JustCare

Category: Medicare

  • 2025: Fewer Medicare Advantage plans get five stars

    2025: Fewer Medicare Advantage plans get five stars

    To encourage insurers to perform well and help people choose a Medicare Advantage plan, The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, rates the performance of insurers offering Medicare Advantage plans through a five-star rating system. Based on this year’s star-ratings, Medicare Advantage plan performance is worsening. Susan Morse reports for HealthCare Finance that CMS gave five star ratings for just seven insurer Medicare Advantage contracts (1.79 percent of contracts), down from 38 in 2024.

    The government’s star-rating system should help people appreciate the quality of different MA plans but it is largely a farce because it misleads people into believing that they can choose a high-quality plan. In truth, CMS does not have the data to distinguish among MA plans effectively. Its ratings are based on insufficient data that lumps together lots of different MA plans offered by an insurer under one government contract, even though the MA plans can have different networks and different rules and processes for covering care.

    As it is, MA plans with five stars can have high rates of inappropriate delays and denials of care, particularly for people needing hospital, skilled nursing and rehab services, inadequate networks, and high mortality rates. The star-rating system won’t help people pick plans that meet their current and future needs.

    CMS is working to improve its star-rating system. But, it doesn’t yet have enough complete, accurate and timely date from the Medicare Advantage insurers to deliver effective ratings. The insurers offering the plans don’t release the data that CMS would need or don’t release reliable data. As a result, at best, the star-rating system tells people which plans to avoid. Don’t consider enrolling in a plan that has three or fewer stars. 

    Here are the MA plans that got five stars: Alignment Health Plan; HealthSun Health Plans by Elevance Health; Highmark Blue Cross Blue Shield; Leon Health; MCS Advantage Classicare; Network Health Medicare Advantage Plans; and Optimum HealthCare by Elevance.

    UnitedHealthcare, which covers the largest number of Medicare Advantage enrollees, lost its five star ratings this year and has sued the government. So has Humana, which in 2025 only has 25 percent of its enrollees in four or five-star plans, down from 94 percent in 2024.

    CMS gave the Medicare Part D prescription drug plans even lower ratings, with only 40 percent of them receiving four or five stars. People should know that Part D insurers often charge higher copays for drugs on their formularies than the full cost of the drug through Costco or Mark Cuban, and they often don’t cover the drugs that your doctor prescribes.

    Here’s more from Just Care:

  • Insurers pay Medicare Advantage brokers to steer you away from Traditional Medicare

    Insurers pay Medicare Advantage brokers to steer you away from Traditional Medicare

    Medicare Advantage insurers incentivize brokers to mislead people about their Medicare choices. A number of Medicare Payment Advisory Commission (MedPAC) Commissioners want to stop Medicare Advantage insurers from paying brokers more to steer people into their Medicare Advantage plans than to steer people into Traditional Medicare, Joyce Frieden writes for MedPage Today. 

    Medicare insurance brokers have no financial incentive to help people understand why Traditional Medicare might better meet their needs, providing easy access to care from doctors and hospitals across the US. They are not paid to do so. MedPAC Commissioner Lynn Barr called out the reality that these insurers are capitalists and said we need to “stop pretending they’re going to do things out of the goodness of their heart.”

    In a series of 24 focus groups, MedPAC staff learned that few people use independent informed sources to make their Medicare choices. Many rely on insurance brokers, who are biased, or friends and family, who might not understand the tradeoffs between Medicare Advantage and Traditional Medicare. Few contact their State Health Insurance Assistance Program (SHIP), which provides free unbiased advice.

    Brokers are often not paid to enroll people in standalone Part D drug plans that people with Traditional Medicare use. But, they earn over $600 to enroll a person in a Medicare Advantage plan and $300 if the person stays in the plan. Insurers pay brokers only a fraction of that amount to enroll people in a Medicare supplemental insurance plan (“Medigap”), and in cases where the person has a disability, they sometimes pay no commission at all.

    The MedPAC Commissioners recognize that people need much more help choosing between Traditional Medicare and a Medicare Advantage plan. They also expressed concern that Medicare Advantage provider directories tend to include a lot of misinformation, making it impossible to know which physicians are in the insurers’ network.

    Also keep in mind: You have no good way to distinguish the good Medicare Advantage plans from the bad ones. Medicare’s five-star rating system should steer you away from plans with fewer than five stars. But, even the five-star plans could have high rates of inappropriate delays and denials of care, high mortality rates, and large administrative and financial obstacles to care. The government doesn’t factor delays and denials into the star ratings. You are forced to gamble with your health.

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  • It’s Medicare open enrollment season, here’s what to do and not do

    It’s Medicare open enrollment season, here’s what to do and not do

    During this Medicare Open Enrollment period between October 15 and December 7, here’s what to know:
    • People on limited incomes can’t make a meaningful Medicare choice.
    • Only Traditional (Original) Medicare gives you the freedom to receive the care you need from the doctors and hospitals of your choice. But it lacks an out-of-pocket cap, so it comes with financial risk unless you also have supplemental coverage, which can be expensive. 
    • Medicare Advantage is always a gamble. MA plans can overrule your doctor and deny you the care you need.
    If you can’t afford Traditional Medicare, call your member of Congress and tell them to add an out-of-pocket cap. 

