The Centers for Medicare & Medicaid Services (CMS) has proposed a new rule for 2025 with the goal of addressing some of the problems with Medicare Advantage (MA). The rule is intended to “promote healthy competition” because so many Medicare Advantage plans have been failing to meet people’s needs, in a multitude of ways. The problem is that the proposed rule, like the vast majority of Medicare Advantage rules, has no teeth.
Here are the rule’s major provisions:
The Administration proposes more guardrails to ensure that insurance brokers and agents are not steering people into Medicare Advantage plans that do not meet their needs. Mountains of evidence reveal that many Medicare Advantage plans are inappropriately delaying and denying care and otherwise restricting access to care, through limited provider networks and large out-of-pocket costs. No one, including insurance agents, has a clue as to which Medicare Advantage plans to avoid–let alone, whether there are any that put patient needs first–because there is no good data to help people understand which Medicare Advantage plans are the bad actors.
The biggest takeaway of the new proposed marketing “guardrail” is that brokers and agents steer people to the MA plans that pay them the highest commissions. They also steer people away from Medicare supplemental insurance plans that pick up most out-of-pocket costs in traditional Medicare, which don’t pay them as high commissions as MA plans. The MA commission is now as high as $601, with lots of bonuses, and would increase to a fixed rate of $632 in 2025. Bottom line: Don’t trust the advice of insurance agents!
The proposed rule also proposes better access for people to outpatient behavioral health providers through changes to Medicare Advantage plan’s network adequacy standards. This year, CMS expanded coverage to marriage and family therapists (MFTs) and mental health counselors (MHCs). About 400,000 more therapists will be able to treat Medicare patients if they so choose. Because reports indicate that Medicare Advantage plans do not often offer easy or any access to mental health providers, as required, CMS is setting a special network adequacy standard for Medicare Advantage plans. But, as it is, CMS does not appear to have the resources to assess network adequacy nor does it have the ability to meaningfully penalize MA plans with inadequate networks.
And, the proposed rule seeks to help people with Medicare make good on the “supplemental benefits” that Medicare Advantage plans offer. Reports indicate that many of these benefits go unused because they come with unaffordable out-of-pocket costs or other burdens on enrollees. CMS allows MA plans to offer food vouchers and transportation services. But, it appears that few use them. So, if the rule is finalized, MA plans would have to let enrollees know of the availability of supplemental benefits midway through the calendar year.
CMS states it does not want MA supplemental benefits used as a “marketing ploy,” as they so often are. But, the administration overlooks the fact that few people will read the notice from their MA plans and fewer still will be able to take advantage of these benefits even if they know about them. Many people with Medicare have serious mental and physical health conditions as well as low health literacy levels that impede their ability to understand Medicare’s complex rules.
To address the disproportionate impact that inappropriate delays and denials of care in Medicare Advantage has on underserved populations, such as people with disabilities, people with Medicaid and people in Medicare Savings Programs, CMS has proposed that Medicare Advantage plans analyze their utilization management (UM) policies and procedures from a health equity perspective.
And, CMS’ proposed rule attempts to give Medicare Advantage enrollees faster access to appeals; right now, in some cases, people in MA plans have far less timely appeals than people in traditional Medicare. This proposed rule is an improvement that might help a tiny fraction of MA enrollees. However, the overwhelming majority of MA enrollees do not know to value of appealing MA plan denials and do not appeal.
Lastly, CMS proposes a rule to allow monthly enrollment in MA plans and appears to help insurers push more people with Medicare and Medicaid into an MA plan. That’s insane given all the reports of bad actors in MA and the availability to this population of traditional Medicare with easy access to care and few if any out-of-pocket costs. Thankfully, the rule also gives these “dual eligibles” the ability to switch to traditional Medicare more easily.
The proposed rule would limit out-of-network cost sharing for D-SNP preferred provider organizations (PPOs) for specific services, beginning in 2026. The proposed rule also would reduce cost shifting to Medicaid, increase payments to safety net providers, expand dually eligible enrollees’ access to providers, and protect dually eligible enrollees from unaffordable costs.
It’s great that CMS is acknowledging many of the major issues with Medicare Advantage. It’s unfortunate that even when it proposes a good rule, the insurers offering Medicare Advantage plans can effectively ignore the rule with impunity, and many of them do.
Here’s more from Just Care:
- What happens when a Medicare Advantage plan endangers people’s health?
- New Medicare Advantage rules won’t stop the misleading marketing
- Government rules won’t curtail Medicare Advantage bad acts without stiff penalties
- Underpayments lead hospitals and specialists to cancel Medicare Advantage contracts
- 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
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