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Weak Care Access Plagues Some Dying Medicare Plan Enrollees: GAO

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What You Need to Know

  • Witnesses talked about Medicare plan provider network problems at a House subcommittee hearing Tuesday.
  • Most Medicare Advantage plan enrollees like the program and stay in the program.
  • When enrollees are in their last year of life, they are much more likely to run into problems and drop out, according to GAO.

One way advisors can help older clients: Call a few of the specialists in their Medicare Advantage plan directories and make sure that a high percentage of them are still in business and still accepting new patients.

That’s a takeaway advisors might draw from a new batch of written testimony that the  Government Accountability Office presented Tuesday at a House Energy and Commerce oversight subcommittee hearing on the Medicare Advantage plan program.

One topic that came up was that some Medicare Advantage plans have problems with the processes they use to decide whether they should cover care or pay claims.

Leslie Gordon, GAO’s acting director for health care, also raised another point: Some Medicare Advantage plans have skimpy provider networks or misleading provider network directories, and those provider network weaknesses can make patients miserable in their last year of life.

“In particular, provider networks may provide limited access to specialized care,” Gordon and other GAO officials said in the written version of the testimony.

GAO has given the Centers for Medicare & Medicaid Services ideas in the past about how to improve Medicare Advantage plans’ provider networks and provider directories, but “as of March 2022, the recommendations had not not yet been fully implemented,” officials said.

GAO officials did not try to compare the accuracy of Medicare Advantage plan directories with other types of health plan directories, such as health insurers’ directories for patients in employer-sponsored group health plans for active employees.

What It Means

Many advisor clients will avoid Medicare Advantage plan provider network problems by sticking with “Original Medicare,” in combination with Medicare supplement insurance, and many of the clients who sign up for Medicare Advantage plan coverage will end up in plans with excellent provider networks.

But insurance agents or financial advisors with the staff resources might be able to provide an important value-added service by calling 10 of the specialists in a client’s Medicare plan provider directory at random to check the accuracy of the directory, or by hiring a directory checking service.

The Background

The original Medicare program comes with many complicated deductibles and other coverage holes.

About 29 million of the 64 million Medicare enrollees now have Medicare Advantage coverage, according to data from Mark Farrah Associates.

More than 98% Medicare Advantage plan enrollees stay in the Medicare Advantage program in a typical year. They may like the extras that come with Medicare Advantage coverage, such as access to dental benefits, hearing care coverage and exercise programs.

But in 2017, the last time GAO checked, about 4.6% of the enrollees who were in the last year of their lives had dropped out of the Medicare Advantage program.

The Medicare Advantage program dropout rate in the last year of life ranged from about 2% for one plan provider that GAO checked up to more than 12% for another plan provider, according to a 2021 GAO report cited in the new testimony.

The Reasons

GAO officials said they talked to health care researchers, provider groups and beneficiary advocacy groups and found that one problem was the Centers for Medicare & Medicaid Services’ approach to plan provider directories.

“For example, we found that CMS did not adequately verify the accuracy of provider network information submitted by [Medicare Advantage organizations (MAOs)], and accordingly could not verify whether MAO networks were in compliance with the agency’s provider network criteria,” GAO officials said. “We also found that the agency’s network criteria did not account for aspects of provider availability, such as whether a provider is accepting new patients.”

CMS agreed to accept GAO recommendations for addressing those problems, but it has not yet fully implemented the network directory verification improvements, officials said.

A Medicare Advantage Group’s Response

The Better Medicare Alliance, a group that represents health insurers and other individuals and organizations with an interest in the Medicare Advantage program, has asserted that one reason for the relatively high end-of-life disenrollment rate may be that Congress has created a confusing reimbursement approach for Medicare Advantage plan enrollees who are getting hospice care, and some enrollees who like their plans may disenroll because of the hospice coverage confusion issue.

The alliance notes, in response to the suggestion that some plan provider directories could be faulty, that Medicare program enrollee survey data show that, in 2019, 95.6% of enrollees said they are satisfied or satisfied with the convenience of getting to health care professionals near where they live.

The the Original Medicare program, the percentage who are satisfied or very satisfied with ease of provider access is 95%, according to an analysis commissioned by the alliance.

(Photo: Adobe)