The Medicare Advantage (MA) program, which now encompasses over half of all Medicare enrollment, faces significant data gaps that need to be addressed by the Centers for Medicare and Medicaid Services (CMS). The Center for American Progress (CAP) estimates that MA plans are overpaid by 22 percent to 39 percent, with overpayments in 2024 alone ranging between $83 billion and $127 billion. Despite steps taken by the Biden-Harris administration to enhance accountability and transparency within the MA program, critical data deficiencies hinder comprehensive assessment of program quality, oversight of plan performance, identification and resolution of disparities, and provision of essential information for enrollees.
A recent column from CAP responds to a CMS request for information on MA data transparency. It underscores six key areas where CMS must bridge existing data gaps:
1. **Broker and agent financial arrangements**: With nearly one-third of all Medicare enrollees relying on brokers or agents who may benefit financially from directing enrollees to specific plans, it is recommended that brokers disclose their compensation structures.
2. **Network adequacy and directory accuracy**: Prospective MA enrollees should have certainty about their access to in-network providers when selecting a plan. Strengthening marketing restrictions on MA plans is suggested to ensure confidence in network options.
3. **Prior authorization (PA)**: Enrollees should be informed about the extent to which individual plans use PA in care or reimbursement decisions. Publicizing PA usage data could aid prospective enrollees in making informed choices between plans.
4. **Supplemental benefits use and spending**: CAP advises CMS to collect and publish comprehensive data on utilization and out-of-pocket spending for all supplemental benefits at both the plan and beneficiary levels.
5. **MA plan disenrollment rates**: To identify concerning trends in plan coverage, it is crucial to understand the demographic and health characteristics of those switching or leaving MA plans. Making this data publicly available at the plan level is recommended.
6. **Enrollee out-of-pocket cost expenditures**: Publishing actual out-of-pocket spending information as part of MA encounter data can help enrollees compare plans more effectively and enable researchers to study variations between MA and traditional Medicare enrollees.
Andrea Ducas, vice president of Health Policy at CAP and co-author of the column, stated, “To ensure the Medicare Advantage program is functioning as intended and meeting the needs of Medicare enrollees and providers, CMS must fill remaining data gaps related to MA broker compensation, network adequacy and accuracy, prior authorization, supplemental benefits, disenrollment, and enrollee OOP cost expenditures.”
The column titled “6 Medicare Advantage Data Gaps That the Centers for Medicare and Medicaid Services Must Fill” was co-authored by Brian Keyser and Andrea Ducas.
For further details or expert consultations, contact Sarah Nadeau at [email protected].