    Whether you’re in Traditional Medicare or a Medicare Advantage plan, your Medicare Part B premiums will increase and your Part D prescription drug coverage will change in 2025. You should compare your prescription drug Part D options. And, you should be aware that sometimes it is less costly to get your drugs from Costco or another low-cost pharmacy than to get them through your Part D insurance.

    To ensure you get covered for the care you need from the doctors and hospitals you want to use, without administrative hurdles, make sure you are enrolled in Traditional Medicare, the government-administered Medicare program.Only Traditional Medicare gives you the freedom to receive the care you need from the doctors and hospitals of your choice. Unlike Medicare Advantage, Traditional Medicare allows you and your treating physician to decide the care you need without second-guessing. And, with supplemental insurance you have few if any out of pocket costs. But because TM lacks an out-of-pocket cap, millions of Americans can’t afford it.

    If you cannot afford Traditional Medicare or you cannot get supplemental coverage to fill coverage gaps, you have no choice but to enroll in Medicare Advantage. Medicare Advantage is always a gamble. You cannot make a meaningful choice of a Medicare Advantage plan. MA plans can overrule your doctor and deny you the care you need. Reports show widespread and persistent delays and denials of care and coverage in many MA plans. You cannot avoid that. The best you can do is pick a plan with a five-star rating and hope you don’t get sick.

    Don’t assume that anything about your Medicare Advantage plan will remain the same in 2025. Your physicians and hospitals could be leaving the network. Your costs could be rising. Your prescription drug coverage could be changing. Review all your Medicare options carefully, including Traditional Medicare.

    How to choose a Medicare Advantage plan? You can’t make an informed choice or avoid bad actor MA plans.You can’t know in advance whether an MA plan is engaged in widespread and persistent inappropriate delays and denials of care, as many of them are. The government cannot protect you from Medicare Advantage bad actors that do not cover your Medicare benefits, as required. The best you can do is pick a plan with doctors and hospitals you want to use in its network and hope they don’t leave. You can’t count on them staying. This year alone, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care. Unfortunately, in Medicare Advantage, you are gambling with your health care and could incur thousands of dollars in out-of-pocket costs. Insurers have a financial incentive to deny care; the less care they cover, the more they profit. Don’t be seduced by “extra” benefits, which are often very limited and can come with high out-of-pocket costs.

    Keep in mind that when you need costly and complex care, your Medicare Advantage plan is likely to require prior authorization and could overrule your treating physician, denying you coverage. You can appeal, but you might need to pay out of pocket for the full cost of your care. Even when Medicare Advantage plans approve your care, they generally force you to go through hoops and face delays before they will cover your care.

    Don’t trust an insurance agent’s advice about your Medicare options. Unfortunately, insurance agents are paid handsomely to steer you away from Traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. You can’t know whether you can trust an insurance agent.

     If you have Medicare and Medicaid:

    • You will have much easier access to physicians and inpatient services in Traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition. And, you will have no out of pocket costs.

    For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).

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  • Project 2025: A plan to destroy Medicare quickly

    Project 2025: A plan to destroy Medicare quickly

    Project 2025 proposes to make private Medicare plans, also known as Medicare Advantage (MA) plans, the default enrollment option for beneficiaries. Similar to Trump-era programs that automatically enrolled beneficiaries in privatized Medicare programs known as Direct Contracting Entities, Project 2025 would shuttle seniors and people with disabilities into private Medicare very quickly.

    Given the importance of Medicare to the overall health and well-being of the people of the United States, it’s important to understand how this forced migration of almost all beneficiaries into privatized Medicare Advantage plans would affect the future of the program. Extrapolating upon the projections of the Medicare Trustees based on the current flux of people in Medicare and Medicare Advantage, shifting 100% of beneficiaries into Medicare Advantage would bankrupt the Hospital Insurance Trust Fund within 5 years.

    Though MA was originally cast as a cost-saver, the Medicare Payment Advisory Commission found that payments to MA insurers are 22% higher than they are for similar patients in traditional Medicare. Unfortunately, this higher spending does not lead to better health outcomes; it just results in billions of dollars in profits for Big Insurance. The higher cost of MA compared to traditional Medicare means that carrying the strategy of Project 2025 to its possible endgame, if all Medicare beneficiaries are compulsorily enrolled in a private plan, the Medicare Trust Fund will immediately go into deficit spending. By 2030 the Medicare Hospital Trust Fund would run out of funds and become insolvent, disrupting the health care of more than  60 million seniors and people with disabilities unless Congress intervened in ways the authors of Project 2025 didn’t bother to call out. Ten years of Project 2025’s policy of all beneficiaries being in MA plans would cost taxpayers an additional $1.5 trillion.

