Insurance Exchange Online

08/27/2025

Health insurers submit rate filings annually to state regulators detailing expectations and rate changes for Affordable Care Act (ACA)-regulated health plans for the coming year. A relatively small, but growing, share of the population is enrolled in these plans (compared to the number in employer p...

07/25/2025

This law makes unprecedented cuts to critical safety-net programs that provide health care and other assistance.

02/12/2025

California Health Advocates (CHA) strongly supports Senator Blakespear's recently introduced bill, SB 242, the Medigap Access and Protection Act, which

01/17/2024

https://www.facebook.com/100064898823624/posts/760200556153232/?mibextid=Nif5oz

It's finally done. Medi-Cal's asset limit was officially eliminated as of January 1, 2024. This is a moment that we at California Health Advocates, as well as

10/20/2023

This is why you are prescribed Brand-name medications

10/21/2022

Medicare Advantage Overpayments

A recent and notable article about Medicare Advantage was published in the New York Times, titled ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions” (Oct. 8, 2022) by Reed Abelson and Margot Sanger-Katz. This article focuses on “how major health insurers exploited the [Medicare] program to inflate their profits by billions of dollars.” Noting that most large insurers offering MA plans have been accused of fraud in various lawsuits, the article outlines how MA insurers, “among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits” and “[a]s a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.”

The article notes that even conservative estimates of the scope of such overpayment ($12 billion in 2020 alone, according to MedPAC), would be enough to “cover hearing and vision care for every American over 65.” As discussed in a previous CMA Alert (March 3, 2022), for a brief period of time during the Build Back Better debate , Congress contemplated reining in these overpayments to help pay for expanding dental, hearing and vision services for all Medicare beneficiaries – not just those enrolled in private plans – until the insurance industry stepped in to keep things the way they are.

Noting that there are trade-offs in enrolling in Medicare Advantage rather than traditional Medicare, the article states that MA plans “often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.” This phenomenon, of course, draws more people to MA, accelerating the privatization of the Medicare program.

Not surprisingly, the insurance industry is trying to change this narrative by claiming that MA actually saves Medicare money – despite overwhelming evidence to the contrary. For example, STAT recently published an article titled “Health insurers are painting a misleading picture of Medicare Advantage savings, experts say” (Sept. 26, 2022), by Bob Herman, which documents how “[t]he health insurance industry is continuing its campaign to convince the public that Medicare Advantage saves taxpayers money, but experts say federal data still concludes the exact opposite — and that the program as currently designed is a drain on Medicare’s trust fund.”

The Urban Institute recently added another analysis of MA overpayments in a paper titled “Understanding Medicare Advantage Payment: How the Program Allows and Obscures Overspending” (Sept. 27, 2022) by Robert A Berenson, Bowen Garrett and Adele Shartzer. Among other things, the paper describes components of the MA payment system, how they contribute to overpayment to MA plans, and outlines reform proposals “that would improve MA and generate program savings that could help shore up Medicare's financing or reduce federal budget deficits.” As simply stated in the report’s introduction, “although MA was also supposed to generate Medicare program savings, it never has.”

The Center for Medicare Advocacy has long called upon policymakers to address the growing imbalance between Medicare Advantage and traditional Medicare, and to step up enforcement over plans to stop plans’ inappropriate denials and delays in care. It is long past time to act.

09/22/2022

Kaiser Family Foundation Releases Report Regarding Differences Between Traditional Medicare and Medicare Advantage



On September 16, 2022, the Kaiser Family Foundation (KFF) released a report titled Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare: A Review of the Literature. The report reviewed 62 studies published since 2016 that compare Medicare Advantage (MA) and traditional Medicare on a number of measures, including “beneficiary experience, affordability, utilization, and quality [and] finds few differences that are supported by strong evidence or have been replicated across multiple studies” according to a press release accompanying the report.



