Medicare Advantage

By Mike Tuffin, AHIP President & CEO

Oct 15, 2024 • by AHIP (America’s Health Insurance Plans)

Millions of seniors are seeing their current Medicare Advantage coverage disrupted because of two consecutive years of cuts to the Medicare Advantage program.

Data released by the Centers for Medicare & Medicaid Services (CMS) on MA plan offerings for 2025 confirm that many seniors are now experiencing a reduction in coverage choices, higher costs and reduced benefits, which can vary substantially based on where a beneficiary lives.

While health plans have worked to shield seniors from the full impact of these cuts, AHIP’s initial analysis of the CMS data shows:

Fewer Coverage Choices:

• About 1.3 million Americans are currently enrolled in MA general enrollment plans that will not be available to them in 2025, forcing these beneficiaries to change their Medicare coverage for 2025.
• The number of general enrollment MA plans in 2025 decreased by 6% relative to 2024.
• Over 60% of Medicare eligible Americans live in counties with fewer general enrollment plans in 2025 relative to 2024.
• Nine insurers stopped offering any MA general enrollment plans in 2025.

Higher Costs:

• National averages on MA premiums do not tell the whole story. In fact, MA seniors in many states are seeing double-digit premium increases.
  • MA seniors in 19 states are seeing an average premium increase of more than 10%: AL, GA, ID, IN, IA, LA, ME, MA, MO, NJ, NY, ND, SC, SD, UT, VT, WA, and WY.
• The number of $0 premium general enrollment plans fell by 5% in 2025, though the share of all general enrollment plans that are $0 premium rose slightly.
  • An estimated 243,000 beneficiaries are currently in MA general enrollment plans that have $0 premium in 2024 but will have a premium in 2025.
• Maximum out-of-pocket (MOOP) levels in MA plans are rising for 2025.

• The share of general enrollment MA plans with a MOOP of $3,500 or less decreased from 23% to 20%.
• The share of general enrollment MA plans with a MOOP over $5,000 rose from 46% in 2024 to 52% in 2025.

More than 33 million seniors and individuals with disabilities choose MA because it provides them better care at a lower cost than fee-for-service Medicare. These beneficiaries are counting on policymakers to keep the bipartisan promise of protecting their Medicare coverage from additional cuts.

‘Greg Says‘ has seen the recent reduction in benefits and increases in copays among most Medicare Advantage plans.  In fact, some carriers are terminating their more generous plans in 2025 causing their affected members to find new plans.  Part of the reason for this is the Jan. 1, 2025, activation of an Inflation Reduction Act provision setting the annual maximum out-of-pocket limit for the purchase of Rx medications by Medicare beneficiaries at $2,000.  As a result, insurance companies will be paying a much greater share of the cost for high-cost medications than they ever have.  We believe the days of Medicare Advantage plans with ultra-generous benefits and super-low copays are over.  Hopefully, the days of numerous plan terminations are over as well.

Medicare Advantage enrollment has doubled in ten years and, in 2020, 16 percent more plans score four stars or more than did in 2015.

By Kelsey Waddill April 24, 2020

Medicare Advantage plans are continuing along a trend of burgeoning enrollment and rising quality, although costs for certain services may be more expensive than traditional Medicare, according to recent analysis from Kaiser Family Foundation (KFF).

Early in the coronavirus outbreak, CMS zeroed in on Medicare Advantage populations which, along with the rest of Medicare, promised to be among the most vulnerable populations in the US.

Kaiser Family Foundation’s analysis drew from CMS Medicare Advantage data to piece together the status of Medicare Advantage currently and the potential impacts of coronavirus as 2020 progresses.

MEDICARE ADVANTAGE ENROLLMENT, PENETRATION IS HIGHER THAN EVER

As of April 22, 2020, 36 percent of Medicare beneficiaries are in a Medicare Advantage plan. This comes after a 9 percent increase between 2019 and 2020. This enrollment is distributed unevenly across the country, with nine states holding over 40 percent of Medicare Advantage beneficiaries. Around ten percent of the Medicare population resides in metropolitan counties, consistent with recent trends.

There are three Medicare Advantage titans that are responsible for nearly 60 percent of all Medicare Advantage beneficiaries. UnitedHealthcare holds 26 percent of the Medicare Advantage population, Humana has 18 percent, and Blue Cross Blue Shield has 15 percent of Medicare Advantage enrollees.

