Summary:Â The Center for Medicare and Medicaid Services (CMS) just released 957 pages of proposed regulations for Medicare Advantage (MA). Despite the massive verbiage, and purported reflection of public comments, they fail to remedy the fundamental dynamics that make MA so lucrative for private insurers and so inadequate for sick enrollees.
U.S. Health Officials Seek New Curbs on Private Medicare Advantage Plans, The New York Times, December 17, 2022, by Reed Abelson and Margot Sanger-Katz
Federal health officials are proposing an extensive set of tougher rules governing private Medicare Advantage health plans, in response to wide-scale complaints that too many patients’ medical claims have been wrongly denied and that marketing of the plans is deceptive.
Despite their popularity, the plans have been the subject of considerable scrutiny and criticism lately. A recent report by the inspector general of the U.S. Department of Health and Human Services found that several plans might be inappropriately denying care to patients. And nearly every large insurance company in the program, including UnitedHealth Group, Elevance Health, Kaiser Permanente and Cigna, has been sued by the Justice Department for fraudulently overcharging the government.
The period leading up to this year’s enrollment deadline, Dec. 7, amplified widespread criticism about the deceptive tactics some brokers and insurers had used to entice people to switch plans. In November, Senate Democrats issued a scathing report detailing some of the worst practices, including ads that appeared to represent federal agencies and ubiquitous television commercials featuring celebrities.
Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the company behind the ad be identified.
Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the company behind the ad be identified.
The new proposal would require plans to disclose the medical basis for denials and rely more heavily on specialists familiar with a patient’s care to be involved in the decision-making.
Dr. Meena Seshamani, the director of the Center for Medicare and a deputy administrator at the Center for Medicare and Medicaid Services, said the changes had been influenced by thousands of public comments solicited by the agency and by lawmakers.
“The proposals in this rule we feel would really meaningfully improve people in Medicare’s timely access to the care they need,” she said.
Hospitals, which have been pushing for changes that would address their concerns that insurers were abusing prior authorization, applauded the proposals.
The proposed regulations are not yet final. Health officials are soliciting comments from the public and may make changes.
Comment:
By Don McCanne, M.D.
The Feds are finally listening to the uproar against the privatized Medicare Advantage plans and all of their abuses. Or are they?
Let’s see. CMS proposed a 957 page set of rules which you can read and respond to by February 13, 2023. Actually reviewing the first 72 pages should be adequate since it contains the Executive Summary.  Therein you will find that our bureaucrats are attacking issues such as warning insurers that if they use the Medicare logo we will tell on them, though using the term “Medicare” is still acceptable.
Addressing evidently more significant problems, as an example Medicare will mandate that prior authorization reveal clinical justifications and incorporate expert review. But this is a micro-fix; the real issue is that insurers don’t want patients who need expensive health care and will continue to make getting care difficult so that patients switch to other coverage. The lawsuits they face for denying coverage are a drop in the bucket compared to the billions they rake in by avoiding expensive care. Most private Medicare Advantage patients are relatively healthy and thus not dissuaded by limited provider panels or lack of access to centers of excellence that they don’t need right now, if they can have their teeth cleaned or join an exercise club. It really isn’t their concern that extra taxpayer dollars are diverted to enrich these private plans.
Sorry, burying us in 957 pages of rules is not going to cut it. The privatization of Medicare, as a wealth-creating business model, has significantly damaged the program and these rules are only camouflage for perpetuating it. Our traditional Medicare program has some real problems that need to be addressed, and that is where the effort should have been directed. As a public program the traditional program is designed to serve all of us well, whereas the private Medicare Advantage model is designed primarily to serve business interests.
Sadly, our government is going to use this proposed rule to try to convince us that they are addressing the Medicare privatization issue. They clearly are not. They have been listening to us but not acting on what we say. We need to turn the volume up even higher. Let’s throw out the privatizers and enact a single payer Medicare for All system. Then we can have Health Justice for All!
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