    And all for providing care that is not on par with traditional Medicare.

    Instead of improving Medicare, an overwhelmingly popular program, Project 2025, would dismantle the program quicker than many even thought possible. In a post-solvency world, Medicare would either become a fully privatized system, turning beneficiaries into revenue generators for earnings reports to Wall Street, or require hefty increases in deductibles, premiums, copays, and taxes. Either way, the result would be little to no health coverage for our most vulnerable communities, and worse care for everyone.

    Medicare turns 60 next year. The implementation of Project 2025’s health care agenda would leave the program careening toward full privatization. A more prudent approach would be to stop the $140 billion in overpayments to Medicare Advantage insurers each year and use the savings to improve the traditional Medicare program. Instead of sending those billions to insurance corporation shareholders, use it to expand coverage in traditional Medicare to include dental, vision and hearing care and establish an out-of-pocket cap that our seniors and disabled citizens can afford.

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  • Health insurers successfully gouge Medicare

    Health insurers successfully gouge Medicare

    Fred Schulte and Holly Hacker report for KFFHealthNews on the power of the health insurance industry to reap extra billions from Medicare with near impunity. Millions of dollars in lobbying money and campaign contributions have helped the biggest health insurers to continue to collect and keep tens of billions of dollars in Medicare overpayments. The government appears unwilling or unable to recoup these funds.

    Anyone who doesn’t trust government to do the right thing should recognize that the government can’t control the health insurance industry to do the right thing. And, unlike the government, big health insurers have the money, the power and the financial incentive to put their profits ahead of the needs of older adults and people with disabilities with Medicare. A combination of political contributions large enough to oust members of Congress when they are up for re-election if they don’t support the health insurers, huge investments in marketing and lobbying Congress, and money to outspend the government in any lawsuit, put the health insurers in control.

    When you couple insurer control over policymakers with a gameable Medicare Advantage payment system, limited government dollars for oversight and enforcement of the insurers, and 4,000 different Medicare Advantage plans, it’s to be expected that the big losers in the long run will be our nation’s older adults and people with disabilities and taxpayers.

    Working alongside many experts and advocacy organizations, I’ve spent more than two decades trying to reform Medicare Advantage to little if any effect. Overpayments are projected to be as much as $1.4 trillion over the next 10 years and inappropriate denials of care and coverage are on the rise. Whatever people believe to be the deficiencies of Traditional Medicare, it is far more cost-effective and it is far easier to oversee than Medicare Advantage.

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  • Medicare Advantage offerings change little in 2025

    Medicare Advantage offerings change little in 2025

    The Centers for Medicare and Medicaid Services just announced that the Medicare Advantage insurers are not raising costs or cutting benefits for enrollees in 2025. This should have been expected, given how handsomely the insurers profit from the Medicare Advantage program and how much they want to enroll more members to increase their profits further. But, for months, the insurers spouted lies about 2025 enrollee costs rising and benefits being cut in a vain attempt to secure higher payment rates and boost their already excessive Medicare payments.

    You can imagine the resources the insurers invested lobbying for rate increases, as the Centers for Medicare and Medicaid (CMS) was determining how much to increase their Medicare payment rate in 2025. Every year, insurers scare older adults and people with disabilities and lobby Congress heavily in order to pressure the government into overpaying them more. Thankfully, recognizing the $83 billion to $140 billion in overpayments to the MA insurers this year alone, CMS decided to raise MA insurer rates by 3.7 percent in 2025.

    It’s no surprise the rate increase–too much in the view of dozens of experts and advocates–did not lead to higher costs for MA enrollees or cuts in their “extra” benefits. People can still choose among a large number of MA plans with no additional monthly premiums. The MA insurers knew they had to keep upfront costs down and deliver extra benefits in order to increase their enrollee ranks and their profits. And, while that sounds good, it’s not possible for people to know whether the plan they choose will cover the care they need or offers a lot of nothing.

    The surprise will come to those people enrolled in MA plans who develop a serious condition and cannot see the specialists they want to see or can’t get approval for the care they need. Narrow provider networks and high denial rates continue to be the M.O. for many MA plans. The “extra” dental, vision and hearing benefits are the sweetener; little do enrollees know how hard it can be in many MA plans to find providers to deliver these benefits to them or how high their out-of-pocket costs can be even with some coverage.

    If you can get a low-cost Medicare supplemental insurance plan, seriously consider enrolling in Traditional Medicare, where you can choose your physicians and hospitals and get the care you need when you need it, without administrative hurdles. MA plans would be a fine option if: 1. The insurers did not have a strong financial incentive to avoid providing costly care to people with complex conditions; 2. Enrollees could meaningfully compare MA plans and avoid the bad actors; and 3. The government could kick out the worst actors. Sadly, that is not the case.

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  • Who should take Leqembi, an Alzheimer’s drug?

    Who should take Leqembi, an Alzheimer’s drug?

