For years, the federal government has paid Medicare Advantage plans and Part D prescription drug plans hundreds of billions of dollars to cover Medicare benefits, demanding little transparency and accountability regarding the amounts they spend on medical care and drugs and the quality of coverage they provide. HealthcareDive reports that the Biden administration has issued a proposed rule that, if finalized, would demand greater transparency and accountability from Medicare Advantage and Part D plans. But, it’s hard to imagine it’s enough to ensure these corporate health plans cover the care people need.
If you are enrolled in a Medicare Advantage plan and you develop a serious condition, you might find unwarranted and inappropriate delays and denials of care. Please let us know if you do. And, fight back. Appeal the denials. It’s easy. Medicare Advantage plans are obligated to cover all reasonable and necessary care, and the vast majority of denials are overturned on appeal.
The challenge is that Medicare Advantage plans can be engaged in all sorts of behaviors that are harmful to their enrollees and difficult, if even possible, to detect.
For example, MA and Part D plans sold in the individual market are charging their enrollees (27 million and 24 million respectively) copays based on their negotiated drug prices at pharmacies, even though these plans sometimes pay pharmacies lower rates. The proposed rule would require the Medicare Advantage and Part D plans to disclose those lower prices and pass their savings along to their enrollees through lower copays.
The proposed rule also recognizes the dangers of deceptive marketing by Medicare Advantage plans and the third parties they hire to get people to join their health plans. It aims to do a better job of protecting people. Nice to hear, but it’s hard to see how that’s possible. Scammers abound.
The proposed rule is intended to require MA plans to behave in compliance with their legal obligations in disasters and emergencies. During COVID, many MA plans were slow to advise their enrollees that referral and network coverage requirements are waived, as required. It’s a bit Orwellian that the proposal requires private MA plans to comply with requirements already in place.
MA and Part D plans would also be required to disclose more information about their networks and how they report medical expenses. But, already these plans face requirements to disclose data that they have never disclosed completely or accurately, according to MedPac, the agency that oversees them. And, even if it appears they have an adequate network, who’s to know if the providers they list are seeing more than a handful of new patients.
The proposed rule would enable CMS to keep MA plans that have performed poorly in the past–which ones are those, you might ask–from growing their MA plans. CMS has always had tools to penalize plans. But, the punishment never fits the crime. And, of course, there is little if any way for CMS to protect all the enrollees already in the MA plan.
So while the proposed rule sounds great in theory, it’s hard to see how it will lead to lower costs or better quality of care. How exactly will CMS hold MA plans to these new standards? What’s the punishment if they don’t comply?
Here’s more from Just Care:
- Avoid bad Medicare Advantage plans
- UnitedHealth Group found guilty of denying millions needed care, under court supervision
- Anthem keeps people from getting ER care simply by claiming it may not pay for it
- Aetna under investigation for denying care without appropriate review of medical records
- OIG finds that Humana Medicare Advantage overbilled government big time
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