In response to widespread complaints that too many patients have been unfairly denied medical entitlements and that the plans’ marketing is deceptive, federal health officials are proposing a comprehensive set of stricter rules for private Medicare Advantage health plans.
Medicare Advantage is the private-sector alternative to the federal program for those age 65 and older and those with disabilities. By next year, more than half of Medicare beneficiaries are expected to be enrolled in private plans. These policies are often cheaper than traditional Medicare and sometimes offer attractive perks like dental care.
Despite their popularity, the plans have recently been the subject of considerable scrutiny and criticism. A recent report from the US Department of Health and Human Services inspector general found that several plans may be inappropriately denying patients care. And nearly every major insurance company in the program, including UnitedHealth Group, Elevance Health, Kaiser Permanente, and Cigna, has been sued by the Justice Department for fraudulently overtaxing the government.
The period leading up to this year’s registration deadline, 7/12, fueled widespread criticism of the fraudulent tactics some brokers and insurers had used to trick people into switching plans. In November, Senate Democrats released a scathing report detailing some of the worst practices, including ads that appeared to represent federal agencies and ubiquitous television commercials starring celebrities.
Federal Medicare officials had said they would review television ads before they aired, and the new rule addresses some of the practices identified in the Senate report that led some consumers to confuse the companies with the state’s Medicare program. A proposed regulation would ban plans from using the Medicare logo and require that the company be identified behind the ad.
“For brokers and insurers, this is certainly a shot across the bow in response to the growing number of complaints about deceptive marketing activities,” said Tricia Neuman, executive director of the Center for Medicare Policy at the Kaiser Family Foundation. Woman. Neuman and her team routinely review television commercials from the plans.
The proposal would also allow beneficiaries to opt out of marketing calls for plans and would limit how many companies can contact a beneficiary after he or she fills out a form requesting information. The Senate report described patients who had received dozens of aggressive marketing calls they had not requested.
David Lipschutz, associate director of the Center for Medicare Advocacy, said that while the federally proposed rules didn’t include everything on his wish list, the goals were broad and significant.
“That’s really a sensible answer,” he said. “And where we’re sitting, we can’t say that very often.”
Mr. Lipschutz said the changes would ultimately be judged on how effectively and aggressively Medicare has enforced the standards. Much of the deceptive marketing is now done by brokers, agents and other third-party marketing firms, who receive commissions when they enroll people, rather than the insurers themselves. The proposed rule would hold insurers accountable for the actions of the firms they hire drag.
“These proposals are an important step in protecting seniors on Medicare from fraudsters and unscrupulous insurance companies and brokers,” said Senator Ron Wyden, the Oregon Democrat who chairs the Senate Finance Committee, in a statement.
The rules would also address the health plans’ use of techniques that require the company to approve certain treatments before they are covered. Patients and their doctors complained to Medicare that private health plans abused prior approval processes to deny needed care. The inspector general’s report estimates that tens of thousands of people have been denied essential medical care that should be covered under the program.
The new proposal would require plans to disclose the medical basis for denials and rely more on specialists familiar with a patient’s care to be involved in decision-making. Medicare has also set stricter approval response deadlines; Today, patients often wait up to 14 days. The new rules would also require one permit to cover the entire duration of a treatment, so patients don’t have to apply for identical permits all the time.
Dr. Meena Seshamani, the director of the Center for Medicare and associate administrator of the Center for Medicare and Medicaid Services, said the changes were influenced by thousands of public comments requested by the agency and lawmakers.
“The proposals in this rule, we think, would really meaningfully improve people’s timely access to the care they need on Medicare,” she said.
The insurance industry has said it supports regulators’ efforts to protect Medicare members from misleading marketing in general, and the Better Medicare Alliance, a group that advocates for Medicare Advantage, said it agrees with officials, “That there must be no place in the system for those who would deceive seniors,” said the group’s chief executive, Mary Beth Donahue, in a statement.
Woman. Donahue added that her group is continuing to review the agency’s proposals for how patients must obtain prior authorization for treatment. She said the organization hopes to work with Medicare officials to improve the process.
Hospitals, which have been pushing for changes that would address their concerns that insurers are abusing prior approval, welcomed the proposals. However, they emphasized that the Biden administration’s health authorities must commit to enforcing the stricter oversight.
“The agency really needs to stay on the ball,” said Molly Smith, group vice president of public policy at the American Hospital Association, a trade organization.
The proposed regulations are not yet final. Health officials solicit comments from the public and may make changes.