Medicare Advantage (MA) plans should be required to publish data “that demonstrates they provide sufficient access to care and patient choice, including measures of beneficiary satisfaction and complaints, as well as the number of in-network DME suppliers by product category and geography.”
That was among the comments provided by the American Association for Homecare (AAHomecare) in response to a request for MA information by the Centers for Medicare & Medicaid Services (CMS).
In a May 29 bulletin to stakeholders, AAHomecare also recommended requiring MA plans “to publish data regarding their appeal process for prior authorization decisions, as well as disclosing detailed prior authorization approval/denial statistics by product category.”
AAHomecare: MA transparency needed on prior authorization policies
The comments were sent by AAHomecare in a letter to CMS Administrator Chiquita Brooks-LaSure on May 15.
“Overall, AAHomecare supports the agency’s objective to have comprehensive high-quality MA plans’ programmatic data and promote more program transparency through increased public releases of MA data,” the letter said. “We support enhancing data capabilities to gain better insight into current MA programs and increase MA data transparency.”
Regarding a potential requirement for MA plans to prove that they offer sufficient beneficiary access to care, AAHomecare said, “CMS should require MA plans to establish clear network adequacy criteria by DMEPOS product category and by geographic area to ensure there is real patient choice.
“For example, some DMEPOS suppliers only provide respiratory items and services, while others only provide Complex Rehab Technology items and services. There should be multiple DMEPOS suppliers providing the same product category in a geographic area.”
In explaining why the organization recommends that MA plans be required to publish data on its appeal process for prior authorizations, AAHomecare said, “Our members’ experience is that many MA plans lack an objective/impartial and expeditious appeal process for negative prior authorization determinations. We recommend that CMS require MA plans to establish a timely, objective prior authorization appeal process that is available to providers/suppliers and enrollees, to quickly appeal a negative prior authorization determination and ensure access to care.”
Current concerns over MA appeal processes, the letter said, include a “lack of timeliness and a lack of impartiality/objectivity.”
Concerns over MA marketing to Medicare beneficiaries
AAHomecare also asked CMS to require MA plans to “disclose their use of artificial intelligence in prior authorizations and claims processing” and “to disclose data on what benefits they cover under Part D that are also covered under Part B.
“Despite the fact that Medicare has determined that continuous glucose monitors (CGMs) are covered as DME under Part B, and that MA plans are required to provide CGMs under Part B, many MA plans are instead covering these devices and related supplies under Part D prescription drug plans.”
The letter also recommended greater transparency about MA marketing: “Brokers should be required to publicly disclose how many beneficiaries enroll in which MA plan, after the broker communicates the details of those MA plans to beneficiaries,” AAHomecare said. “Therefore, brokers should be required to disclose the specific benefits, geographic coverage, and the number of beneficiaries enrolled in each MA plan.”
Criticism of MA plans continues to grow louder, as traditional health insurance giants gobble up Medicare marketshare.
The Center for Economic and Policy Research (CEPR), a research and public education nonprofit based in Washington, D.C., said in a November 2023 report, “Deceptive and fraudulent advertising for MA plans cost taxpayers $6 billion in 2022 alone; however, this symptom only constitutes between 4% and 7% of the larger issue: MA itself. In 2022, the privatization of Medicare through MA cost taxpayers between $88 billion and $140 billion.”
Noting that UnitedHealthcare and Humana accounted for 46% of MA enrollment in 2022, CEPR added, “While MA plans advertise comprehensive, inexpensive coverage, they fail to make clear the realities of poor coverage through restricted networks, prior authorizations and denials of care, and high costs for their supplemental benefits.”
AAHomecare’s letter made clear the urgent need to hold MA plans accountable by requiring the plans to provide data related to their actions and outcomes.
“This data is also critical to effective oversight and evaluation of these plans by legislators and regulators,” the association’s bulletin to stakeholders said. “AAHomecare will continue to press for measures that increase transparency in the Medicare Advantage space.”