Recent Medicare Advantage updates are shaping the healthcare landscape. CMS is proposing 2025 policy changes, including stricter broker payment limits and an audit appeal process. Lawmakers advocate for AI oversight in prior authorizations. Research finds rural MA enrollment doesn’t harm rural hospitals. Cigna considers selling its MA business. MA enrollees exhibit a 70% lower hospital readmission rate. SCAN Health Plan tailors plans for older women and LGBTQ+ individuals. The legislation addresses inaccurate provider directories, and concerns arise about misleading marketing. A former HealthSun executive faces Medicare fraud charges. Innovative partnerships, like Select Health’s collaboration with Instacart, are expanding access to health insurance. These updates reflect MA’s dynamic evolution and challenges.
Medicare Advantage (MA) has been making waves in the healthcare landscape, with notable developments and policy changes on the horizon. The Centers for Medicare & Medicaid Services (CMS) are in the process of proposing significant updates to the Medicare Advantage program, set to take effect in 2025. Concurrently, lawmakers are closely scrutinizing various aspects of the program, including marketing practices and provider networks. In this article, we will delve into ten crucial updates related to Medicare Advantage that have come to the forefront since October 24.
1. CMS Proposes New Rules for Medicare Advantage
CMS has put forth a comprehensive set of new rules and regulations for Medicare Advantage, which are slated for implementation in 2025. These proposed updates encompass several critical areas. First and foremost, they introduce stricter limitations on payments made to brokers, aiming to enhance transparency and prevent undue financial incentives in the industry. Additionally, CMS seeks to restrict the involvement of third-party marketers within the MA program. The agency also intends to introduce an audit appeal process for MA plans to ensure accountability and compliance with the new rules. Another vital aspect of these proposed updates is focused on health equity. CMS is striving to reform prior authorization policies and procedures at Medicare Advantage organizations to better assess any disproportionate impact on underserved populations, potentially leading to delays or denials in accessing essential healthcare services.
2. Lawmakers Call for Enhanced Oversight of AI in Prior Authorization
In a move to keep pace with advancements in healthcare technology, a group of lawmakers has expressed concerns regarding the use of artificial intelligence (AI) in the Medicare Advantage prior authorization process. They are urging CMS to bolster its oversight of AI applications, ensuring that they are used fairly and ethically while maintaining the highest standards of accuracy and patient care.
3. Rural Medicare Advantage Enrollment and Hospital Financial Distress
Recent research published in the American Journal of Managed Care has shed light on the relationship between Medicare Advantage enrollment in rural areas and the financial stability of rural hospitals. Contrary to some concerns, the study found that increasing Medicare Advantage enrollment in rural regions did not exacerbate the financial distress or risk of closure for rural hospitals. This data provides valuable insights into the impact of Medicare Advantage in underserved communities.
4. Cigna Group Explores Sale of Medicare Advantage Business
The Cigna Group has been making headlines for its contemplation of a potential sale of its Medicare Advantage business. This development, exclusively reported by Reuters, has raised questions about the evolving dynamics within the Medicare Advantage marketplace and the strategic decisions made by key players in the industry.
5. Lower Hospital Readmission Rates for Medicare Advantage Enrollees
Medicare Advantage continues to prove its effectiveness in healthcare management, as evidenced by a white paper from researchers at Harvard Medical School and Inovalon. According to their findings, Medicare Advantage enrollees enjoy a remarkable 70% reduction in hospital readmission rates compared to their counterparts in traditional fee-for-service Medicare. This substantial decrease in readmissions signifies the program’s success in improving patient outcomes and reducing the burden on healthcare facilities.
6. SCAN Health Plan’s Innovative Approach
SCAN Health Plan is breaking new ground by introducing Medicare plans that are specifically designed to cater to the unique needs of older adults who are women or part of the LGBTQ+ community. Becker recently engaged in a conversation with SCAN Group CEO, Sachin Jain, MD, to explore the development and the business rationale behind these innovative plans. In an increasingly competitive Medicare Advantage market, this approach aims to address the diverse healthcare requirements of specific demographic groups.
7. Legislation to Improve Provider Directories
Lawmakers are taking action to address the issue of inaccurate provider directories in the Medicare Advantage program. Senators Thom Tillis, Ron Wyden, and Michael Bennet have introduced the Requiring Enhanced & Accurate Lists of (REAL) Health Providers Act. This proposed legislation seeks to enhance the requirements for Medicare Advantage plans to maintain accurate and up-to-date directories of healthcare providers. Accurate directories are crucial to ensuring that beneficiaries can easily access the care they need.
8. Concerns Over Misleading Marketing
To curb misleading marketing practices within the Medicare Advantage space, fourteen Democratic senators on the Senate Finance Committee have voiced their concerns. They penned a letter to CMS Administrator Chiquita Brooks-LaSure, urging the agency to take more decisive action to combat deceptive marketing of MA plans. The move underscores the commitment of lawmakers to protect beneficiaries from misinformation and ensure they make informed choices.
9. Charges in a Medicare Fraud Scheme
A former executive of HealthSun Health Plans, owned by Elevance, is facing serious legal charges related to an alleged multimillion-dollar Medicare fraud scheme. This case serves as a stark reminder of the ongoing battle against fraud and abuse in the Medicare Advantage program, emphasizing the importance of robust oversight and enforcement mechanisms.
10. Expanding Access to Health Insurance through Unconventional Partnerships
The landscape of health insurance is evolving, and new, unconventional partnerships are emerging. One notable example is the collaboration between Select Health and Instacart. Jason Worthen, Select Health’s Vice President of Government Markets, recently discussed the innovative partnership, highlighting how a grocery delivery service like Instacart can now provide access to health insurance. This illustrates the ever-expanding reach and accessibility of health insurance options, emphasizing the industry’s adaptability to the changing needs of consumers.
Overall, Medicare Advantage is undergoing significant transformations and facing various challenges and opportunities in the healthcare sector. From proposed regulatory changes to groundbreaking initiatives and the impact on rural healthcare, these ten recent updates shed light on the dynamic and evolving nature of Medicare Advantage. As the program continues to evolve, stakeholders, policymakers, and beneficiaries must remain vigilant and adaptable to ensure its continued success in delivering quality healthcare to millions of Americans.
