A group of Democratic lawmakers recently expressed concerns that Medicare Advantage (MA) is failing to meet its standards.
Medicare Advantage is an optional, private insurance alternative to traditional Medicare created to provide seniors and people with disabilities with private-sector plan options.
The lawmakers, led by Sen. Ron Wyden (D-OR), chair of the Senate Finance Committee, wrote a letter to the head of the Centers for Medicare & Medicaid Services and raised several concerns.
Specifically, they said the Medicare Advantage plans are not delivering for seniors and Americans with disabilities, including the growing use of prior authorization to deny or delay care and, in particular, the use of algorithms and artificial intelligence tools to make coverage determinations.
“In many instances, Medicare Advantage plans are failing to deliver, compromising timely access to care and undermining the ability of seniors and Americans with disabilities to purchase the coverage that’s right for them,” the lawmakers wrote. “We call on CMS to use every regulatory, oversight, and enforcement tool at the agency’s disposal to rein in rampant misuse of prior authorization, simplify the experience of choosing a Medicare plan, and put an end to rampant marketing abuses.”
Along with Wyden, the letter was sent by Rep. Richard Neal (D-MA), ranking member of the House Ways and Means Committee, and Rep. Frank Pallone Jr. (D-NJ), ranking member of the House Energy and Commerce Committee.
“The Medicare program has taken positive steps in recent years to improve consumer protections, but much more needs to be done in order to hold Medicare Advantage plans accountable for inappropriate delays and denials of care and marketing misconduct,” David Lipschutz, co-director of the Center for Medicare Advocacy, said. “We applaud Chairman Wyden of the Senate Finance Committee and Ranking Members Neal of Ways & Means and Pallone of Energy & Commerce for calling for more oversight and transparency regarding the Medicare Advantage industry.”
The letter also highlights shortfalls among Medicare Advantage plans regarding core Medicare medical benefits or access to providers. They added that the plans focus marketing efforts on supplemental benefits like gym memberships and flex cards.
“Medicare beneficiaries deserve coverage that puts their health care needs above insurers’ bottom lines, but time and time again, we see proof that Medicare Advantage plans play games to delay and deny patient care. FAH thanks Chairman Wyden, along with Ranking Members Neal and Pallone, for their leadership protecting patient access to care, and we urge CMS to hold MA plans accountable,” FAH Executive Vice President of Public Affairs Charlene MacDonald said
In addition, the American College of Surgeons supports changes.
“The overutilization of prior authorization in Medicare Advantage plans has rapidly increased over the last several years,” American College of Surgeons Executive Director and CEO Patricia Turner, MD, said. “We thank Congressional leaders for strongly supporting increased transparency and streamlining this overly burdensome process to ensure patients have access to timely and high-quality care as part of its oversight of Medicare Advantage plans’ use of prior authorization.”