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Medicare Advantage Places Us at a Disadvantage

December 20, 2021

Summary: This week we scrutinize Medicare Advantage (MA). Today: A survey from the Center for Medicare Advocacy found that MA plans deny, reduce, delay, and charge beneficiaries more for home health services. And a leading researcher estimated that Medicare overpaid MA plans by $106 billion over ten years for sicker patients. So … overpaying for worse care. Hmm.

Home Health Survey: Medicare Beneficiaries Likely Misinformed and Underserved
Center for Medicare Advocacy
December 2021

From April 28, 2021 – November 19, 2021, the Center for Medicare Advocacy conducted a survey of 217 Medicare-certified home health agencies in 20 states to learn what beneficiaries may experience when seeking home care.

The Medicare Act mandates that Medicare Advantage plans cover, at least, all the medically necessary services that traditional (also known as “original”) Medicare covers. However, when surveyed home health agencies were asked if there were differences in the services they could provide to clients enrolled in Medicare Advantage plans versus clients with traditional Medicare coverage, their comments describe a very different reality.

Major themes among agency comments were that Medicare Advantage plans deny more services, allow fewer visits per care modality, delay onset of care, lead to more changes to provider-approved plans of care, are significantly harder for agencies to work with, and require greater out-of-pocket costs. Many agencies also mentioned discrepancies in care caused by the pre-authorization process.


* “Abso-freakin-lutely! Medicare Advantage plans in our area are rotten.”

* “Very much so, there’s a difference. Medicare Advantage plans don’t approve as much services.”

* “Medicare Advantage patients are reimbursed for less, and do not have therapy covered. Typically they only provide nursing services.”

* “The payment model is different so we can’t take as many Medicare Advantage beneficiaries. Traditional Medicare is better.”

* “Medicare Advantage plans typically offer less coverage.”

* “Medicare Advantage plans can be very limiting. Anthem and Humana are terrible, and very often do not cover services that patients need.”

* “Medicare Advantage plans often fight tooth and nail on the number of visits they will allow. Anthem is the worst. They use MyNexus, a company for prior authorization work, and allow very few visits.”

* “MA authorizations are limited. We [the agency] fight and appeal for more services. United Healthcare and Aetna provide particular coverage challenges.”

* “Managed Medicare seems to be a lot stingier with what they authorize than traditional Medicare.”

Researcher: Medicare Advantage Plans Costing Billions More Than They Should
By Fred Schulte
November 11, 2021

Switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in original Medicare, a cost that has exploded since 2018 and is likely to rise even higher, new research has found.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. “They are paying [Medicare Advantage plans] way more than they should,” said Kronick.

Kronick called the growth in Medicare Advantage costs a “systemic problem across the industry,” which CMS has failed to rein in. He said some plans saw “eye-popping” revenue gains, while others had more modest increases.

Making any cuts to Medicare Advantage payments faces stiff opposition, however.

On Oct. 15, 13 U.S. senators, including Sen. Kyrsten Sinema (D-Ariz.) sent a letter to CMS opposing any payment reductions. (Sen. Manchin also signed – DMc)

Comment by: Don McCanne

We have been witnessing the privatization of the Medicare program through the introduction of the private Medicare Advantage plans, and, more recently, the Direct Contracting Entities as a means of converting much of the remaining traditional Medicare program into private plans.

We have recently been inundated with heavy marketing of these plans during the open enrollment period, promising eligible Medicare beneficiaries much better benefits at considerably lower costs.

Better benefits? Look at the report on services provided by home health agencies, the type of services the marketing suggests are superior when provided by the Medicare Advantage plans. This study showed that services were emphatically inferior to services provided under the traditional Medicare program.

And lower costs? The other report cited above indicates that Medicare Advantage plans were overpaid by tens of billions of dollars.

When there is a popular movement to eliminate private plans and establish a single payer Medicare for All program, it is ironic that our government is establishing policies to suppress our existing Medicare program and replace it with private plans when the evidence is that they are a major source of much of the detrimental dysfunction in health care financing.

What we need is an equitable, publicly administered and publicly financed health care program for everyone: a single payer, improved Medicare for All. But we do need to consider getting rid of the politicians who want to use our public funds to support the private health plans while suppressing our public programs.

© Health Justice Monitor
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