As noted in the report, “[t]he growing role of Medicare Advantage and the relatively high spending on this program raise the question of how well private plans serve their enrollees compared to traditional Medicare.” While the press release noted that “relatively few studies specifically examined specific subgroups of interest, such as beneficiaries from communities of color, living in rural areas, or dually eligible for Medicare and Medicaid, making it difficult to assess the strength of the findings or how broadly they apply”, the research did identify “noteworthy differences” between MA and traditional Medicare.



The Executive Summary of the report states:





We found few differences between Medicare Advantage and traditional Medicare that are supported by strong evidence or have been replicated across multiple studies. Both Medicare Advantage and traditional Medicare beneficiaries reported similar rates of satisfaction with their care and overall measures of care coordination. Medicare Advantage outperformed traditional Medicare on some measures, such as use of preventive services, having a usual source of care, and lower hospital readmission rates. However, traditional Medicare outperformed Medicare Advantage on other measures, such as receiving care in the highest-rated hospitals for cancer care or in the highest-quality skilled nursing facilities and home health agencies. Additionally, a somewhat smaller share of traditional Medicare beneficiaries than Medicare Advantage enrollees experienced a cost-related problem, mainly due to lower rates of cost-related problems among traditional Medicare beneficiaries with supplemental coverage. Several studies found lower use of post-acute care among Medicare Advantage enrollees but were inconclusive as to whether that was associated with better or worse outcomes. Findings related to the use of other health care services, including hospital care and prescription drugs, and condition-specific quality of care measures varied – likely due to differences in data and methodology across studies.





According to these studies, MA appears to perform worse than traditional Medicare in certain areas, including:

Switching from MA to TM: “rates of switching from Medicare Advantage to traditional Medicare were relatively higher among beneficiaries who are dually eligible for Medicare and Medicaid, beneficiaries of color, beneficiaries in rural areas, and following the onset of a functional impairment. Switching rates may be a proxy for dissatisfaction with current coverage arrangements.” Post-Acute Care: “lower rates of skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and home health use among Medicare Advantage enrollees, and shorter lengths of stay in SNFs and IRFs for Medicare Advantage enrollees than traditional Medicare beneficiaries” Quality of Providers: “Medicare Advantage enrollees were less likely than traditional Medicare beneficiaries to receive care in the highest-or lowest-rated hospitals overall or in the highest-rated hospitals for cancer care, skilled nursing facilities (SNFs), and home health agencies.” Affordability: “a somewhat larger share of Medicare Advantage enrollees than traditional Medicare beneficiaries experienced a cost-related problem, mainly due to lower rates of cost-related problems among traditional Medicare beneficiaries with supplemental coverage […] Medicare Advantage enrollees who are Black, under age 65 with disabilities, or in fair or poor health were more likely to report cost-related problems than their traditional Medicare counterparts.”

Correspondingly, the areas in which MA appears to outperform TM include:

“use of preventive services” “more likely to report having a usual source of care” “Medicare Advantage enrollees reported better experiences getting needed prescription drugs than traditional Medicare beneficiaries overall, but among beneficiaries with specific conditions, findings were mixed” Hospital readmission rates “were generally lower in Medicare Advantage than in traditional Medicare”

The conclusion of the report notes: “As Medicare Advantage plans continue to have an expanding role in the Medicare program, the studies in our review provide useful context for understanding how well Medicare Advantage plans are serving their enrollees relative to traditional Medicare. At the same time, data limitations remain a significant concern.”



Analysis



As noted in a separate KFF report, Medicare Advantage is projected to exceed more than half of all Medicare beneficiaries as soon as next year. At the same time, it is well documented that MA plans are overpaid, and such overpayments unnecessarily drive-up programmatic spending. But what have Medicare beneficiaries and the Medicare program as a whole gained from these overpayments?



Not surprisingly, the insurance industry often paints MA as “better” for beneficiaries than traditional Medicare, issuing statements such as “More than 28 million seniors and people with disabilities choose Medicare Advantage (MA) because it delivers better services, better access to care, and better value” (AHIP), and MA is “delivering better health outcomes, through better quality care at a better cost for Medicare beneficiaries” (Better Medicare Alliance).



