Introduction
It
is critical that Medicare beneficiaries know all of their options when it comes
to their health coverage. Currently a Medicare beneficiary can receive
her coverage through Original (sometimes called “traditional”) Medicare or can
enroll in a Medicare Advantage (MA) plan. With each of these options
comes advantages and disadvantages and it is only with clear, unbiased
information that a Medicare beneficiary can truly make an informed
decision. The Center for Medicare Advocacy (the Center) has helped
thousands of Medicare beneficiaries and has witnessed the harm caused by
individuals not having the necessary information or relying on incorrect
information to make sure they have appropriate coverage. Any entity that
distributes information about Medicare beneficiary coverage choices,
particularly the Centers for Medicare & Medicaid Services (CMS), must
communicate information in a way so that enrollees know and understand all of
their options.
CMS
recently posted the Medicare & You
2021 handbook on their website. The handbook is described as “[t]he
official U.S. government Medicare handbook.” Given this, beneficiaries can
infer that the handbook is a neutral catalogue of accurate information with the
objective of guiding beneficiaries in making decisions about their care. Therefore,
any bias towards one choice or another can undermine the trust beneficiaries
have in government-supplied information.
The
Center for Medicare Advocacy reviewed the new handbook with an eye toward
assessing the balance of information provided about Original Medicare vs.
Medicare Advantage, and the accuracy of information regarding coverage. Similar
to what we found in our review of the 2020 handbook in our September 2019 Weekly Alert published last year, in short,
while there have been general improvements in the handbook, bias towards Medicare Advantage remains,
and in some ways, has gotten worse. Enrollment in MA plans is
promoted at the same time that important restrictions and challenges faced when
enrolling in an MA plan are downplayed or omitted.
Language
matters, especially in a document that is widely read by beneficiaries who may
use this as their sole or primary source of information about Medicare.
Changes and distinctions in language that may, at first glance, appear to be
subtle, can significantly alter the meaning and interpretation of certain
concepts. Below we outline our concerns with how the handbook treats
Medicare coverage options in a way that is not balanced or neutral, as it
should be.
Background
As
outlined in last year’s Alert analyzing the 2020 handbook, since Fall
2017, the Center has expressed concerns about bias towards Medicare Advantage
in CMS materials. The 2018 Medicare
& You handbook, along with outreach and enrollment documents,
encouraged beneficiaries to choose a private Medicare plan over Original
Medicare instead of more objectively presenting all enrollment options (see,
e.g., here and here). When the draft 2019 Medicare & You handbook
was released in May 2018 for stakeholder input, the Center and other
beneficiary advocates were alarmed at glaring inaccuracies in the document,
which, among other things, continued to steer beneficiaries toward MA
plans. As discussed in a previous CMA Alert, the Center joined Justice in Aging
and the Medicare Rights Center in writing to CMS about concerns with the
draft handbook.
As
our organizations asserted at the time, rather than presenting information in
an objective and unbiased way, the draft handbook’s information about Original
Medicare and Medicare Advantage (MA) distorted and mischaracterized facts in
serious ways.
In
the final version of the 2019 handbook, as discussed in a previous CMA Alert, CMS addressed the most serious
inaccuracies and omissions. More could have been done, however, to ensure a
neutral and balanced perspective. Further, while some revisions were made to
the 2019 Medicare & You
handbook that improved the information comparing Original Medicare with MA, the
Center and others remained concerned about other administration efforts to
steer people toward MA plans. Similarly, as noted in our assessment of
the 2020 handbook, there were still shortcomings concerning the accuracy and
balance in describing differences between Original Medicare and MA.
Since
the issuance of the 2020 handbook, the current Administration has made it even
more clear that bias in favor of Medicare Advantage is to be tolerated, if not
outright encouraged. On October 3, 2019, President Trump issued his
“Executive Order on Protecting and Improving Medicare for Our Nation’s
Seniors”. Section 3 of the EO states that within a year, the Secretary is directed
to, among other things, “ensure that, to the extent permitted by law, FFS [aka
traditional, or Original] Medicare is not advantaged or promoted over MA with
respect to its administration.” (For the Center’s analysis of the EO, including
additional statements made by the Secretary of Health and Human Services that
make this bias abundantly clear, see this previous Alert.)
In
some ways, the Medicare &
You handbook is getting better about providing people with
necessary information. For instance, it is better about highlighting the
imbalance in access to Medigap plans vs. MA plans, including the dangers of
dropping Medigap coverage and the limitations in rights to get it back.
