Efforts Continue to Address Medicare Advantage Challenges

(Oct. 22, 2024) Many members report challenges when interacting with large commercial Medicare Advantage (MA) organizations, including payment denials and reductions, low reimbursement rates, and onerous prior authorization practices. Federal policymakers have been focusing on these issues with LeadingAge National actively engaged in the discussions, which includes providing feedback to help inform future actions. Most recently, the U.S. Senate issued a report from the Subcommittee on Investigations titled Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care. The report finds that the plans examined – United Healthcare (UHC), CVS/Aetna, and Humana – which comprise 60 percent of the MA market nationwide, are denying care in pursuit of cost savings. The LeadingAge press statement on the report can be found here.

Specifically, the report noted that:

in 2022, UHC and CVS/Aetna denied prior authorization requests for post-acute care at rates 3 times higher than their overall rates of denial, while Humana denied post-acute care service requests at a rate 16 times higher than its overall rate of denial.
UHC’s denial rate for skilled nursing facility care increased by a factor of nine between 2019 and 2022, from an initial denial rate of 1.4 percent in 2019 to an initial denial rate of 12.6 percent in 2022.
NaviHealth’s artificial intelligence (AI)-driven algorithm was used to determine length of stay regardless of the person’s actual clinical need.

In support of these efforts, LeadingAge National continues to seek member organization participation in their MA prior authorization data collection initiative. Members, especially nursing home members who do a material volume of business with MA plans, are urged to submit their data to assist in efforts to improve the Advantage program. Information on participation is available here.

Along these lines, LeadingAge National offered its input to the Centers for Medicare and Medicaid Services (CMS) on CMS' proposed data collection regarding MA plan initial service determinations and appeals (CMS-10905) in a comment letter submitted Oct. 8^th. In addition to CMS-outlined goals of ensuring that plans are operating in accordance with CMS guidelines, and providing appropriate access to covered services and benefits, LeadingAge National has been pushing for CMS to have Advantage plans report prior authorization data for these exact purposes. Under the proposed data collection, MA plans would be expected to report quarterly to CMS on a series of data elements related to initial service determinations and appeals.

MA discussions are timely given that Medicare beneficiaries are currently in the open enrollment period through Dec. 7^th, during which they can decide how to receive their Medicare benefits. A fact sheet from LeadingAge National titled Top 5 Things to Know About Medicare Open Enrollment outlines important considerations for beneficiaries along with tips on how aging services providers can support clients and share information on available options during open enrollment. These include:

hosting an education session or coffee chat on MA and Medicare;
distributing a list of plans with which you contract;
inviting local State Health Insurance Assistance Program staff to present on the various plan options and answer questions;
sharing resources for unbiased information in your newsletter or through email; and
hosting Medicare/MA office hours in your computer lab or community room.

Note that MA regulations permit providers to:

distribute unaltered, printed material created by CMS (e.g., Medicare and You Handbook);
provide a list of MA organizations with which they contract or participate;
answer questions or discuss merits of a MA plan(s), including cost sharing and benefit information;
refer patients/residents/individuals to other information sources like the State Health Insurance Assistance Program or Medicare.gov;
refer to MA plan marketing materials available in common areas; and
provide information and assistance in applying for a MA plan.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841