Medicare Advantage (MA) is private insurance that Medicare beneficiaries can enroll in as an alternative to traditional Medicare. The MA program has grown significantly in recent years and now accounts for more than half of all Medicare enrollment. The Center for American Progress estimates that the Centers for Medicare and Medicaid Services (CMS) overpays MA plans by 22 percent to 39 percent, with overpayments in 2024 alone estimated to total between $83 billion and $127 billion. Yet there is no clear evidence that the MA program leads to improved health care quality, nor is there evidence that the program advances health equity for enrollees. With this in mind, CMS must exercise a high degree of oversight over the program, which necessitates more and better information about how MA plans are operating.
CMS has taken several important steps to bring more transparency and accountability to MA, yet remaining data gaps limit regulators' ability to conduct oversight of plan performance; constrain researchers' ability to fully assess the program’s impact; prevent beneficiaries from making fully informed choices; and make it difficult for policymakers and others to fully address disparities in health equity.
In January 2024, CMS released a request for information seeking public feedback on ways to strengthen MA. As outlined in CAP’s May 2024 response, CMS must enhance MA data collection and reporting requirements to enable Medicare beneficiaries to make more fully informed enrollment choices, protect MA plan enrollees from inadequate coverage and harmful practices, and support MA-contracted clinicians’ ability to practice appropriate and high-quality care. To advance these goals, CMS must fill data gaps related to MA broker compensation, network adequacy, prior authorization, supplemental benefits, disenrollment, and enrollee out-of-pocket (OOP) cost expenditures.
1. Broker and agent financial arrangements
Nearly one-third of all new Medicare enrollees receive guidance from brokers or agents when choosing an MA plan. Brokers can benefit financially by directing enrollees toward specific plans with which they have financial arrangements. Brokers and agents currently do not have to publicly disclose how they are compensated by MA plans.
Beneficiaries should know whether and how the people steering them toward enrollment decisions are benefiting from those decisions. To that end, CMS should collect and publish complete data on broker compensation, report when a broker is involved in a beneficiary’s enrollment in an MA plan, maintain a public database of payments, and require brokers to proactively disclose whether they are being compensated by plans.
2. Network adequacy and directory accuracy
Prospective MA enrollees should know with certainty whether they will have access to a range of in-network providers sufficient for their needs upon signing up for an MA plan. Recent CMS regulations have partially addressed this issue by strengthening marketing restrictions on MA plans and third-party marketing organizations but further action is needed.
One step would be requiring MA plans to attest network data accuracy every 90 days according with standards set by the No Surprises Act. Network accuracy reporting compliance should also be made public alongside other information so prospective enrollees can see clearly whether each plan's networks are up-to-date.
3. Prior authorization
Prior authorization (PA) requires advance approval for certain medical care or medications as a condition for payment. While traditional Medicare requires PA for very few services, 99 percent of MA enrollees are in plans that require PA for some services.
PA requirements create administrative burdens on healthcare providers—one AMA survey found physicians completed an average of 45 PA requests per week requiring about 14 hours of work—and may result in harm due delays waiting approval.
When making enrollment decisions beneficiaries should know how heavily individual plans use PA but current rules do not require sufficient granularity at plan level only contract level which may cover multiple plans under one contract with CMS without specifying service type or conditions details required improving transparency allowing comparisons between different offerings ensuring compliance with rules
4 .Supplemental benefits use spending
Supplemental benefits like dental fitness extensively marketed attracting potential beneficiaries but often unutilized underutilized negating any potential value limited research available suggests such coverage hasn’t resulted improved access recently required utilization cost reporting still lacks beneficiary level detail necessary determine variations among groups understanding true costs incurred
5 Disenrollment rates
Understanding demographics characteristics switching between leaving favoring traditional medicare spotting alarming patterns ensuring consistency commitment equity knowing numbers leaving particular helpful choice comparison aggregate reported needs granular stratified across demographic health characteristics published available both researchers prospective
6 Enrollee out-of-pocket cost expenditures
Comparing upper limits estimating impacts actual collected unpublished reflecting typical ranges proportions hitting maximum annually enabling comprehensive actuarial value studies comparing publishing encounter data essential completing picture decision-making processes evaluating overall performance
Conclusion
CMS important steps bringing accountability transparency significant taxpayer expense functioning intended meeting needs filling remaining gaps especially crucial stratifiable key characteristics monitoring disparities swift adjustments reinforcing commitment health equity.
