U.S. Health Officials Seek New Curbs on Private Medicare Advantage Plans

In response to widespread complaints that many patients' claims were wrongly denied or that the marketing of private Medicare Advantage plans is misleading, federal health officials have proposed a comprehensive set of stricter rules for private Medicare Advantage plans.

Medicare Advantage, a private sector alternative to the federal program that covers those aged 65 and older and those with disabilities, is Medicare Advantage. More than half of Medicare beneficiaries will be enrolled in private plans by next year. These policies can be more affordable than traditional Medicare, and often offer attractive additional benefits such as dental care.

Despite their popularity the plans have come under intense scrutiny and criticism. Recent inspections by the U.S. Department of Health and Human Services revealed that many plans could be delaying care. The Justice Department has sued nearly all large insurance companies in the program, including UnitedHealth Group and Elevance Health as well as Kaiser Permanente and Cigna for fraudulently charging the government.

In the period before Dec. 7, this year's enrollment deadline, there was widespread criticism of the misleading tactics used by brokers and insurers to get people to switch plans. Senate Democrats released a damning report in November detailing the worst practices. This included ads that appeared to be from federal agencies, and ubiquitous TV commercials with celebrities.

Federal Medicare officials had stated that they would inspect television advertising before it was aired. The new rule targets some of those practices identified by the Senate report that led to confusion among consumers about the differences between the private sector and government Medicare programs. The proposed regulation would prohibit the use of the Medicare logo by the plans and require that the company behind it be identified.

Tricia Neuman (executive director, Kaiser Family Foundation's center for Medicare policy) stated that it was a positive step for insurers and brokers to respond to growing complaints about misleading marketing. Ms. Neuman, along with her team, regularly review TV ads based on the plans.

It would allow beneficiaries to opt-out of marketing calls regarding plans. The proposal would also limit the number of companies that can contact beneficiaries after they have filled out a form asking information. According to the Senate report, patients had received numerous aggressive marketing calls that they didn't request.

David Lipschutz, associate director at The Center for Medicare Advocacy, stated that although the federally proposed rules didn't include all of his wishes, the goals were significant and broad-reaching.

He said, "This is a really meaningful response." "And we don't get that much time to say it where we are sitting."

Mr. Lipschutz stated that the final outcome of the changes would be determined by how aggressively and effectively Medicare enforced them. Many deceptive marketing activities are now being carried out by agents, brokers, and other third-party marketers who receive commissions for enrolling people. The rule proposed would make insurers responsible for the actions taken by the firms they hire.

Senator Ron Wyden (an Oregon Democrat) stated in a statement that these proposals were an important step towards protecting Medicare seniors from scammers, unscrupulous insurers and brokers.

These rules will also cover the use of certain techniques by health plans that require approval from the company before they can be covered. Medicare received complaints from patients and doctors that private plans used prior authorization processes to deny necessary care. According to the inspector general's report, tens of thousand of people were denied medical care that was required by the program.

New proposals would require that plans disclose the medical reason for denials, and that they rely more heavily upon specialists who are familiar with the patient's care in order to participate in decision-making. Patients are often left waiting up to 14 days for authorizations. Medicare also has tighter deadlines. Patients won't need to request the same approvals every time they receive authorization under the new rules.

Dr. Meena Sashani, director of the Center for Medicare and deputy administrator at Center for Medicare and Medicaid Services, stated that the changes were influenced by the thousands of comments received by the agency and lawmakers.

She stated that she felt the proposals in this rule would improve Medicare's timely access to care for people who need it.

According to Mary Beth Donahue, chief executive of the Better Medicare Alliance (a group that promotes Medicare Advantage), the insurance industry said it supports regulators' efforts to protect Medicare enrollees against deceptive marketing. Mary Beth Donahue, the group's chief operating officer, stated that the group agreed with officials that there should be no place in the system for seniors who would deceive them.

Ms. Donahue said that her group continued to examine the proposals of Medicare regarding how patients should seek prior authorization to receive treatment. She stated that the organization was open to working with Medicare officials to improve this process.

The proposals were welcomed by hospitals, who have long pushed for reforms to address concerns about insurers abusing prior authorization. They stressed that the Biden administration's health officers would have to take a stronger stance in enforcing these changes.

Molly Smith, Molly Smith, group vice president for policy at the American Hospital Association, said that the agency needs to be focused on the big picture.