    After years of review, the FDA approved Leqembi—lecanemab–for the treatment of Alzheimer’s. So, now, Medicare covers this drug. But, it’s not clear if any of the 6.5 million Americans with Alzheimer’s should take the drug, given that it can cause brain swelling and bleeding. Laurie McGinley reports for the Washington Post on the pros and cons of Leqembi.

    The clinical data indicate that, in some cases of individuals with early-stage dementia and a build-up of amyloid in their brains, Leqembi can slow cognitive decline for five months or so. But, Leqembi cannot stop the progression of Alzheimer’s disease, and it appears that it might not always be safe or effective.

    Medicare covers Leqembi under Medicare Part B for people with amyloid buildup in their brains. Patients who want the drug might have to pay out of pocket for a PET scan to demonstrate that building or get a spinal tap. They or their supplemental insurer is also responsible for the 20 percent coinsurance, more than $5,000.

    Medicare is requiring anyone administering the drug, which is injectable, to participate in a registry that documents Leqembi’s efficacy in the real world. And, people who take it will see a warning label that underscores the drug’s dangerous side effects, including brain bleeding and swelling.

    People on blood thinners are at extra risk of brain bleeds if they take Leqembi. So, the FDA has warned physicians to consider carefully whether to prescribe the drug to these people.

    To be clear, Leqembi does not improve memory or cognitive skills. It might help people be a little bit less forgetful. Patients who take Leqembi will need to undergo several brain scans and travel to receive the drug at an infusion center.

    Medicare’s registry will help scientists better understand the safety and efficacy of Leqembi. But, curiously, the Alzheimer’s Association is seemingly not interested and opposes the registry, claiming it will create a barrier to access.

    People with Alzheimer’s who are overweight or who smoke and people with hypertension or diabetes, could slow cognitive decline by losing weight, stopping smoking and/or treating their hypertension and diabetes.

    Leqembi comes with a price tag of $26,500 a year. The Medicare program is expected to spend $500 million on Leqembi this year and $3 billion on it next year. If so, Medicare Part B premiums will rise significantly because of this one drug over time, as will premiums for Medicare supplemental coverage.

    Here’s more from Just Care:

  • Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers

    Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers

    Since 2018, the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) has warned that Medicare Advantage (MA) plans sometimes deny enrollees’ requests for essential services they need.1 2

    In response to these findings, the Centers for Medicare and Medicaid Services (CMS) finalized a 2024 rule to clarify “clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in traditional Medicare.”3 Unfortunately, providers report little improvement since the rule became effective in January. Inappropriate denials continue to cause poor outcomes for patients, hospital readmissions and increased waste of taxpayer dollars.

    Inpatient Rehab Denials

    The 2024 MA rule did not help U.S. Air Force veteran and Pearl River, LA resident George Carrigan. After complications from diabetes required an amputation of his leg, Humana denied his doctors’ recommendation for care at an inpatient rehabilitation facility (IRF), despite Medicare rules listing amputation as a condition requiring such services.4

    Humana’s two denial letters said he did not need supervision from a rehab physician or interdisciplinary care team, even though these clinicians would have helped control his diabetes, monitored the healing of his wound, managed his medications, and prepared him to return home independently. “The services you need can be provided safely in other settings,” wrote Humana, before sending him to a less expensive setting where his condition deteriorated.

    Carrigan’s daughter and family caregiver, Colleen Fickle, said her dad slipped in the nursing home’s shower and now needs wound care on the amputated limb. Poor catheter maintenance also caused him to be readmitted to the hospital with sepsis. Fickle, who works full time while also caring for her child with a brain injury, said her father is now bedbound at home and dependent on family. She believes none of these complications would have happened and that her father would be walking today if Humana had permitted him to receive close medical supervision at an IRF.5

    Mandeville resident William Sercovich, also a U.S. Air Force veteran, suffered two strokes and faced multiple denials before Humana approved his request for IRF services. Both Humana denial letters repeated Medicare’s rehab criteria without explaining why Sercovich did not need a rehab doctor, intensive team or three hours of therapy per day.

    “We were in the hospital for two weeks longer than we should have been because of denials from the insurance company,” said his daughter, Sondra Sercovich. “I hope people take action, so it doesn’t take so many denials to get the proper medical care.”

    The OIG estimated a difference of more than $8,500 in average payments per stay between IRFs and nursing homes for 2018.6 OIG has also warned that MA plans may deny needed care “in an attempt to increase their profits,” misusing funds that CMS paid for people’s healthcare.7 In 2022, OIG physicians audited MA care denials for IRF services and found that in some cases patients met admission criteria, needed higher-level care and alternatives were insufficient to meet their needs.8 Studies have found that MA enrollees “are more likely to enter lower-quality nursing homes compared to fee-for-service enrollees.”9

    When used appropriately, prior authorization can limit low-value services, but healthcare providers also caution that “cost containment provisions that do not have proper medical justification can put patient outcomes in jeopardy.”10

    A recent Kaiser Family Foundation (KFF) study comparing MA plans found that “prior authorization requests were most common for Humana plans.”11 Humana did not respond to requests for comments on its prior authorization practices under new federal rules.