It is also better about addressing the so-called improvement standard myth in
certain care settings (however, without mentioning the Center’s Jimmo case).
This
Alert, though, focuses on our assessment of the 2021 Medicare & You handbook
and bias in favor of the Medicare Advantage program. Unfortunately, such
bias remains, and in some instances, has become worse. Below we discuss:
General, Ongoing “Plan” bias in the handbook; review the book’s Comparison
Charts and Scales; and touch on how the handbook treats certain subject areas -
Restricted Access to Providers, Beneficiary Costs, Covered and Supplemental
Benefits, and Access to Care.
General, Ongoing “Plan” Bias
As
noted in our Alert last year about the 2020 handbook, as
with any summary of complex information, there is a risk that
oversimplification or shortcuts can lead to incomplete or misleading
information. Given recent CMS history, as outlined above, there is a concern
that information about MA plans would be presented in the most favorable light,
and any downsides of MA would be minimized.
Throughout
CMS education and outreach materials, in recent years there has been a focus on
“plans”, often inferring that a Medicare “plan” is the only or best option for
individuals. This undermines the option of Original Medicare, and assumes
that private MA plans are the default option. While people with Original
Medicare may have stand-alone Part D plans, which they would be advised to
review every year, CMS language has often blurred the distinction between MA
and Part D plans and refer to them as “health and drug” plans or other
characterizations that imply that they are either one and the same, or that a
combination of both (a Medicare-Advantage Prescription Drug, or MA-PD) is the
best choice.
As
the Center has argued previously, CMS should make clear in its
materials that people with Original Medicare can stay put if they wish, and
people enrolled in MA can consider the option of returning to Original
Medicare. Instead, information coming from CMS focuses almost exclusively on
“plans” and “plan choices” with little or no reference to Original Medicare as
an option.
Although
CMS has not yet begun its education and outreach campaign via email for the
2020 enrollment period, last year, such emails tended to focus only on “plans.”
For example, one opened:
“Happy
with your current 2019 Medicare coverage? Plans — and your health care needs —
may change from year to year, so it’s still important to take a few minutes and
shop around during Medicare Open Enrollment.” [And, after touting the new
Medicare Plan Finder, concluded:] “If you’re happy with the coverage you have
now, and your plan is still being offered next year, you don’t need to do
anything further. But if you find a plan that better meets your needs for 2020,
you can easily enroll
online until December 7.”
In recent years, CMS outreach and enrollment materials have
framed Medicare coverage choices as being all about “plans” without making
adequate distinctions between drug coverage and other types of coverage, and
has actively promoted enrollment in MA plans.
General
messaging in the Medicare
& You handbook is no different. At the outset of the 2021
handbook, under “What’s New” on page 2, there is a prompt to “Get help with your Medicare coverage
choices - Visit Medicare.gov/plan-compare to shop for and
compare health and drug plans that meet your needs. You can also enter your
drugs to get more accurate costs for plans in your area.” This implies
that, in addition to Part D plan changes, people in traditional Medicare should
get help with their coverage choices, which includes “health plans”.
In
the “Get Started” section on page 4, the handbook suggests, under “If you
already have Medicare” to “Review your Medicare health and drug coverage and
make changes if it no longer meets your needs, or if you could lower your
out-of-pocket costs. You don’t need to sign up for Medicare each year, but you
should still review your options.” If Original Medicare is your
“health coverage” you are advised to review it and explore other, cheaper
options. The annual exercise for those in Original Medicare is encouraged
to be expanded beyond merely reviewing Part D plans.
Similarly,
on the same page, under “Mark your calendar ….” it notes that during the Annual
Enrollment Period (AEP) one can “Change your Medicare health or drug coverage
for 2021, if you decide to. This includes changing to Original Medicare, or
joining or changing a Medicare Advantage Plan.” While at least Original
Medicare is listed as an option – which, as noted above, some AEP materials in
recent years have omitted altogether -- the language suggests that, as a
default, someone is enrolled in a private MA plan (or should be).
Elsewhere
in the 2021 handbook, e.g., under “Who has to sign up for Part A/and or Part B”
on page 16, a text box is titled “Once you’re enrolled in Medicare you’re not
done yet” and states that “People get coverage in different ways. You’ll need
to review all of your Medicare coverage options and find what best meets your
needs. See pages 6–8 for more information.” In comments to CMS on the
draft version, we stated that the phrase "...you're not done yet" -
implies that a new beneficiary must enroll in something else. While this
may be true for individuals in Original Medicare who need Part D drug coverage,
the prompt is overly broad and does not account for people with Medicaid,
retiree coverage, etc. Our suggestion was that if not deleted, this direction
should be tempered, such as “there is more to explore, including whether you
might need any additional coverage.” CMS left the language as is.
