Why would people with serious health conditions remain in a Medicare Advantage plan that restricts access to good doctors and hospitals and delays and denies approval for the care their treating physicians say they need? Many don’t. But, when they leave, they burden traditional Medicare and certain Medicare Advantage plans with higher spending.
A new study published in Health Affairs finds that Medicare Advantage enrollees in sicker health tend to disenroll and switch into traditional Medicare, if they can, or Medicare Advantage plans with broader networks, at a disproportionate rate. Consequently, traditional Medicare and certain Medicare Advantage plans are left with enrollees who need more medical care and cost more. What should be done about this?
Ideally, CMS would stop allowing insurers to offer Medicare Advantage plans if they do not disclose key data about their plans, as they are required to do. And, CMS would penalize insurers with inadequate networks and inappropriate prior authorization rules in meaningful ways. Until then, people cannot make an informed choice about Medicare Advantage plans and gamble with their health and, sometimes, their lives, when enrolling in one. Of course, CMS should allow them to leave if they cannot get the care they need.
When designing Medicare Advantage, people considered the risk of adverse selection–people in poorer health signing up at disproportionate rates with certain Medicare plans–and attempted to address it through higher payments to MA plans with sicker enrollees and restricted ability for enrollees to disenroll. But, that was not enough to ensure Medicare Advantage plans meet the needs of enrollees with complex conditions. It is still against the interest of insurers to enroll people with cancer and other costly conditions and, when their enrollees need costly care, insurers have ways of encouraging them to disenroll.
Insurers have been able to game the Medicare payment system and design their MA plans so that they are unattractive to people in poor health. The biggest insurers find ways to make their enrollees look sicker than they are, limit their provider networks and use prior authorization to deter people with serious conditions from remaining in their Medicare Advantage plans.
There is no way for people to avoid MA plans that can’t meet their needs. Information that would allow people to distinguish among MA plans is limited at best. Star-ratings are a farce and enrolling in four and five-star plans offers no guarantee that people will get needed care.
So, allowing MA enrollees to disenroll when they discover their plans won’t meet their needs is critical. Thankfully, the Centers for Medicare and Medicaid Services has opened up new pathways for MA enrollees to disenroll outside of the Annual Open Enrollment Period between October 15 and December 7 each year and the Medicare Advantage Open Enrollment Period between January 1 and March 31 each year. People can also disenroll in order to switch into a five-star MA plan or to leave a poor performing MA plan, or an MA plan whose network providers leave, among other reasons.
Here’s more from Just Care:
- Seven questions you should be asking this Medicare Open Enrollment period
- Medicare Advantage offers less care at greater cost
- People living in rural communities disenroll from Medicare Advantage at a high rate
- People with serious health needs more likely to disenroll from Medicare Advantage plans
- Medicare Advantage insurers face few penalties for their bad acts