    This year, CMS warned MA plans they may not deny a hospital patient’s request for discharge to an IRF or redirect care to a different setting if a physician orders these services and the patient qualifies under Medicare coverage rules.12 Yet, plans have significant leeway in how they interpret this directive, and families often lack the time to appeal when the patient is ready to leave the hospital.

    Fickle said her father needed intensive therapy at Northshore Rehabilitation Hospital in Lacombe, LA. Speaking of the value of IRF care, the hospital’s CEO Laurel Dupont said “one single hospital readmission would cost [MA plans] as much if not more than the entire rehab stay. Northshore Rehab had zero readmissions of an amputee patient during all of 2023.” A study by Dobson DaVanzo & Associates comparing IRF and skilled nursing facility patients found that IRF patients returned home earlier and remained there longer, with lower mortality rates, emergency room visits and hospital readmissions.13

    Several providers report concerning automatic denials for IRF services. In recent months, TIRR Memorial Hermann Health System in Houston reported receiving automatic MA denials for 90% of prior authorization requests. “If they give us a denial, they’ll say you can go to [a peer-to-peer call with our physician] or you can go ahead and discharge to a nursing home, and I’ll give you that approval now,” said financial clearance manager Courtney Roberson, adding that these automatic denials often keep a patient in the hospital for four to five days longer, taking weekends into account.

    Patients also stay in the hospital longer because MA plans are not required to include IRFs in their provider networks, even though IRF services are a Medicare covered benefit. “It’s not right for Medicare beneficiaries to not have access to this level of care,” said TIRR Memorial Hermann CEO Rhonda M. Abbott. “It doesn’t make sense to eliminate a whole level of care.”

    Last year during a congressional hearing, the American Hospital Association (AHA) described how MA plans financially benefit from these post-acute care delays, explaining that “the plan has already paid the hospital a flat rate for care and is either delaying or attempting to avoid discharging the patient to the next site of care, which would require a separate, additional reimbursement. AHA claims data analysis reflects that length of stay in the referring hospital is typically longer for MA beneficiaries than traditional Medicare beneficiaries being discharged to a post-acute setting.”14

    These transfer delays also contribute to the overcrowding of emergency departments. “An example is a patient who is on a regular floor bed who needs to go to post-acute care,” said Baton Rouge emergency physician Dr. John Jones. “I need that bed for my next congestive heart failure patient who’s in the emergency department, and I can’t put them in there because it’s being occupied by somebody who’s waiting three days over the weekend to get placed.”

    Cardiology and Cancer Care

    MA plans also deny care for patients who need high-quality, Medicare-covered cardiology and cancer care services.

    Cardiologist Dr. Joe Deumite, in Baton Rouge, offered two examples. In one case, Humana twice denied care to a man who needed a pacemaker. “He had 73 episodes where his heart paused for more than three seconds and several episodes where his heart paused for up to 5.2 seconds,” he said, adding that the care was finally approved by an independent review entity.

    In another instance, Dr. Deumite said a woman who suffers from irregular heart rhythms has had to go to the emergency room and take medications because Humana denied her appeals to receive a cardiac ablation. “There are several heart rhythms that respond to ablation, where you just slide up a catheter and cauterize a circuit, and its curative.”

    In April, Baton Rouge medical oncologist Dr. Gerald Miletello recorded a social media video testimonial where he described a dangerous care delay for one of his lung cancer patients.15 “A six-week delay is not following the guidelines because you can easily die with stage four cancer in six weeks,” he said.

    Radiation oncologist Dr. William Russell, in Baton Rouge, said his patients have faced delays when they need to start concurrent chemotherapy with radiation. He also criticized MA plans’ requirement that he conduct a CT scan before they will approve a PET scan. “You have to do diagnostic tests that are not going to be as relevant as the one that you wanted,” he said. “It costs the payers more money to go through that process.” The 2024 MA rule prohibits this practice of step therapy for non-drug services.

    Medical oncologist Dr. Michael Castine, in Baton Rouge, said MA plan documentation requests require him to factor in 10 days between planning and implementation of a patient’s cancer treatment. He mentioned risks for patients with small cell lung cancer, aggressive lymphomas or risks of brain metastasis, warning that “a delay of treatment by a week or two might actually change the whole plan.”

    Peer to Peer Frustrations

    Physicians also criticized the quality of communication they received from MA plan physicians when they call to appeal a patient-care denial.

    “They’re making it up as they go along,” said physical medicine and rehabilitation physician Dr. Adam Carter, who serves as medical director of ClearSky Health Rehabilitation Hospital in Flower Mound, Texas. “I see them as constrained by their employer.”

    “You can almost tell by the first 10 seconds into your conversation whether it’s going to work or not, because you can tell whether that physician is reasonable,” said Dr. Deumite. “They’re looking at year-and-a-half old guidelines.”