Such
language outlined above perpetuates the framing of coverage choices as being
all about “plans” without making adequate distinctions between drug coverage
and other types of coverage. As discussed in the next sections, when CMS
materials address Medicare Advantage plans vs. Original Medicare more directly,
they fail to maintain appropriate balance.
Comparison Charts and Scales
The
Medicare & You
handbook, now at 124 pages, can be daunting to read, and one that may not be
routinely read cover-to-cover by Medicare beneficiaries. Understanding
that many people will not carefully study the entire manual, in recent years
CMS has developed some summaries and shortcuts that attempt to provide basic
information that might be helpful to readers.
In
this vein, since 2018, CMS has included a new section toward the beginning of
the handbook that attempts to summarize the different parts of Medicare as well
as differences between traditional (referred to as “Original”) Medicare and the
MA program. In the 2021 version, this information is on pages 6-8. There
will be people who rely solely on these comparison charts rather than wade
through the more detailed information about the respective coverage options
further in the handbook. This is why it is critical that such information
be accurate and balanced. As discussed below in sections devoted to
analyzing how certain subjects are presented, unfortunately, this is not the
case.
Instead of reading the entire handbook, some people will rely
solely on comparison charts and other shortcuts rather than wade through the
more detailed information about the respective coverage options further in the
handbook. This is why it is critical that such information be accurate and
balanced.
In
another attempt to help individuals quickly compare Original Medicare with MA,
CMS added a new feature to the 2020 handbook which is also included in the 2021
version. On page 8, CMS alerts readers to look for certain images “throughout
this book to help you understand your Medicare coverage options” including an
image of scales that “Shows comparisons between Original Medicare and Medicare
Advantage”. There are seven such scales throughout the book.
As
noted in our review of last year’s handbook, subject to the same concerns about
oversimplification, or even outright steering towards MA plans, these scales
can be more problematic than the comparison charts discussed above.
In
both the draft and final 2021 handbook, at least four of the seven scales are
“tipped” towards MA (in other words, the benefits of MA over traditional
Medicare were highlighted) and in favor of Original Medicare only twice. More
than just keeping “score” of how many times the scales tip one way or another
(which a reader is unlikely to do), the final draft both bypassed opportunities
to either highlight the advantages of Original Medicare, or add critical,
clarifying information, and mischaracterized or over-sold some of the benefits
attributed to MA plans.
Here
are comments on the seven scales in the final version (and one that was
removed):
- P. 20 – Health Savings Accounts – similar to the 2020
version, the scale following a discussion of health savings accounts
(HSAs) suggests exploring Medicare Advantage Medical Savings Account (MSA)
plans as an option for those who would like to get benefits through an
HSA-like structure. Given that only approximately 5,600 people were
enrolled in MSAs in 2019, out of 22 million people enrolled in MA plans
overall (and over 64 million people with Medicare in 2019), it seems a
stretch, at best, to use space to promote this very limited option that
appears to be unpopular with both plan sponsors and beneficiaries.
Despite our suggestion to CMS that this scale and text be removed,
CMS left it in as is.
- P. 29 – MA Out-of-Pocket Costs – this scale favoring MA
states: “Medicare Advantage Plans have a yearly limit on what you pay
out-of-pocket for medical services. See page 60 to learn more and to find
out what affects your Medicare Advantage Plan costs.” In comments to
CMS about the draft handbook, we suggested that in order to provide
balance in information concerning MA and Original Medicare, CMS should add
something like “Certain types of supplemental coverage, such as Medigap
plans, can also limit yearly out of pocket costs for those with Original
Medicare. See page 71”. We also suggested adding language about the
MA out-of-pocket limit, such as “Before this limit is reached, however,
Medicare Advantage plans may charge more cost-sharing for certain services
than is allowed under Original Medicare.” Neither suggestion was
adopted.
- P. 48 – Telehealth - The scale states: “Medicare Advantage
plans and providers who are part of certain Medicare Accountable Care
Organizations (ACOs) may offer more telehealth benefits than Original
Medicare. These benefits are available no matter where you’re located, and
you may be able to use them at home instead of going to a health care
facility. Check with your plan to see what telehealth benefits they offer.
If your provider participates in an ACO, check with them to see what
telehealth benefits may be available. For more information on Medicare
Advantage Plans, see page 57. For more information on ACOs, see page 110.”
