What are the Risks to People Enrolled in Medicare Advantage Plans?

January 2023

by Diane Archer, Senior Advisor on Medicare, Social Security Works

Many people are drawn to MA plans because they’re cheaper than Traditional Medicare, as long as you don’t need a lot of medical care. But, Medicare Advantage plans are all different, some far better than others. When you get sick, some MA plans, maybe even many, cost people a lot more financially, emotionally and physically.

 

Three major risks for enrollees requiring costly care in MA plans.

  • Financial barriers to care resulting in health inequities.
  • Inappropriate denials and delays of care by many MA plans.
  • Poor information for people to distinguish among MA plans based on quality of care.

 

Financial barriers to care and health inequities. 

  • Copays and deductibles when you need a lot of care can be as high as $8,300 a year in some MA plans. People on fixed incomes with cancer, stroke, or needing rehab, nursing and hospital services are at substantial financial and health risk, as are Black and Hispanic people.
  • Older adults with complex conditions too often can’t afford the care they need; they might be forced to skip care or to ration limited dollars for food and shelter.

 

Inappropriate denials of care.

  • Some MA plans deny critical coverage to enrollees, even when it is required.
  • The government pays Medicare Advantage plans a fixed upfront amount unrelated to the cost of care they cover. MA plans can maximize profits by delaying and denying care.
  • OIG has twice reported widespread and persistent care denials in some MA plans. Some MA plans restrict access to high value health care providers, including cancer centers of excellence.
  • In plans with high denial rates and restricted networks, quality of care becomes a big concern.

 

Poor information on quality of care to distinguish among MA plans.

  • MedPAC has reported year after year that, overall, MA plans fail to disclose complete and accurate patient encounter data, as required. Without that data, MedPAC can’t assess quality in MA, and enrollees can’t know which MA plans are not delivering good quality care.
  • The MA star-rating system is misleading at best. It’s simply impossible for even the most motivated people to make an informed MA choice. It needs replacing.
  • Moreover, without good data, we don’t know whether any particular MA plan offers value to enrollees or Medicare.

 

Lack of MA plan accountability:

CMS has never held MA plans accountable in a meaningful way for wrongly denying coverage, failing to provide data, inadequate networks and more, nor has CMS acted to protect people from enrolling in MA plans that are bad actors. One academic study found that if CMS canceled contracts with the five percent of MA plans that are the worst actors it would save 10,000 lives each year.

 

What needs to be done to protect enrollees in Medicare Advantage?

  1. The MA five-star rating system needs an overhaul, as MedPAC has said. And, plans that don’t submit the data MedPAC needs to assess quality should get a 1 or no star rating.
  2. MA plans that are found to inappropriately deny care in a widespread and persistent way should get a one or no star rating until they comply with Medicare rules. They should be required to disclose their prior authorization rules to ensure they’re in sync with traditional Medicare coverage policies. If they continue to deny care inappropriately, their contracts should be canceled automatically.
  3. MA plans should, at a minimum, be required to include centers of excellence in their networks and, better still, should be required to cover care from all Medicare providers at the Medicare rate to ensure their enrollees have access to quality care.