Massachusetts U.S. Sen. Elizabeth Warren is warning buyers to beware of some Medicare Advantage health insurance plans for seniors.
At a meeting with health care providers in Boston this week, Warren said many commercial insurers are “boosting their profits with a lot of denials of care,” and “threatening the solvency of the Medicare system overall.”
Medicare Advantage plans are administered by private insurers who are paid by the federal government’s Medicare health insurance program. The plans launched more than two decades ago as a private-sector option for Medicare that are designed to improve efficiency. An estimated 31 million Americans are covered by the plans nationally, including about 1.4 million people in Massachusetts, according to Warren’s office.
Medicare Advantage plans tend to offer more services than traditional Medicare coverage, such as dental and vision benefits. But Warren, a Democrat, said they often don’t cover some other services that beneficiaries expected. She said her office has heard from a number of people who were frustrated after they were denied access to medications that used to be covered by their insurer, or learned certain facilities were deemed out of network by the insurer.
“Frankly, if you lift the hood and look underneath you find out that it’s pretty modest coverage,” Warren said.
Warren said some of the large insurers running Medicare Advantage plans are not just denying coverage and imposing strict prior authorization requirements before care is delivered, they’re also engaging in what’s known as “upcoding,” which is billing for more serious diagnoses and procedures than are actually required.
“Upcoding alone this year is going to cost about $54 billion in money that should not have been reimbursed to these companies,” Warren said. “And that comes out of Medicare, and it ultimately comes out of the pockets of the American people who pay for this.”
About a dozen Boston-area health care providers — including hospital CEOs, family physicians and nursing home executives — attended the Monday roundtable. Warren said much of the conversation focused on the differences between traditional Medicare coverage and Medicare Advantage plans.
“We heard a lot about local Medicare Advantage outfits here in Massachusetts that do a good job of providing care, but that the national Medicare Advantage providers really came in for a lot of criticism in that room,” Warren said.
The Better Medicare Alliance, an advocacy group for Medicare Advantage plans, said it supports several reforms such as improved oversight of marketing and advertising, and efforts to modernize some plans.
The group said data suggests Medicare Advantage plans are effective for thousands of people. It points to reports suggesting Medicare Advantage beneficiaries say they spend less on out-of-pocket costs and premiums than traditional Medicare recipients, and surveys showing that 95% of Medicare Advantage beneficiaries report they are satisfied with the quality of their health care.
Accompanying Warren on the Boston visit was Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services. She said her office is working on ways to improve oversight of Medicare Advantage plans, such as requiring more timely prior authorization determinations and increasing the agency’s monitoring to ensure accurate Medicare payments.
Brooks-LaSure said she is also asking insurers for more specifics about what their plans cover and making sure the plans are not advertising more services than they provide.
She recommended seniors carefully research Medicare options and pointed to theState Health Insurance Assistance Program (SHIP), where navigators will work with seniors to help them determine what coverage will meet their needs.
“We want to make sure that a Medicare beneficiary, someone who is entitled to the Medicare program, gets the services they need,” Brooks-LaSure said, “whether they are enrolled in traditional Medicare or whether they’re enrolled in Medicare Advantage.”
This article was originally published on WBUR.org.
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