On balance, it appears this language favors MA plans, since ACOs are
not as widely available, and since the language concerning ACOs is rather
limiting. In our comments to the draft language, we noted that since this
scale references both MA and ACOs, which are part of Original Medicare, it
does not really compare MA vs. Original Medicare. We suggested that
instead this text be turned into a note rather than under a scale
comparing the two programs, but CMS did not adopt this suggestion.
- P. 52 – Long-Term Care – the text in the scale states:
“Special Needs Plans are a type of Medicare Advantage Plan that may be
able to cover long-term care if you have Medicare and Medicaid. See page
66 to learn more. Also, some Medicare Advantage Plans may cover certain
extra benefits, like adult day-care services. See page 58.” This scale
favors MA plans, although eligibility for SNPs is limited and this
language may over-promise the availability of such benefits.
- P. 56 – Provider Limitations in MA Plans - In a nod to
Original Medicare, this scale references MA network provider limitations,
but, as discussed below, it mischaracterizes access to providers in MA
plans by referencing lower cost network restrictions rather than
restrictions on access to providers.
- P. 58 – Compares Access to Care in Original Medicare vs. MA -
“In most cases, you don’t need a referral to see a specialist if you have
Original Medicare. See page 53. You can also see any provider you want that
takes Medicare, anywhere in the U.S.” This scale appropriately
points out these benefits to Original Medicare over MA plans.
- Note that CMS appropriately removed a comparative scale that
appeared in the 2020 final and draft 2021 versions – On page 60, CMS
followed our suggestion to change certain text from a comparative scale to
instead flagging that it was “Important”: “If you already have Medigap and
join a Medicare Advantage Plan, you can drop Medigap. Keep in mind that if you drop
Medigap to join a Medicare Advantage Plan, you may not be able to get it
back. See page 74” [emphasis in original].
Previously, this appeared as a comparative scale that favored MA plans,
even though the ability to drop a Medigap plan and no longer pay premiums
if one enrolls in an MA plan might be seen as a benefit, the inability to
pick up a Medigap after dropping it is a disadvantage for those in an MA
plan.
- P. 97 – MA Rights – CMS added a new scale that did not appear
in the draft that, as discussed below, misleadingly suggests that the
right for MA enrollees to request a coverage determination from their plan
prior to obtaining a service or item is a benefit of MA enrollment that is
unavailable in Original Medicare, rather than describing it as the prior
authorization hurdle to care that it actually is.
These
summaries, shortcuts and comparisons do a disservice to beneficiaries when they
overplay the benefits of MA and underplay the drawbacks. As discussed in
particular subject areas below, language in both the handbook summaries and
more detailed explanations follow this trend.
Restricted Access to Providers
The
fact that most MA plans use a model that, by design, restricts access to
providers by establishing contracted provider networks, is a key to
understanding how such plans work and is an important factor for prospective
enrollees to consider. While roughly 30% of MA enrollees are in PPOs, which
allow enrollees to see out-of-network providers (usually for a higher cost),
according to the Kaiser Family Foundation, in 2019 nearly
two-thirds (62%) of all Medicare Advantage enrollees are in HMOs (over 13.6
million people), which generally will only cover services provided by
in-network providers. While HMO point-of-service (POS) plans do allow enrollees
to go out-of-network for certain services, CMS enrollment data (Sept. 2020) show that
approximately 2.01 million people are enrolled in such plans – roughly 15% of
all MA HMO enrollees. This means that most plans will not cover services from
providers outside the network. This is particularly important after CMS
weakened MA plans’ network adequacy standards they must meet in a final rule
issued earlier this year, as discussed in a previous Center Weekly Alert.
In several places in the handbook, CMS mischaracterizes access
to providers in an MA plan by expressing the need to use network providers “for
the lowest costs” rather than the fact that most plans don’t allow you to use
out-of-network providers at all, let alone at the lowest cost.
In
the 2020 version of the handbook at page 6, the Original Medicare v. MA
comparison chart states: “In most cases, you’ll need to use doctors who are in
the plan’s network.” In the 2021 version, however, “most” was changed to
“many.” Although, at first glance, this might appear to be a minor
semantic change, it diminishes the impact that the widespread prevalence of network
restrictions in MA plans should have on a reader. “Most” raises awareness that
something applies to a majority of situations; “many”, on the other hand, can
more easily be dismissed as something that may or may not be applicable in a
given scenario.