But is Medicare Advantage really “better” than traditional Medicare? According to this KFF report and its analysis of recent studies, coupled with our own experience serving Medicare beneficiaries who need care for significant illnesses or injuries, the answer is an unequivocal “no”.

09/07/2022

Key Medicare Enrollment Improvements Start in January 2023, Thanks to the BENES Act 😊

Plus many other great updates in our September newsletter
- https://mailchi.mp/cahealthadvocates/key-medicare-enrollment-improvements-start-in-january-2023-thanks-to-the-benes-act

04/10/2022

Commonwealth Fund Blog Series About Medicare Advantage



Over the last several weeks, the Commonwealth Fund, a private foundation with a mission “to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable”, has posted a series of blogs focusing on different aspects of the Medicare Advantage (MA) program: Payment, Risk Adjustment, Choice, Quality, Special Needs Plans and Benefit Design.



One of the most recent posts, for which the Center for Medicare Advocacy was consulted, is titled Taking Stock of Medicare Advantage: Benefit Design (March 31, 2022). While this blog series draws from a number of perspectives about the MA program, including those with which we disagree, they touch on many issues that the Center for Medicare Advocacy has been highlighting, including:

Payments – “Among the experts we spoke with, there was broad consensus that the payment system creates inefficiencies. While there was less agreement on how to fix it, many pointed to policy changes that could make the payment system more equitable and competitive.” Risk Adjustment – Noting that “payments to Medicare Advantage plans continue to be above what CMS spends on comparable beneficiaries in traditional Medicare,” the post includes an examination of “whether the current system fuels overpayments to plans or encourages plans to enroll certain beneficiaries but not others and, if so, what policy changes may be needed to remedy these problems.” Choice – “The health economists and Medicare experts we spoke with said choosing among plans can be difficult, even for the savviest consumers.” Further, “the experts agreed that most beneficiaries aren’t making informed or active decisions. Instead, many choose plans based on advertising, word-of-mouth, or brand loyalty, then stay with those plans year after year, even if another plan would better serve their interests.” Among potential remedies, “States or the federal government could substantially enhance beneficiary choice by requiring insurers that sell Medigap policies.” Quality – “The quality bonus program in Medicare Advantage is expensive. Since 2015, it has paid out $47.5 billion in additional plan payments, offsetting cuts imposed by the Affordable Care Act.” Further, “Several of the experts we spoke with consider the quality bonuses unjustifiably expensive and ineffective.” In addressing the question “How does Medicare Advantage compare to the traditional, fee-for-service program when it comes to quality of care?” several research topics were proposed, including “the factors driving disenrollment from Medicare Advantage plans as patients become sicker, and how plans’ prior-authorization requirements affect quality of care.” Special Needs Plans – “Most of the experts viewed SNPs as a good platform for tailoring care to people’s needs” but they “also agreed not enough is known about whether and how SNPs are customizing care” and that “[m]ore should be done to assess the impact of SNPs on beneficiaries’ health.” Benefit Design – Because of flexibility given to MA plans with respect to the type of supplemental benefits they offer and to whom, “determining which plans offer which supplemental benefits and to whom is not easy.” Further, “Despite the out-of-pocket cap, Medicare Advantage enrollees may be exposed to higher costs than in traditional Medicare (e.g., during an extended hospital stay). These costs may not be anticipated or easily determined when enrolling in a Medicare Advantage plan. Some experts wanted to see more standardization in cost-sharing methods to help beneficiaries sort through plan options.” In addition, “Some experts raised concerns about the ubiquity of prior authorization requests, noting they are increasing as more people enroll in Medicare Advantage and are now used even for low-cost services like transportation to medical appointments. […] A related concern is that plans are using proprietary, algorithm–driven systems to make decisions (including those requiring prior authorization) about approving coverage for services. Some experts wanted to see more regulation — if not an outright ban — on such systems until their validity is established.”