    Policy Solutions for Improving Medicare Advantage

    Federal leaders have designed a broad range of solutions to help hold MA plans more accountable. Some changes will not begin until 2026, and stakeholders want additional timeliness and transparency requirements for meaningful patient-care improvements.

    Timeliness

    Today, MA plans must make a prior authorization decision within 14 business days for standard requests and 72 hours for expedited or emergency requests. In 2026, the deadline for standard requests will become seven business days. Stakeholders have called for a 24-hour deadline for emergency requests; pending federal legislation would suggest, but not require, CMS to institute such an expedited timeline.16 17

    Reporting

    In 2026, MA plans must begin publicly reporting aggregate contract-level prior authorization metrics, including denial rates and timeliness. Much of this information already exists today. According to KFF, MA plans denied 3.4 million prior authorization requests in 2022. Only one in ten denials were appealed, but more than 8 out of 10 appeals resulted in overturning the denial. With limited data, it’s not possible to determine the initial reasons for these improper care delays. A study by Premier found that MA denials are more common for higher cost treatments, and that hospitals’ average administrative cost to fight these denials is nearly $20 billion a year.18

    Federal leaders, including Louisiana’s U.S. Sen. Bill Cassidy, and multiple provider groups have asked CMS to require MA companies to report more specific and meaningful data.19 20 KFF researchers found that “substantial data gaps remain that limit the ability of policymakers and researchers to conduct oversight and assess the program’s performance, and for Medicare beneficiaries to compare Medicare Advantage plans offered in their area.”21 KFF also found that “without plan-level data, by type of service, it will not be possible to determine whether plans are complying” with the 2024 MA rule.

    KFF also reported that MA companies “do not report the reasons for prior authorization denials to CMS. If most denials of prior authorization requests are because the service was not deemed medically necessary, efforts to increase transparency of the coverage criteria, such as those recently included in a final rule, may be more likely to have an impact.” KFF has also pointed to a lack of transparency related to decisions from the independent review entity that considers appeals after an MA physician denies a request.22

    CMS opted against requiring plan-level data in 2026, saying it did not want to overwhelm consumers and that it wanted to “limit plan burden.”23 The agency will consider more detailed reporting requirements during future rulemaking.

    Internal MA Plan Monitoring

    CMS now requires all MA plans to establish a Utilization Management Committee to review prior authorization policies annually and ensure compliance with traditional Medicare’s national and local coverage guidelines.24 The AHA urged the Medicare Payment Advisory Commission to monitor whether these committees will have authority to overturn harmful policies, writing that “many providers fear that these committees will serve as little more than a rubber stamp for plan policies.”25

    During the public comment period on the 2024 MA final rule, health insurance companies argued that forcing them to follow traditional Medicare’s clinical criteria would lead to “fewer affordable, high-quality plan choices for beneficiaries” and “adverse health impacts.”

    “CMS in the rule does give MA plans certain limited sets of circumstances where they can use their own internal coverage criteria when traditional Medicare criteria is not fully established,” said Michelle Millerick, AHA director for health insurance coverage and policy. “Some MA plans are over-extending that limited flexibility, and there’s not necessarily a clear definition of exactly when Medicare criteria is fully established, especially for level of care determinations. Stronger enforcement of these provisions from the 2024 MA final rule is needed to ensure plans do not continue to use more restrictive criteria than Medicare.”

    Denial Letter Language

    Beginning in 2026, CMS said the prior authorization denial letters must be “sufficiently specific to enable a provider to understand why a prior authorization has been denied and what actions must be taken to resubmit or appeal.” The agency said the MA plans’ reason for denial “could include” a variety of explanations, such as “how documentation did not support a plan of care for the therapy or service” or “specifically, why the service is not deemed necessary.” Experts say they are cautiously optimistic, but that it remains to be seen how effectively CMS will enforce this policy for patients like Carrigan and Sercovich.

    Targeted Auditing/Aggressive Enforcement

    This year, CMS said it will conduct routine and focused audits to assess compliance with the 2024 MA rule. In a statement, the agency said that it “may issue compliance and enforcement actions, including civil monetary penalties to MA organizations who fail to comply with our regulations.” Providers may send complaints with specific examples of MA plans’ noncompliance to [email protected].

    The OIG recently announced plans to audit MA IRF denials and will issue a report in 2026.26 “I can tell you with great certainty that you will see us expanding our oversight of Medicare Advantage in the coming months and years,” said HHS Inspector General Christi A. Grimm during a recent speech to MA company leaders. “We want Medicare Advantage to be successful. OIG’s work helps ensure that the program works as intended for Medicare enrollees and for taxpayers.”27

    In a statement for this article, OIG said providers may email specific concerns to the agency at [email protected]. “Input from health care providers about managed care practices are regularly sent to relevant subject matter experts, including in our agency’s leadership, for their awareness and to inform our work,” wrote OIG.