Similarly,
CMS has changed language in the “At a Glance” side-by-side comparison chart
between Original Medicare and MA plans at page 7. In the 2020 version, it
stated: “In most cases, you’ll need to use doctors who are in the plan’s network (for
non-emergency or non-urgent care). Ask your doctor if they participate in any
Medicare Advantage Plans” [emphasis in original].
This
was how the language appeared in the draft 2021 version, but the current, final
2021 language is much diminished: “In many cases, you’ll need to use doctors and other providers who are in
the plan’s network and service area for the lowest costs. Some plans
won’t cover services from providers outside the plan’s network and service
area” [emphasis in original]. Not only did CMS change the language from “most”
to “many” again, it added a qualifier that does not apply to most MA enrollees
–in-network providers need to be seen “for the lowest costs.” Such advice
only applies to PPO enrollees; for the majority of MA enrollees in HMOs, there
is no coverage (outside emergency or urgent care – as noted by last year’s
version). Most plans, not “some”, won’t cover services provided outside
the network. Further, the updated language leaves off the critical advice
that prospective (and even current) enrollees should ask their doctor if they
participate in any MA plans, and whether they will continue to do so.
Even
a comparative “scale” image included in the Original Medicare section –
inserted seemingly to infer an instance in which Original Medicare is favorable
to MA, has been altered in a misleading way. Both last year’s comparable
scale (at p. 53) and the draft 2021 version stated: “If you have Original
Medicare, you can see any provider you want that takes Medicare, anywhere in
the U.S.” However, the current language at the scale (at p. 56) states:
“If you have a Medicare Advantage Plan, in many cases, you’ll need to use
doctors and other providers who are in the plan’s network and service area for
the lowest costs.” As noted above, this language mischaracterizes access to
providers in an MA plan by expressing the need to use network providers “for
the lowest costs” rather than the fact that most plans don’t allow you to use
out-of-network providers at all, let alone at the lowest cost. HMOs generally
will not cover services out of network (unless urgent or emergent); to leave
the text as is implies that everyone in an MA plan can have out-of-network
coverage, but need only be concerned about the network for purposes of lower
costs.
In
addition to the comparison charts and comparative scales, there is similar
language in the lengthier descriptions of Original Medicare and MA further
along in the handbook. For example, in the 2020 handbook under the
Medicare Advantage section at p. 55, text states that “In most cases, you’ll
need to use health care providers who participate in the plan’s network.
However, many plans offer out-of-network coverage, but sometimes at a higher
cost.” But in the same section in the 2021 version (now at p. 57), CMS made the
same revisions described above so that the text now reads: “In many cases,
you’ll need to use health care providers who participate in the plan’s network
and service area for the lowest costs. These plans set a limit on what you’ll
have to pay out-of-pocket each year for covered services, to help protect you
from unexpected costs. Some plans offer out-of-network coverage, but sometimes
at a higher cost.” An official government publication has an obligation
to the people it serves to accurately relay this information. Beneficiaries who
are misled by this and opt for an MA plan, may be left with large out-of-pocket
costs that they would not have in traditional Medicare.
These changes to the language and descriptions of access to
providers water down the restrictions that the majority of MA enrollees in HMOs
face. If anything, CMS should err on the side of highlighting rather than
downplaying such restrictions so that individuals can make better, informed
decisions about how they wish to access their Medicare coverage.
In
related information about access to providers, the handbook, on p. 8, discusses
“Travel” but only focuses on international, rather than domestic travel, which
is much more relevant to many more Medicare beneficiaries. One of the key
distinctions between Original Medicare and MA plans is that the former allows
access to providers across the country regardless of where an individual lives,
whereas the latter usually restrict access to providers based upon designated
service areas. In our comments to CMS concerning the draft version, we
suggested that CMS revise this section to state "People with Original
Medicare can get care anywhere in the U.S., however Original Medicare generally
doesn’t cover care outside the U.S."; similarly, under the "Medicare
Advantage" field, we suggested that CMS revise language as follows:
"Most Medicare Advantage plans require you to go to providers in limited,
local networks. Also, plans don't generally cover care outside the
U.S." CMS did not do this, and missed a key opportunity to educate
people about MA restrictions on access to providers.
The
Center made a similar suggestion to revise the discussion of “Travel” on p. 49
to add a section that describes travel within the U.S., highlighting that those
in Original Medicare can see providers across the country whereas most Medicare
Advantage plans usually limit non-emergency or urgent coverage to a network of
providers within a geographic area. While there is a helpful comparative
scale at p. 58 concerning access to providers in Original Medicare, we suggested
that CMS add a similar scale here comparing Original Medicare and MA that
articulates this, but CMS did not adopt this suggestion.