However, the field is seeing some significant shifts as Humana’s plans begin to catch up with UnitedHealthcare’s and CVS Health’s 2018 purchase of Aetna spurred major growth extending into 2019 and 2020, as expected.

This growth is expected to continue, with Medicare Advantage plans accounting for over 50 percent of Medicare beneficiaries by 2030, KFF said, citing Congressional Budget Office predictions. Other sources, such as LEK Consulting’s estimates, have projected a 70 percent increase in Medicare Advantage enrollment between 2030 and 2040, although enrollment for dual eligible members lags.

MEDICARE ADVANTAGE BENEFITS AND QUALITY ARE EVOLVING

In 2020, Medicare Advantage enrollees will have more benefits than traditional Medicare enrollees. CMS expanded Medicare Advantage benefits to include more supplemental benefits. Nearly three-quarters of Medicare Advantage beneficiaries, for example, will have a dental benefit and the same percentage have a fitness benefit. Over 70 percent will have access to hearing aid benefits and 61 percent will have access to over the counter medication benefits.

Perhaps most relevant given the status of coronavirus, 77 percent will have a telehealth benefit. With many states imposing shelter-in-place orders and authorities enjoining residents to stay at home to prevent the spread of coronavirus, health plans have been relying heavily on telehealth to connect patients to care.

Most Medicare Advantage beneficiaries are now enrolled in a plan that scores well on Medicare Advantage Star Ratings. In 2015, 62 percent of Medicare Advantage beneficiaries were in plans that got four stars or higher, but in 2020, 78 percent will be in such plans.

RESULTS ARE MIXED ON MEDICARE ADVANTAGE OUT-OF-POCKET SAVINGS

Medicare Advantage has long been touted as a cost-saving alternative to traditional Medicare, with recent statistics showing that Medicare Advantage costs 40 percent less than fee-for-service Medicare. In many ways this remains true for 2020. Medicare Advantage beneficiaries still tend to see much lower out-of-pocket healthcare spending than Medicare beneficiaries.

For example, 60 percent have no premium aside from Part B. For those who do, the average premium is $25 per month. This continues a downward trend in Medicare Advantage premium rates starting in 2015.

For coronavirus, Medicare Advantage plans received flexibility and guidance from CMS to cover both testing and treatment costs early on in the crisis. Medicare will cover hospitalizations, including if a patient is diagnosed with coronavirus and must extend their stay to quarantine in a hospital setting.

In contrast, according to a separate KFF report from mid-April 2020, beneficiaries on traditional Medicare are still responsible for the deductible for such a stay and susceptible to out-of-pocket costs as a result. This could mean up to $1,408 in out-of-pocket costs for a Medicare beneficiary.

However, the evidence points to one area in which many Medicare Advantage patients do not necessarily see greater savings than their Medicare counterparts: inpatient hospital stays. While nearly all Medicare Advantage patients saved money on three-day hospital stays, anything over a five-day stay meant a majority of Medicare Advantage patients were paying more than traditional Medicare patients in cost-sharing.

As payers evaluate their strategies for what is turning out to be a year full of uncertainties, the KFF report indicates that their Medicare Advantage plans remains on a trajectory to enhance and expand.

Greg Says can confirm the increasing Medicare Advantage enrollment trend.  It’s important however to consult with a licensed health insurance agent certified in Medicare Advantage products before deciding that Medicare Advantage is the right option for you.  There are circumstances where Original Medicare plus a Medicare Supplement is a better choice depending on one’s recent medical history and maintenance medications.

By ELEANOR LAISE, Senior Editor

Kiplinger’s Retirement Report – Feb. 2020

If a Medicare Advantage plan denies you coverage for medically necessary care, don’t take it lying down. File an appeal, and your odds are good that the plan will overturn its decision.

That’s the message for consumers in a recent government report examining service and payment denials in Medicare Advantage plans, which are offered by private insurers and often combine basic Medicare benefits with drug, dental and vision coverage in a single package.

Looking at appeals filed by Advantage enrollees and health care providers between 2014 and 2016, the U.S. Department of Health and Human Services’ Office of Inspector General found that plans overturned 75% of their own denials.