    Last year, the federal government paid MA plans more than $454 billion to provide high-quality care to more than 30 million people.28 KFF reports that nearly 60 percent of Louisiana’s Medicare beneficiaries are enrolled in an MA plan this year.29 Providers have applauded the OIG for exposing dangerous care denials and for calling on MA corporate leaders to provide better value to patients and taxpayers.30 “The Medicare Advantage plans aren’t going to change until their board of directors at the company understands as a matter of corporate policy that this isn’t the way to go,” said Dr. Carter.

    [1] https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp

    [2] https://oig.hhs.gov/reports-and-publications/all-reports-and-publications/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/

    [3] https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f

    [4] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/downloads/fs1classreq.pdf

    [5] https://www.facebook.com/LAHospitals/videos/252495247935007

    [6] https://oig.hhs.gov/documents/evaluation/3150/OEI-09-18-00260-Complete%20Report.pdf

    [7] https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf

    [8] https://oig.hhs.gov/documents/evaluation/3150/OEI-09-18-00260-Complete%20Report.pdf

    [9] https://pubmed.ncbi.nlm.nih.gov/29309215/

    [10] https://www.ama-assn.org/system/files/principles-with-signatory-page-for-slsc.pdf

    [11] https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022

    [12] https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf

    [13] https://amrpa.org/portals/0/dobson%20davanzo%20final%20report%20-%20patient%20outcomes%20of%20irf%20v_%20snf%20-%207_10_14%20redated.pdf

    [14] https://www.aha.org/testimony/2023-05-17-aha-statement-senate-subcommittee-medicare-advantage-delays-and-denials

    [15] https://www.facebook.com/LAHospitals/videos/1156382158614094

    [16] https://www.congress.gov/bill/118th-congress/senate-bill/4532/text

    [17] https://amrpa.org/Portals/0/AMRPA%20Comments%20on%20MA%20Data%20RFI%20May%202024_Final.pdf

    [18] https://premierinc.com/newsroom/blog/trend-alert-private-payers-retain-profits-by-refusing-or-delaying-legitimate-medical-claims

    [19] https://www.cassidy.senate.gov/newsroom/press-releases/cassidy-warren-blackburn-cortez-masto-call-for-better-medicare-advantage-data-collection-reporting/

    [20] https://www.aha.org/lettercomment/2024-05-29-aha-rfi-response-cms-medicare-advantage-data-and-oversight

    [21] https://www.kff.org/medicare/issue-brief/gaps-in-medicare-advantage-data-remain-despite-cms-actions-to-increase-transparency/

    [22] https://www.kff.org/private-insurance/issue-brief/final-prior-authorization-rules-look-to-streamline-the-process-but-issues-remain/

    [23] https://www.govinfo.gov/content/pkg/FR-2024-02-08/pdf/2024-00895.pdf

    [24] https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C/section-422.137

    [25] https://www.aha.org/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket

    [26] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp

    [27] https://oig.hhs.gov/documents/speeches/1106/IG-Grimm-RISE-transcript.pdf

    [28] https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends

    [29] https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/

    [30] https://youtu.be/fDzAb-6aog8?si=KIuiXj23d2yr8eoP

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  • How much of their revenue do Medicare Advantage insurers spend on care?

    How much of their revenue do Medicare Advantage insurers spend on care?

    You likely do not know that the corporate health insurers offering Medicare Advantage plans are required  to spend at least 85 cents of every dollar they receive from the federal government on enrollees’ health care and can reserve up to 15 percent of their payments for administrative expenses and profits. If insurers get caught spending less than required, the government can prevent them from enrolling new members, as it just did with Centene Medicare Advantage in Missouri. But, Medicare Advantage insurers have ways to get around their spending requirement, leaving many wondering how much of their revenue they spend on enrollees’ health care.

    The well-intentioned goal of the government’s medical spending requirement for insurers, called “the medical loss ratio” or “MLR,” is to help ensure that insurers do not stint on care in Medicare Advantage plans. They have an incentive to do so since they are paid upfront for the services they deliver, regardless of the amount they spend on care. The less they spend, the more they profit. However, the insurers have ways to circumvent the MLR requirements, including through vertical integration. They can pay their subsidiary companies–which might employ providers or distribute medical supplies and prescriptions–for the services they offer, at rates higher than their actual cost.

    No question that CMS should punish Centene for failing to meet its medical loss ratio requirements. But, it’s probably the case that UnitedHealthcare, Aetna and Humana have engaged in similar conduct, and they are not being punished. Experts at Brookings explain that it is permissible for insurers to pay their subsidiary businesses more than they actually spend, when calculating the MLR. For example, UnitedHealthcare can pay its subsidiary OptumHealth, which employs providers, 85 percent of the amount it receives from the government, and then pay its providers less than that amount. It can then keep, as part of its Optum business, whatever it doesn’t spend as profits.