Beneficiary Costs
Similar
to 2020, there is text in the comparison charts on p. 6 that says “Plans may
have lower out-of-pocket costs than Original Medicare.” A separate box
below on the page reiterates this point: “Some plans also include: Lower
out-of-pocket costs.” The reverse point that costs in Original Medicare
might be lower than those in MA is not made, although the reality is decidedly
mixed.
Since
2011, MA plans have been required to provide a maximum out-of-pocket (MOOP)
limit for Part A and B services not to exceed $6,700 (for in-network services)
or $10,000 (for in-network and out-of-network combined) in 2020 (note these
amounts will increase in 2021 as individuals with ESRD are allowed to enroll in
MA plans). According to the Kaiser Family Foundation, in 2020, MA
enrollees’ average MOOP for in-network services is $4,925 (HMOs and PPOs) and
$8,828 for out-of-network services (PPOs). Even with a MOOP applicable to
MA enrollees, whether or not someone faces lower costs in an MA plan is far
more nuanced. For example, an April 2020 Kaiser Family Foundation report analyzing Medicare beneficiary
out-of-pocket costs found that “[o]verall, a larger percentage of beneficiaries
enrolled in Medicare Advantage plans reported problems getting care due to cost
or paying medical bills than beneficiaries in traditional Medicare, even after
controlling for income and health status.”
Further,
costs can vary considerably in an MA plan, including based on the duration of
care needed. For example, another report by the Kaiser Family Foundation notes
that in 2020, virtually all MA enrollees would pay less than those in
traditional Medicare for the Part A hospital deductible ($1,408 in 2020) for an
inpatient stay of three days. When looking at cost-sharing for hospital
stays beyond three days, however, costs in a MA plan can significantly
increase: for stays of five days, half of MA enrollees would be required to pay
more than the beneficiaries in traditional Medicare; for a seven-day inpatient
stay, nearly two-thirds (64%) of MA enrollees are in a plan that requires
higher cost-sharing than the Part A deductible; and for a ten-day inpatient
stay, more than seven in ten (72%) are in a plan that requires higher
cost-sharing.
Thus,
beneficiaries with high or unexpected healthcare costs could face significant
out-of-pocket costs in MA plans. In fact, those with Original Medicare with a
Medicare Supplement (Medigap) may experience lower costs or be better protected
for out-of-pocket health care expenses than those in MA plans, even with a
MOOP. According to one insurance agency selling Medigap plans, the
national average cost of a Medigap G plan for a 65 year old in 2020 is $143.46
in premiums per month (or $1,721.52 per year). This amount is well below
both the average and maximum MOOP amounts referenced above.
The handbook promotes MA plans as an opportunity to have lower
out-of-pocket costs than those in Original Medicare, but downplays variables
that could make the opposite true.
Elsewhere
in the handbook CMS did make some improvements that will help with informed
decision-making, such as in the “Original Medicare” sections on pp 53-4.
For example, under “Should I get a supplement?” at p. 53 the handbook added in
Medicaid and military coverage so that the text reads: “You may already have
Medicaid, military, or employer or union coverage that may pay costs that
Original Medicare doesn’t. If not, you may want to buy a Medicare Supplement
Insurance (Medigap) policy if you’re eligible. See pages 71–74.” Similarly,
under the “What Else Should I Know?” section on p. 54, CMS added in language
about other insurance in addition to Original Medicare that can cap
out-of-pocket expenses, so the text now reads: “There’s no yearly limit for what
you pay out of pocket unless you have other insurance (like Medigap, Medicaid,
or employee or union coverage).”
In
other places, CMS missed opportunities to further flush out important
information. For example, under “Paying for Long-Term Care” on p. 52, the
text notes that “Medicare and most health insurance, including Medicare
Supplement Insurance (Medigap), don’t pay for this type of care, sometimes
called ‘custodial care.’” CMS did not take our suggestion to include
Medicare Advantage along with Medigaps as a type of insurance that does not
cover long-term care. In addition, in the MA section under “What do I
pay?” on p. 60, CMS did not follow our suggestion to add to the fourth bullet
that "Medicare Advantage Plans can charge more than Original Medicare for
certain services, such as co-pays for home health services” and note that, with
respect to services that MA plans are prohibited from charging more than
Original Medicare for certain services, that the limitation on dialysis
cost-sharing should be highlighted here, and/or reprinted in the section above
re: individuals with ESRD joining MA plans in 2021.
