In a bid to prioritize transparency and empower Medicare beneficiaries, the Biden-Harris administration has launched a concerted effort to increase integrity and transparency within the Medicare Advantage program. With millions of Americans relying on Medicare for their healthcare needs, ensuring transparency within Medicare Advantage plans is a significant step towards providing clarity and improving healthcare outcomes for seniors. Let’s delve into what this initiative entails and its potential impact on beneficiaries.
The Biden-Harris Administration is making strides in promoting competition and transparency in the healthcare sector, particularly within the Medicare Advantage (MA) insurance market. With over 50% of Medicare beneficiaries enrolled in MA, plans and the government projected to invest over $7 trillion in MA health insurance companies over the next decade, ensuring transparency and accountability is paramount.
Fraud Within The Program
According to the NY Times, Most large insurers in the program have been accused in court of fraud. The fraud involves incentivizing doctors to add additional diagnosis codes to their patient population, thus increasing the amount of money Medicare pays the health plan on a monthly basis. For example, United Health Group, which controls 27% of the Medicare Advantage (MA) market, was caught doing this by the Inspector General’s Office (OIG), whistleblowers, and Medicare itself.
Aetna (Now CVS Health) is well known for demanding unreasonable pre-authorizations for covered services or denying continued hospital and urgent care for its subscribers.
MA plans to get paid a set amount of money each month (like an HMO) to provide all the care a patient/subscriber requires. Medicare incentivizes Plans to take on sicker patients by paying them more monthly to provide services that exceed traditional Medicare benefits. For example, eye care, dental care, and money for groceries or a gym membership are offered to people who live in Zip codes and have lower incomes.
Medicare does this so that the plans can keep people out of high-cost hospital and nursing home care. The reality is that the Plans act like these payments are their money, and they don’t want to spend it. This is in contrast to traditional Medicare, which pays insurance companies to process claims (called fiscal intermediaries) to pay claims on behalf of Medicare.
Although MA plans are contracted to provide the full array of services that traditional Medicare provides (and the additions offered to keep people healthy), they tend to scrimp on services by limiting their contracts to low-quality medical care and subacute care (primarily nursing homes) providers.
Understanding Medicare Advantage
Medicare Advantage, also known as Medicare Part C, offers an alternative way for Medicare beneficiaries to receive their Medicare benefits. These plans are offered by private insurers approved by Medicare and provide all the benefits covered under Original Medicare (Part A and Part B), often with additional services such as prescription drug coverage, dental, vision, and hearing benefits, and wellness programs.
The Importance of Transparency
Transparent communication is essential in empowering individuals to make informed decisions about their healthcare coverage. In the context of Medicare Advantage, transparency means providing clear, accessible information about plan benefits, costs, coverage limitations, and provider networks. Improved transparency can help beneficiaries understand their coverage options, compare plans effectively, and ultimately choose the plan that best meets their healthcare needs and budget. Life Span Care Management helps promote this transparency by delivering crucial information about the care and plan of action. Get Help Today
The Biden-Harris Administration’s Initiative
The Biden-Harris administration’s effort to increase transparency in Medicare Advantage aims to address several key areas:
- Improved Access to Information: The administration seeks to enhance the availability and accessibility of information about Medicare Advantage plans. This includes making plan details, such as coverage, costs, and provider networks, more readily available to beneficiaries through user-friendly channels, such as the Medicare Plan Finder tool.
- Enhanced Consumer Protections: The initiative aims to strengthen consumer protections by ensuring beneficiaries have clear information about their rights and how to navigate the Medicare Advantage program. This includes educating beneficiaries about their right to appeal coverage decisions and providing resources to help them resolve disputes with their plan providers.
- Promoting Accountability: The administration is committed to holding Medicare Advantage plans accountable for their performance and ensuring they uphold high quality and transparency standards. This may involve increased oversight and enforcement measures to address inaccurate marketing practices and coverage denials.
Potential Impact on Beneficiaries
Increased transparency within the Medicare Advantage program has the potential to benefit beneficiaries in several ways:
- Empowering Informed Decision-Making: Clear and accessible information can help beneficiaries make well-informed decisions when selecting a Medicare Advantage plan, ensuring they choose the coverage that aligns with their healthcare needs and preferences.
- Preventing Surprise Costs: Improved transparency around plan costs and coverage limitations can help beneficiaries avoid unexpected out-of-pocket expenses and better budget for their healthcare needs.
- Enhancing Trust and Confidence: By promoting transparency and accountability, the initiative can foster trust and confidence in the Medicare Advantage program, reassuring beneficiaries that they are receiving comprehensive and reliable coverage.
Conclusion
The Biden-Harris administration’s effort to increase transparency within the Medicare Advantage program marks a significant step towards empowering beneficiaries and improving the overall quality of care. By providing clear, accessible information and promoting accountability, this initiative can potentially enhance the healthcare experience for millions of Medicare beneficiaries across the country. As transparency becomes a central focus within Medicare Advantage, beneficiaries can look forward to greater clarity, confidence, and control over their healthcare coverage decisions.