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U.S. Health Officials Seek Latest Curbs on Private Medicare Advantage Plans


Federal health officials are proposing an in depth set of tougher rules governing private Medicare Advantage health plans, in response to wide-scale complaints that too many patients’ medical claims have been wrongly denied and that marketing of the plans is deceptive.

Medicare Advantage is the private-sector alternative to the federal program covering those 65 and over and the disabled. By next yr, greater than half of Medicare recipients are expected to be enrolled in private plans. These policies are sometimes inexpensive than traditional Medicare and sometimes offer attractive, additional advantages like dental care.

Despite their popularity, the plans have been the topic of considerable scrutiny and criticism currently. A recent report by the inspector general of the U.S. Department of Health and Human Services found that several plans could be inappropriately denying care to patients. And nearly every large insurance company in this system, including UnitedHealth Group, Elevance Health, Kaiser Permanente and Cigna, has been sued by the Justice Department for fraudulently overcharging the federal government.

The period leading as much as this yr’s enrollment deadline, Dec. 7, amplified widespread criticism concerning the deceptive tactics some brokers and insurers had used to entice people to modify plans. In November, Senate Democrats issued a scathing report detailing among the worst practices, including ads that appeared to represent federal agencies and ubiquitous television commercials featuring celebrities.

Federal Medicare officials had said they might review television promoting before it aired, and the brand new rule targets among the practices identified within the Senate report that caused some consumers to confuse the businesses with the federal government Medicare program. A proposed regulation would ban the plans from using the Medicare logo and require that the corporate behind the ad be identified.

“It’s definitely a shot across the bow for brokers and insurers in response to the rising variety of complaints about misleading marketing activities,” said Tricia Neuman, the manager director of the middle for Medicare policy on the Kaiser Family Foundation. Ms. Neuman and her team routinely review television ads from the plans.

The proposal would also allow beneficiaries to opt out of selling calls for plans and would limit what number of firms can contact a beneficiary after she or he fills out a form asking for information. The Senate report described patients who had received dozens of aggressive marketing calls they didn’t request.

David Lipschutz, an associate director on the Center for Medicare Advocacy, said that while the federally proposed rules didn’t include all the things on his wish list, the goals were wide-reaching and significant.

“This is basically a meaningful response,” he said. “And where we sit, we don’t get to say that that always.”

Mr. Lipschutz said that the changes would ultimately be judged by how effectively and aggressively Medicare enforced the standards. Much of the deceptive marketing is now conducted by brokers, agents and other third-party marketing firms who’re paid commissions once they enroll people, not by the insurers themselves. The proposed rule would hold insurers accountable for the actions of the firms they hire.

“These proposals are a vital step toward protecting seniors in Medicare from scammers and unscrupulous insurance firms and brokers,” Senator Ron Wyden, the Oregon Democrat who chairs the Senate Finance Committee, said in a press release.

The foundations would also address the health plans’ use of techniques that require the corporate to approve certain care before it will be covered. Patients and their doctors complained to Medicare that the private plans were misusing prior authorization processes to disclaim needed care. The inspector general’s report estimated that tens of hundreds of people had been denied mandatory medical care that ought to be covered under this system.

The brand new proposal would require plans to reveal the medical basis for denials and rely more heavily on specialists conversant in a patient’s care to be involved within the decision-making. Medicare has also established tighter deadlines for answers on authorizations; patients now often wait as much as 14 days. The brand new rules would also require authorization to cover the total length of a treatment so patients don’t have to repeatedly request an identical approvals.

Dr. Meena Seshamani, the director of the Center for Medicare and a deputy administrator on the Centers for Medicare and Medicaid Services, said the changes had been influenced by hundreds of public comments solicited by the agency and by lawmakers.

“The proposals on this rule we feel would really meaningfully improve people in Medicare’s timely access to the care they need,” she said.

The insurance industry has said it is usually supportive of regulators’ efforts to guard Medicare enrollees from deceptive marketing, and the Higher Medicare Alliance, a bunch that advocates for Medicare Advantage, said it agreed with officials “that there have to be no room within the system for individuals who would deceive seniors,” in accordance with a press release from the group’s chief executive, Mary Beth Donahue.

Ms. Donahue added that her group was continuing to review the agency’s proposals on how patients must seek prior authorization for treatment. She said the organization hoped to work with Medicare officials to enhance the method.

Hospitals, which have been pushing for changes that will address their concerns that insurers were abusing prior authorization, applauded the proposals. But they emphasized that the Biden administration’s health officials would must commit to enforcing the stricter oversight.

“The agency really needs to maintain their eye on the ball,” said Molly Smith, the group vp for public policy on the American Hospital Association, a trade organization.

The proposed regulations are usually not yet final. Health officials are soliciting comments from the general public and should make changes.

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