Covered and Supplemental Benefits
In
general, MA plans must cover what is covered under Parts A and B of Medicare.
One thing that sets MA plans apart from Original Medicare is that they can
offer benefits that are not covered in Original Medicare, using rebate dollars
based upon the plan’s bid or charging extra premiums for such coverage.
While most MA plans do offer some additional, or supplemental coverage, the
scope of such coverage is often limited (e.g., restricted number of visits,
dollar cap, etc.). Often, CMS materials over-sell the value of extra
benefits MA plans offer.
On
the one hand, CMS has tempered expectations in some places. For example,
the 2021 handbook, in the comparison chart at p. 8 states: “Plans must
cover all of the medically necessary services that Original Medicare covers.
Most plans offer extra
benefits that Original Medicare doesn’t cover—like some vision,
hearing, dental, routine exams, and more. Plans can now cover more of these
benefi[t]s (see page 57)” [sic; emphasis in original]. CMS did add the
qualifying language “some” in front of “vision, hearing, dental” because such
coverage is often, indeed, limited in scope.
On
the other hand, while language on p. 58 describing “Extra Benefits” available
in MA plans similarly includes the qualifying “some” before “vision, hearing,
dental”, etc., CMS fails to appropriately temper expectations with respect to
the new flexibilities MA plans have to offer supplemental benefits, including
the Special Supplemental Benefits for the Chronically Ill (SSBCI). The
text goes on to state: “Plans can also choose to cover even more benefits. For
example, some plans may offer coverage for services like transportation to
doctor visits, over-the-counter drugs, and services that promote your health
and wellness. Plans can also tailor their benefit packages to offer these
benefits to certain chronically-ill enrollees. These packages will provide
benefits customized to treat specific conditions. Check with the plan before
you enroll to see what benefits it offers, if you might qualify, and if there
are any limitations.”
Provision
of such services is entirely voluntary and at the discretion of a given MA
plan. Without language further limiting the potential extra benefits, including
SSBCI, this oversells how many plans are offering such benefits, and the scope
of such benefits (which can be, we find, very limited; see, e.g., Center for
Medicare Advocacy issue brief Medicare and Family Caregivers (June 2020)
with an example of limited availability and scope of in-home support offered by
MA plans in Los Angeles county in 2020). Further, CMS did not follow
suggestions that people should not be advised to check with a prospective plan
to see if they qualify for such services because eligibility will not actually
be determined until someone is enrolled in a plan and they are confirmed to
have both a chronic condition and an individualized assessment. The assessment
will determine whether the services for this individual have a reasonable
expectation of improving or maintaining their health or overall function (see,
e.g., the Center’s Issue Brief: New Medicare Advantage Supplemental Benefits: An
Advocates’ Guide to Navigating the New Landscape (October 2019)).
Access to Care
In
addition to restricting enrollees’ choice of providers, another hallmark of
managed care plans is – “managing care.” This often involves restricting
services enrollees can receive and from whom, often in the form of prior
authorization requirements or other utilization management tools.
As
noted by the Kaiser Family Foundation in an April 2020 issue brief, virtually all MA enrollees are
subject to some form of prior authorization:
Medicare
Advantage plans can require enrollees to receive prior authorization before a
service will be covered, and nearly all Medicare Advantage enrollees (99%) are
in plans that require prior authorization for some services in 2020. Prior
authorization is most often required for relatively expensive services, such as
inpatient hospital stays, skilled nursing facility stays, and Part B drugs, and
is infrequently required for preventive services. The number of enrollees in
plans that require prior authorization for one or more services increased from
2019 to 2020, from 79% in 2019 to 99% in 2020. In contrast to Medicare
Advantage plans, traditional Medicare does not generally require prior
authorization for services, and does not require step therapy for Part B drugs.
Such
use of prior authorization often serves as a barrier to accessing care.
For example, a 2018 Dept. of Health and Human Services Office of Inspector General
(OIG) report found “‘widespread and persistent problems
related to denials of care and payment in Medicare Advantage’ plans”. The
report’s findings included: when beneficiaries and providers appealed
preauthorization and payment denials, MA plans “overturned 75 percent of their
own denials”; however, OIG found that “beneficiaries and providers appealed
only 1 percent of denials to the first level of appeal.”
