BMA Shares How CMS Can Improve Medicare Advantage Program

Better Medicare Alliance (BMA) has called on CMS to improve the Medicare Advantage program by auditing all health plans annually, creating best practices for in-home health risk assessments, and increasing supplemental benefit offerings.

“Policymakers are weighing important decisions about the future of more than 29 million Americans’ Medicare Advantage coverage. With these recommendations, we are offering new solutions to inform an even more transparent, accountable Medicare Advantage that continues to provide exceptional value for beneficiaries and taxpayers alike,” Mary Beth Donahue, president and chief executive officer of BMA, said in the press release.

According to BMA, CMS can help ensure program integrity by adopting a comprehensive and accurate approach to risk adjustment data validation (RADV). This strategy includes conducting RADV audits of all Medicare Advantage plans annually to increase program oversight.

CMS already conducts annual audits of Affordable Care Act (ACA) health plans, and ensuring equal auditing practices would increase confidence in CMS sustainability efforts and support stability for beneficiaries.

In addition, RADV audit changes should be applied prospectively, not retroactively, as retrospective applications would invalidate actuarial assumptions plans incorporated in plan bids starting in 2011. CMS should also apply a fee-for-service adjuster to incorporate payment impacts of beneficiary-level discrepancies into RADV audits.

Medicare Advantage uses in-home HRAs as a preventative care measure to assess beneficiaries’ overall health, document diagnoses, and identify care gaps and unmet needs. The report recommended that CMS codify a set of best practices for in-home HRAs to ensure plans apply consistent criteria and to prevent sub-standard HRAs that do not offer clinical value.

Some best practices include medication reviews and reconciliation, conducting an environmental scan for safety risks, scheduling appointments with appropriate providers, and enrolling beneficiaries into disease or case management programs as needed.

BMA has also asked CMS to increase regulation and oversight of Medicare Advantage marketing materials to make sure beneficiaries receive accurate information about their options. This includes boosting oversight of third-party marketing organizations (TPMOs) and improving beneficiary decision-making support tools.

In addition, CMS should improve communication with beneficiaries by issuing warnings about misleading marketing tactics, reflecting marketing complaints in Medicare Advantage Star Ratings, and simplifying the process for comparing Medicare Advantage plans online and offline.

Requiring agents and brokers to follow best practices, such as reviewing beneficiaries’ prescription drugs and healthcare providers, can help also enhance the beneficiary experience, BMA said.

The report emphasized the importance of providing supplemental benefits that help enhance beneficiaries’ holistic health.

“BMA recommends that plans and policymakers work together to ensure that Medicare Advantage provides coordinated supplemental benefits rather than cash benefits to ensure beneficiaries are accessing services that will meet their health needs,” the press release stated.

CMS should also include structured benefits like vision, dental, and hearing to promote access to high-quality providers. Additionally, BMA encouraged health plans to tailor benefits to allow beneficiaries to receive services that align with their care plans to improve care coordination.

Strengthening the quality of Medicare Advantage is a top priority for stakeholders as enrollment continues to grow.

As of April 2022, Medicare Advantage plans accounted for 50 percent or more of Medicare enrollment in 123 congressional districts. In more than 30 states, over 40 percent of Medicare beneficiaries were enrolled in Medicare Advantage plans.

Beneficiaries are typically drawn to Medicare Advantage because of the supplemental benefits offered. Specifically, 24 percent of beneficiaries 65 and older said they chose the program for its additional benefits, such as vision and dental coverage.

Almost 4,000 Medicare Advantage plans are available for the 2023 open enrollment period. Nearly 60 percent of plans are health maintenance organizations (HMOs), with UnitedHealthcare and Humana accounting for the largest share of plans offered.