In response to wide-scale complaints that too many patients' medical claims have been wrongly denied and that marketing of the plans is deceptive, federal health officials are proposing an extensive set of tougher rules for private Medicare Advantage health plans.
Medicare Advantage is a private sector alternative to the federal program. More than half of Medicare recipients are expected to enroll in private plans. These policies are usually less expensive than traditional Medicare and sometimes offer attractive benefits.
The plans have been criticized recently despite their popularity. Several plans may be denying care to patients according to a recent report by the inspector general. The Justice Department has sued several large insurance companies for overcharging the government.
The period leading up to this year's enrollment deadline amplified widespread criticism about the deceptive tactics some brokers and insurers had used. The Senate Democrats issued a report detailing some of the worst practices, including ads that appeared to represent federal agencies.
Federal Medicare officials had said they would review television advertising before it aired, and the new rule targets some of the practices identified in the Senate report that caused some consumers to confuse the companies with the government Medicare program The plans would not be allowed to use the Medicare logo and the company behind the ad would have to be named.
The executive director of the center for Medicare policy at the Kaiser Family Foundation said that it was a shot across the bow for brokers and insurers. Ms. Neuman and her team look at the ads.
The proposal would allow beneficiaries to opt out of marketing calls for plans and limit the number of companies that can contact them after they fill out a form. Patients who received a lot of aggressive marketing calls did not request them.
According to David Lipschutz, an associate director at the Center for Medicare Advocacy, the goals of the proposed rules were wide-reaching and significant.
He said that the response was a meaningful one. We don't get to say that a lot where we sit.
The changes will be judged by how aggressively Medicare enforces the standards. Most of the deceptive marketing is done by third-party marketing firms who are paid commission when they enroll people. Insurers would be held accountable for the actions of firms they hire.
Senator Ron Wyden, who chairs the Senate Finance Committee, said in a statement that the proposals are an important step towards protecting seniors in Medicare from scam artists.
The health plans would have to approve certain care before it would be covered under the rules. Private plans were using prior authorization processes to deny needed care, according to patients and their doctors. Tens of thousands of individuals were denied necessary medical care that should have been covered under the program, according to the inspector general.
The new proposal would require plans to reveal the medical basis for denials and rely more heavily on specialists familiar with a patient's care. Patients now have to wait up to 14 days for answers to their authorizations. Authorization to cover the full length of a treatment is required by the new rules.
The director of the Center for Medicare and a deputy administrator at the Center for Medicare and Medicaid Services said the changes were influenced by thousands of public comments.
She said that the proposals in the rule would make it easier for people in Medicare to get the care they need.
The Better Medicare Alliance, which advocates for Medicare Advantage, said it agreed with officials that there must be no room in the system for those who would deceive seniors.
The agency has proposed how patients have to seek prior authorization for treatment. She said the organization wanted to improve the process.
Hospitals applauded the changes that would address their concerns. They made it clear that the Biden administration would have to enforce the stricter oversight.
Molly Smith is the vice president for public policy at the American Hospital Association.
The regulations are still being worked on. Comments from the public are being solicited by health officials.
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