As
discussed in a previous CMA Alert addressing the report’s findings,
OIG stated that MA plans: “may have an incentive to deny preauthorization of
services for beneficiaries, and payments to providers, in order to increase
profits. High overturn rates when beneficiaries and providers appeal denials,
and CMS audit findings about inappropriate denials, raise concerns that some
beneficiaries and providers may not be getting services and payment that [MA
plans] are required to provide.”
Although
the Medicare & You
handbook isn’t necessarily the forum in which to cite OIG reports, the OIG results
justify an obligation by CMS to provide individuals with information about
restrictions to care and coverage in both Original Medicare and MA plans.
It accomplishes this goal in some ways. For instance, on p. 58, there is
a comparative scale – appropriately painting Original Medicare in a more
favorable light in a section addressing MA plans – that states: “In most
cases, you don’t need a referral to see a specialist if you have Original
Medicare. See page 53. You can also see any provider you want that takes
Medicare, anywhere in the U.S.”
CMS has an obligation to provide individuals with information
about restrictions to care and coverage in both Original Medicare and MA
plans. In the handbook, though, CMS misleadingly suggests that the right
for MA enrollees to request a coverage determination from their plan prior to
obtaining a service or item is a benefit of MA enrollment that is unavailable
in Original Medicare, rather than describing it as the prior authorization
hurdle to care that it actually is.
In
the draft version of the 2021 handbook, CMS proposed, in a text box, the
following language: “If you have a Medicare Advantage Plan, you may get an
organization determination to see if a service, drug, or supply is covered. You
also may get plan directed care. This is when a plan provider refers you for a
service or to a provider outside the network without getting an organization
determination in advance. See page 61.” Our comment to CMS concerning
this language was as follows: “Medicare Advantage appeals, specifically the
right to getting an organization determination, remains a source of so much
confusion for Medicare Advantage enrollees, particularly since the appeals
process for Medicare Advantage enrollees differs from those who have Original
Medicare. This section should be expanded upon. Specifically people
should be told they have a right to an organization determination and should call
their plan to request one to see if a service, drug, or supply is
covered. Also that they should follow the instructions on the
organization determination to file a timely appeal.”
Instead
of following this suggestion for language in the regular text of the handbook,
which proposed addressing MA enrollee rights – specifically to mitigate against
restrictions to care and coverage due to prior authorization requirements – in
the final version CMS added a new comparative scale on page 97 in the “Know Your
Rights” section that states: “If you have a Medicare Advantage Plan, you have
the right to an organization determination to see if a service, drug, or supply
is covered. Contact your plan to get one and follow the instructions to file a
timely appeal. You also may get plan directed care. This is when a plan
provider refers you for a service or to a provider outside the network without
getting an organization determination in advance (see page 61).”
Although
it is critical that this right be articulated, to do so in a comparative box
that is meant to “help you understand your Medicare coverage options” and
“Shows comparisons between Original Medicare and Medicare Advantage” without
including further information is highly misleading. Here, without adding
that in Original Medicare such prior approval is rarely needed, highlighting
this enrollee right here suggests that this is in fact a benefit available only
in MA plans – rather than a necessary safety measure to mitigate against MA
plan restrictions.
Such
presentation of information is reminiscent of how a previous draft of Medicare & You
characterized prior authorization. As noted in the Background section
above, the Center, along with Medicare Rights Center and Justice in Aging,
wrote to CMS in May 2018 about concerns in the draft 2019 handbook. As
stated in our joint letter about that draft:
Even
more problematic is the treatment of prior authorization requirements in
Medicare Advantage. On both page 6 and page 62, the Handbook attempts to paint
this restriction on access to services as a benefit, rather than as what it is,
a mandatory hurdle for Medicare Advantage members that is not required for
individuals in Original Medicare. On page 62, the Handbook goes so far as to
describe prior authorization as a “right” that people in Original Medicare
“can’t get.” Describing a restriction as a “right” and then saying that people
who are not subject to this restriction are disadvantaged twists the facts
beyond recognition.
Thankfully,
this characterization of prior authorization as a benefit did not make it into
the final 2019 handbook. Unfortunately, although this issue was not even
in the proposed 2021 handbook draft, it is now included in the final version.
Conclusion
The
Medicare & You
handbook is one of the primary ways that Medicare beneficiaries, their families,
and those who assist them get their information about the Medicare
program. It is critical that the information therein is accurate and
unbiased so Medicare beneficiaries can make a fully informed choice about
whether to choose Original Medicare or a private MA plan to receive their
healthcare. Unfortunately, over the last several years, the handbook has been
influenced by the same forces that have pushed other CMS materials away from
balance and towards bias in favor of private MA plans.
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