“We support building on [the administration’s] progress by ending delays and denials of care by insurance companies running MA plans, strengthening transparency efforts, reining in overpayments to insurance companies, and supporting efforts to lower costs and expand benefits in [Traditional Medicare].”
Washington (March 5, 2024). -Senator Edward J. Markey (D-Mass.) joined Senators Elizabeth Warren (D-Mass.), Sherrod Brown (D-Ohio), Richard Blumenthal (D-Conn.), Cory Booker (D-N.J.), Richard Durbin (D-Ill.), Jeff Merkley (D-Ore.), Bernard Sanders (I-Vt.), Tina Smith (D-Minn.), and Peter Welch (D-Vt.) in calling on the Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS) to curb abuses in Medicare Advantage (MA), which would save taxpayers hundreds of billions of dollars, and use those savings to make long-needed improvements in traditional Medicare (TM).
MA was intended to reduce costs for taxpayers, but instead CMS pays Medicare Advantage six percent more per enrollee, on average, than it would cost to cover the same enrollee in traditional Medicare. At the same time, insurance companies in MA routinely delay and deny medically necessary care for patients, and MA plans are producing disproportionately poor clinical outcomes for Black, Native American or Alaskan Native, and Hispanic enrollees, who are offered and enrolled in plans with lower quality ratings.
Now, as CMS works to finalize the the Calendar Year (CY) 2025 Advance Notice of Methodological Changes for MA Capitation Rates and Part C and Part D Payment Policies, the lawmakers are pushing reforms to make it easier for beneficiaries to seek out and receive care, ensure funds that are incorrectly going to MA companies are redirected to patients and providers, and modernize the benefits in TM. They proposed five key areas of focus for increasing care and coverage for enrollees: 1) prevent insurance companies from imposing barriers to care, such as onerous prior authorizations, Artificial Intelligence (AI) algorithms, or limited networks; 2) strengthen transparency to improve public understanding of the effects of insurer-run Medicare Advantage plans on patients and the Medicare program; 3) crack down on upcoding and other deceptive tactics to rein in overpayments to insurance companies in MA; 4) address misleading and deceptive marketing practices; and 5) use administrative action to strengthen TM.
“We share your goal of improving the Medicare program to ensure it provides comprehensive and affordable care for beneficiaries today and in the future, and we support CMS making necessary changes to the program to realize this shared vision,” the lawmakers wrote. “Nearly all of the following actions could be paid for solely by stopping overpayments to insurance companies in MA.”
The following organizations also expressed support for the proposed reforms to Medicare Advantage in the lawmakers’ letter:
“The Medicare Advantage program was created 25 years ago with the promise that the private sector could reduce costs by better managing care. But instead, it has become a shameless profiteering scheme. Through waste, fraud, and abuse of the rules, insurance corporations will be overpaid by taxpayers by at least $88 billion this year — all while restricting provider networks, and wrongly denying and delaying care for many older Americans and people with disabilities,” said Dr. Jamila Headley, Executive Director of Be a Hero. “This Senate letter prescribes urgent solutions to these pressing problems. Most critical among them is the need to reclaim the billions of dollars being gouged from taxpayers by large health insurance corporations each year, and instead invest these precious resources into improving Medicare and ensuring that this vital public program is there for generations to come.”
“Right now, the government cannot protect people from joining Medicare Advantage plans that endanger their health. And, Medicare Àdvantage is driving up Medicare premiums by tens of billions of dollars a year and compromising the Medicare Trust Fund. These proposed actions would go a long way towards keeping Medicare strong and honoring Medicare’s commitment to guaranteeing older Americans and people with disabilities good affordable health care,” said Diane Archer, Senior Advisor, Social Security Works.
“Medicare Advantage is neither Medicare nor an advantage. It is a scam promoted by Big Insurance hiding behind the name of a trusted program. All while giving seniors a lesser product. The truth of the matter is Medicare Advantage plans often provide worse coverage than traditional Medicare. Sensible reforms can fix many of the problems of Medicare Advantage and bring better care to our seniors. But Big Insurance has fought them at every turn. It is far past time that policymakers implement sensible reforms to the program. Seniors in this country deserve a comprehensive, sustainable Medicare program that serves patients’ needs, not corporate profits,” said Wendell Potter, President, Center for Health and Democracy.
“The Administration has taken some important steps to rein in Medicare Advantage overpayments and increase consumer protections, but much more must be done. Policymakers must confront the challenges posed by the MA industry, including holding plans accountable for improper denials and delays in care. Further, wasteful overspending on MA could be used to bolster coverage in traditional Medicare,” said David Lipschutz, Associate Director, Center for Medicare Advocacy.
“The corporations that run insurance plans delay and deny care for too many people when they need it the most. These systemic prior authorization and claims denials generate profits for shareholders and CEOs while poor and working class people are left in debt or without care. In the case of Medicare Advantage plans, these profits come from taxpayer dollars. People’s Action applauds Senators Warren and Brown and the letter’s signatories for calling for greater transparency, oversight, and accountability in privatized Medicare plans,” said Sulma Arias, Executive Director, People’s Action.
"In my practice, I have seen up close how Medicare Advantage can be especially burdensome to patients with cancer. Prior authorization requirements for preoperative clearance studies and staging scans result in treatment delays, patients face limited networks in their search for the best doctor to treat their condition, and insurers sometimes even deny coverage for chemotherapy regimens, forcing patients to pursue alternative treatments which may be less effective or have more side effects. We need to do everything we can to protect vulnerable patients by cracking down on these and other abuses in Medicare Advantage, and improving traditional Medicare. This letter represents a step toward needed reforms," said Dr. Julianne Qualtieri, M.D., Practicing Physician and Member, Physicians for a National Health Plan.
“Medicare Advantage plans have taken advantage of seniors, people with disabilities, and the Medicare program by putting profits ahead of patients for far too long. We join Sen. Warren, Sen. Brown, and the other signers of this important letter in demanding enhanced accountability for insurers who reap massive profits while limiting access to care for enrollees through delaying and denying care, creating narrow provider networks, using misleading advertising, and cherry-picking healthier patients while pushing less profitable seniors and people with disabilities back to traditional Medicare. It is time to put patients before profits by enhancing protections, clawing back overpayments to insurers and reinvesting that money to improve the Medicare program,” said Eagan Kemp, Health Care Policy Advocate, Public Citizen.
###