    Centene is facing a suspension of its enrollment of new members in Wellcare of Missouri, its Medicare Advantage plan, because it violated the medical loss ratio requirements, as well it should. The question is why Medicare Advantage insurers should be allowed to escape penalty for not spending enough money on patient care by transferring payments to subsidiary companies?

    Until Congress and the administration find ways to prevent insurers from gaming the Medicare Advantage program and to hold insurers accountable through meaningful penalties when they engage in fraud, insurers will continue to do so and patient care will be at risk.

    Here’s more from Just Care:

  • 24 health systems drop their Medicare Advantage contracts

    24 health systems drop their Medicare Advantage contracts

    When Congress passed legislation allowing corporate health insurers to offer Medicare benefits, our representatives may not have appreciated that the new law would effectively be increasing shareholder value for the biggest health insurers and putting millions of vulnerable older adults and people with disabilities at risk of not getting needed care. They likely did not imagine that Medicare Advantage insurers would inappropriately underpay hospitals, nursing homes, home health agencies and rehabilitation facilities, harming them financially or, worse still, forcing them to close their doors. Jakob Emerson reports for Beckers on how 24 health systems across the country are dropping their Medicare Advantage contracts because they are not able to deliver Medicare Advantage enrollees the care they need and because insurers are not paying them appropriately.

    In all likelihood, the corporate health insurers offering Medicare Advantage likely did not start off engaging in the bad acts many of them currently engage in, including using prior authorization processes excessively, delaying and denying care inappropriately, and failing to pay physicians and hospitals adequately. Nor were they overcharging the government excessively at the outset. But, today, more than six in ten provider CFOs say that the obstacles to care and payment are only getting worse.

    Beckers now lists 24 health systems that are ending their Medicare Advantage contracts, some with all Medicare Advantage insurers. Other health systems are cancelling contracts with UnitedHealthcare and/or Humana, two of the largest Medicare Advantage insurers. The list is not comprehensive. So, if you’re in a Medicare Advantage plan now, check to see whether you will be able to continue to use the doctors and hospitals you want to use or whether they are no longer in the provider network.

    In California, Scripps Health ended all its Medicare Advantage contracts for its integrated medical groups this year.

    In Delaware, ChristianaCare cancelled its contract with Humana’s Medicare Advantage plans as of Jan. 1.

    In Illinois, Blessing Health is only continuing its contracts with BCBS, UnitedHealthcare, Molina and Total Retiree Advantage.

    In Indiana, Powers Health (formerly Community Healthcare System) cancelled their contracts with Humana and Aetna’s Medicare Advantage plans on June 1.

    In Kansas, LMH Health is cancelling contracts with Aetna and Humana Medicare Advantage in 2025.

    In Kentucky, Baptist Health cancelled its contract with UnitedHealthcare Medicare Advantage and Centene’s WellCare this year.

    In Maine, Northern Light Health is cancelling its Medicare Advantage contract with Humana beginning October 1.

    In Michigan, MyMichigan Health is cancelling its Aetna Medicare Advantage contract in 2025.

    In Minnesota, HealthPartners is cancelling its contract with UnitedHealthcare Medicare Advantage plans in 2025. Essentia Health is cancelling its contracts with UnitedHealthcare and Humana Medicare Advantage in 2025.

    In Missouri, Cameron (Mo.) Regional Medical Center cancelled its Aetna and Humana Medicare Advantage contracts this year.

    In Nebraska, Kimball (Neb.) Health Services is cancelling all its Medicare Advantage contracts in 2025.

    In Nevada, Carson Tahoe Health is cancelling its contract with UnitedHealthcare Medicare Advantage in 2025.

    In New York, Med Health System cancelled its contract with Humana Medicare Advantage on July 1.

    In North Carolina, ECU Health cancelled its Humana’s Medicare Advantage plans in January.

    In Ohio, Aultman Health System hospitals are cancelling their contracts with Humana Medicare Advantage in 2025. Genesis Healthcare System cancelled contracts with Anthem BCBS and Humana Medicare Advantage plans in January.

    In Oklahoma, Comanche County Memorial Hospital cancelled its contract with UnitedHealthcare Medicare Advantage plans on May 1.

    In Oregon, Samaritan Health Services‘ hospitals cancelled its contracts with UnitedHealthcare’s Medicare Advantage plans on Jan. 9. They are cancelling contracts for physicians and provider services on Nov. 1. St. Charles Health System cancelled its contracts with Humana Medicare Advantage and Centene MA.

    In Pennsylvania, WellSpan Health ended its Humana Medicare Advantage and UnitedHealthcare Medicare Advantage plans on Jan. 1. It still accepts some UnitedHealthcare D-SNP plans.

    In South Dakota, Sanford Health is cancelling its Humana Medicare Advantage in Minnesota in 2025. Brookings (S.D.) Health System cancelled all its Medicare Advantage contracts this year.

    In Texas, Memorial Hermann Health System ended its contract with Humana Medicare Advantage on Jan. 1.

    Here’s more from Just Care: