Tens of billions of dollars a year in Medicare Advantage overpayments are taking a huge toll on the Medicare Trust Fund and driving up Medicare Part B premiums. They also are not deterring Medicare Advantage plans from inappropriately delaying and denying care and coverage. So, what happens when the administration or Congress ends these overpayments?
Becker’s Payer Issues reports that Aetna Medicare Advantage plans are losing as much as $2 billion in 2024, in part because many fewer of them will receive a four-star rating or better. As it is, the stars are a joke and do not reflect, for example, whether a Medicare Advantage plan engages in widespread inappropriate delays and denials of care. But, a four or five-star rating means real money to the Medicare Advantage plans. Without that money, these Medicare Advantage plans might look for other ways to maximize profits. Will inappropriate delays and denials increase? Will the quality of the provider networks suffer?
CVS Health owns Aetna. It is losing money because of the reduction in number of its four and five-star Medicare Advantage plans. It is also losing money because of a contract it lost with Centene, a Medicare Advantage plan. CVS Health has been providing pharmacy benefits to Centene Medicare Advantage members.
Here, you should take note: If you are in a Medicare Advantage plan and get prescription drug coverage, don’t assume you are getting the lowest price. Always check for other ways to get your drugs that could possibly save you more money, such as through Costco mail-order or CostPlus Pharmacy. The full cost of the drug without insurance could be less than your Medicare Part D copay.
CVS Health continues to invest heavily in getting more Medicare Advantage enrollees. The flawed Medicare payment system pays their Medicare Advantage plans more when their enrollees have more diagnosis codes, even when they do not cost their Medicare Advantage plans more to treat.
Today, CVS Health has 3.4 million Medicare Advantage members. And, it expects a 12 percent increase next year. UnitedHealth and Humana are the two insurers with the highest Medicare Advantage enrollment.
CVS Health recently purchased Oak Street Health, a primary care provider group, which will help ensure that they have more control over the diagnosis codes providers give to their patients. CVS Health also says it will enable them to improve their star ratings.
[This post has been edited to correct a factual error regarding the relationship between Centene and CVS Health.]
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