“The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided,” the report says. To make matters worse, enrollees and providers appeal only 1% of denials, the Inspector General found, suggesting that some beneficiaries may be going without needed services or paying out of pocket for care.

And for patients, plan denials may have even broader repercussions. “If a provider is denied payment, they may be more reticent to provide certain services” in the future, says Leslie Fried, senior director at the National Council on Aging’s Center for Benefits Access.

Inappropriate denials are a growing concern as the number of Medicare Advantage plan beneficiaries soars. Advantage plans had 21 million enrollees in 2018, up from 8 million in 2007. As the government gives Advantage plans added flexibility, such as allowing them to offer supplemental benefits not covered by traditional Medicare, that number is likely to grow. But unlike traditional Medicare beneficiaries, Advantage plan enrollees looking to limit their costs must stay within their plan’s network of providers and may need referrals to see specialists.

“Medicare Advantage plans are committed to providing quality, affordable and appropriate care to patients,” says Cathryn Donaldson, a spokesperson for America’s Health Insurance Plans, a health insurance industry group. A denial, she says, “can often be a request for additional information for the claim, or a move to an alternative treatment that’s more effective.”

Dealing With a Medicare Denial

It’s critical for Advantage plan beneficiaries to read their denial notices, understand their rights to appeal and file appeals promptly, patient advocates say.

But the denial notices that plans send to enrollees aren’t always clear, says Fred Riccardi, vice president of client services at the Medicare Rights Center. In 2015, audits by the Centers for Medicare and Medicaid Services (CMS) found that 45% of Advantage plans sent denial letters with incomplete or incorrect information, according to the Inspector General’s report.

Follow the instructions on the denial notice to make your appeal. Ask your doctor to write a letter explaining why you need the care. And understand the timeline to make your claim. Advantage enrollees have only 60 days from the date of the denial notice to file an appeal with the plan, compared with 120 days for traditional Medicare beneficiaries. The plan must then make a decision within 30 days if it’s denying a service that you haven’t yet received, or 60 days if it’s refusing to pay for a service that you already received. If your health could be harmed by waiting for the standard appeals process to play out, request an expedited appeal, which requires a decision within 72 hours.

If the plan rejects your initial appeal, your claim will be automatically forwarded to an independent entity for review. And if your appeal is rejected there, you still have up to three more levels of appeal.

Helping Hands

The appeals process can be overwhelming, particularly for patients who are sick or frail. Find expert assistance through these resources:

State health insurance assistance programs. To find your local program, go to shiptacenter.org or call 877-839-2675.

Medicare Rights Center. An advocacy group for Medicare beneficiaries. Go to medicarerights.org or call 800-333-4114.

Legal aid programs. Find legal services in your area at eldercare.acl.gov or call 800-677-1116.

By Bruce Japsen, Senior Contributor to Forbes Magazine Nov. 13, 2019

CVS Health’s Aetna health insurance unit is rolling out a new program for seniors in Medicare Advantage plans to address their loneliness, which can lead to poor health outcomes and an array of illnesses, studies and those involved say.

The program Aetna is launching next year with Miami-based Papa Inc., which links seniors with college-aged caregivers, offers a snapshot into health insurer efforts to think outside the box when they address social determinants of health, which can range from food insecurity to homelessness or loneliness and isolation.

“Loneliness and social isolation have many negative effects on older adults, including issues associated with the lack of transportation,” said Papa chief executive officer Andrew Parker, who founded the company in 2017 as a way to support seniors and their families, the company’s web site says.

Papa says it connects “college students to older adults who need assistance with transportation, house chores, technology lessons, companionship, and other senior services.” Financial terms of the collaboration between Aetna and Papa weren’t disclosed.

Aetna rivals, including Cigna, Humana, UnitedHealth Group and Blue Cross and Blue Shield plans are also working to address social determinants of health including loneliness and isolation. And Papa has relationships with a growing list of health insurers that sell Medicare Advantage including Humana, WellCare Health Plans and Alignment Healthcare.

Initially, the effort with Aetna will be available to certain Medicare Advantage health plan enrollees who live in Florida “and have one or more chronic conditions” who will be able to receive assistance via “Papa Pals” beginning in January of 2020.

“We launched in Jan 2018 and now have over 5,000 Papa Pals providing services in 15 states,” Parker said. “We have grown over 3,000% from 2018 to 2019.” 

