CMS calls for public input to improve Medicare Advantage

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Diving Brief:

  • CMS is seeking public input on how to make the Medicare Advantage program more affordable, sustainable, and equitable for enrollees, while improving health outcomes. The agency issued a request for information on Friday to help with future rule and policy development.
  • The request for public input comes after the HHS Inspector General’s office identified a pattern of improper coverage denial by Medicare Advantage plans, and the American Hospital Association accused MA plans of unlawfully restricting access beneficiaries to medically necessary care. The AHA urged the CMS and Congress to hold the plans accountable.
  • CMS said it seeks to increase engagement with its partners and the communities it serves, encouraging contributions from beneficiary advocates, plans, providers, community organizations, researchers, employers, unions and others.

Overview of the dive:

Seniors have flocked to Medicare Advantage plans over the past decade, lured by affordable premiums, prescription drug coverage, additional benefits such as dental and vision care, and other features. The plans’ popularity has pushed overall enrollment in the program to 29 million participants, or 45% of all Medicare members. Medicare pays private insurers flat rates to manage the care of program beneficiaries.

But along with the success of the plans, accusations of abusive payments and denial of care have been added. Senate and House lawmakers have called for increased oversight of the program, raising concerns about the quality of coverage offered by Medicare Advantage plans and unscrupulous practices to increase reimbursement for MA organizations.

HHS’s OIG released a report in April that found Medicare Advantage plans were improperly denying enrollees care, denying 13% of pre-authorization requests that would have been approved under traditional Medicare. Plans also denied 18% of claims that should have been approved.

The OIG report urged CMS to update its audit protocols and issue new guidance on medical necessity reviews conducted by schemes. The researchers also warned that the program is a key factor in Medicare’s overall budget difficulties.

In its request for information from the public, CMS said it was seeking input from a wide variety of voices. “We see a huge opportunity to partner with as many stakeholders as possible to better understand how care innovations are changing outcomes and costs and how Medicare Advantage works for enrollees,” Meena Seshamani, CMS Deputy Administrator and Director from the Center for Medicare, said in a report.

CMS asked for feedback on steps the agency can take to improve health equity for all MA enrollees and what tools beneficiaries need to select Medicare coverage options. The agency also seeks information on how to support payment innovation, responsible care delivery, and effective competition in the Medicare Advantage market.

CMS said public comments must be received by the agency by August 31.

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