” authors wrote.