Aetna, which has more than 2.3 million Medicare Advantage enrollees across the country, will be evaluating the program to see whether it reduces costs and improves health outcomes for possible expansion to other markets.

More broadly, CVS Health and Aetna are working on ways to address social determinants of health in the Medicare population where seniors are known to have multiple chronic conditions. CVS earlier this year announced a partnership to link health plan members to “social providers” like community organizations or a nutritionist. 

In addition to the program with Papa, Aetna is also rolling out a “Social Isolation Index” to determine a senior Medicare Advantage “member’s risk of social isolation” by analyzing health claims data and other information. Those identified will get “proactive outreach from specially-trained consultants” within a new “Resources for Living” program.

“Social connection is a critical determinant of health for most people, but particularly for the Medicare population,” said Dr. Robert Mirsky, chief medical officer for Aetna Medicare. “We want our Medicare beneficiaries to be able to care for themselves or have reliable support, to be safe in their homes and communities and to lead fulfilling lives. Helping our Medicare beneficiaries in this manner not only improves their quality of life, it can also delay the development and progression of chronic conditions.”

Greg Says applauds Aetna and other Medicare Advantage insurers who are taking the initiative to improve the quality of life for seniors and thereby reduce their exposure to costly health issues.

The number of consumers selecting such plans represent an increase from the 76% who did so last year

By Jeff Lagasse, Associate Editor – Healthcare Finance

November 18, 2019

Medicare’s annual enrollment period for 2020 healthcare coverage began on October 15, and among the emerging trends is that Medicare Advantage plans with $0 premiums are all the rage. So much so, in fact, that 83% of consumers are selecting these plans.

That figure comes from eHealth’s snapshot analysis of consumer shopping behavior and average costs from the first half of the annual enrollment period, continues through December 7.

By comparing eHealth’s data with data previously published by the Centers for Medicare and Medicaid Services, it’s possible to see what Medicare beneficiaries are actually purchasing as compared with what is available in the market.

Data culled from the period between October 15 and November 8 found that $5.47 is the average monthly premium for Medicare Advantage plans selected by people enrolling in coverage, down 43% from $9.53 in the same period last year.

The 83% who are choosing $0 premium Medicare Advantage plans represents an increase from the 76% who did so during the same period last year.

Part D premiums are down year-over-year: $19.76 is the average monthly premium for stand-alone Part D prescription drug plans selected by consumers in the first half of open enrollment, a decrease of 15% from the same period in 2018.

Medicare Supplement premiums, meanwhile, showed a modest increase. The average monthly premium is $157.48 for Medicare Supplement plans during the first half of annual enrollment, an increase of 8% year-over-year.

WHAT’S THE IMPACT

According to CMS, 24.4 million Medicare beneficiaries are expected to enroll in Medicare Advantage plans for 2020, up from 22.2 million in 2019. The average monthly premium for 2020 Medicare Advantage plans available nationwide is $23, down 14% from $26.87 in 2019. CMS reports that 90% or more of all Medicare beneficiaries in 46 states now have access to Medicare Advantage plans with a $0 monthly premium.

A new national poll conducted by Morning Consult, and released by advocacy group Better Medicare Alliance, shows that beneficiaries’ satisfaction with Medicare Advantage is at an all-time high: 94% said they were satisfied, topping the previous best of 92%.

The poll also found that 62% of seniors call Medicare Advantage a “better choice” compared to traditional Medicare.

Among the other key findings: 93% of respondents are satisfied with the selection of doctors, physicians, and specialists in their Medicare Advantage plan; 88% say it’s important for seniors to have a choice of plans other than traditional Medicare, such as Medicare Advantage; 84% are satisfied with the customer service offered by their plan administrator or care coordinator; 80% are satisfied with the cost of co-pays and deductibles in their Medicare Advantage plan; and 74% agree that wellness programs in Medicare Advantage help seniors live healthier lives.

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Although there is a place for Original Medicare with a Medicare Supplement, Greg Says acknowledges the definite trend toward Medicare Advantage plans among Medicare beneficiaries.  Not only is the $0 premium a key factor favoring MA plans, they offer more benefits than Original Medicare such as help with the cost of dental, eyeware, hearing aids, transportation, and more.  They also include coverage for prescription drugs.