Becker’s Payer Issues – Updated 1/30/23

Medicare Advantage enrollment topped 30 million in 2023, a benchmark that AHIP, the trade group representing the industry, called a milestone. 

Matt Eyles, president and CEO of AHIP, sat down with Becker’s to discuss why Medicare Advantage plans are so popular among older adults and why he believes it’s important to keep the program strong in the future. 

Question: Medicare Advantage just hit 30 million enrollees. Why do these numbers keep going up? 

Matt Eyles: It’s a really valuable, important program. The 30 million enrollment mark (seniors and people with disabilities) is a bit of a milestone. We believe it delivers better services and better access to care, and that’s why it’s so attractive to so many seniors. 

When you look at the history of the program, it’s really pretty remarkable that a little more than a decade ago we were at about 12 or 13 million [enrollees]. I think the way that MA plans have innovated both in terms of their benefit design, making sure that they’re available with very low premiums, integrated benefits, and include other benefits that aren’t available in original Medicare are some of the big reasons why it’s such a popular program.

Q: What are some of the biggest misconceptions about Medicare Advantage? 

ME: One is that Medicare Advantage plans are getting paid much more than fee-for-service. There’s a significant misconception there. Out there, looking at the bids, for the [Parts] A and B benefits, they’re at the lowest rate that they’ve ever been relative to fee-for-service. They’re only 83 or 84 percent of the cost of providing fee-for-service, and that enables plans to really deliver additional benefits on top of what’s available in original Medicare. 

I think another [misconception] is issues with respect to access to care I think when you look at the evidence, it’s clear that access to care is very high and especially high quality with Medicare Advantage. When you look at the different reports out there, Medicare Advantage [plans] really are delivering on the promise of high quality care. 

When you look at the measures of quality, Medicare Advantage plans outperform the fee-for-service program in 16 of 16 quality measures. When we want to evolve our healthcare system to really be focused on value and quality, I think Medicare Advantage is really helping to lead the way in that regard.

Q: CMS has proposed tightening regulations around Medicare Advantage marketing. Do you think further regulation is needed surrounding MA marketing, whether it’s from plans or brokers? 

ME: I think there’s been appropriate scrutiny and oversight of marketing practices. We think it’s really important that beneficiaries have good information about the plans that they’re choosing. Some of the marketing proposals are being included as part of some of the 2024 proposed rules to make those changes. We’ll look at things like making sure that the content and communications are accurate. 

We think CMS plays an important role in terms of oversight of the program, and we know that there has been a lot of attention to that. But CMS really is doing significant oversight looking at marketing practices, and that’s why some of those proposals are in the latest proposed rule.

Q: CMS is expected to release its final rule on risk adjustment data validation soon. You called this proposed rule “fatally flawed” when it was first put out. What do you expect the impact of this final rule to be on Medicare Advantage plans? 

ME: I’d say our view is unchanged from before. We think the rule is unlawful in terms of its construction. It relies on bad data, some which is almost 20 years old at this point. We think it’s going to harm seniors and reduce health equity. We know how critically important the focus on health equity is, especially when you look at the higher levels of enrollment by minority populations and low income Americans in Medicare Advantage plans.

At the end of the day, we think the rule would raise prices for seniors and taxpayers and reduce benefits, and we don’t think that that’s good for seniors.

Q: Does Medicare Advantage have advantages in terms of equity over traditional Medicare?

ME: Absolutely. There’s a very intense focus by Medicare Advantage plans on addressing issues with respect to health equity. 

Nearly half of all Medicare Advantage enrollees are racial or ethnic minorities, and we know that MA covers a more diverse population, including more than 40 percent of enrollees who make less than $25,000 a year. Many of these individuals might face other challenges with respect to access to transportation, nutrition, and other services. I think we saw this especially through the pandemic, where it was shown how important many of these additional benefits were, as seniors were sort of stuck in their homes and [it was] very difficult to get access to care. 

The way that health equity is being addressed with these populations is perhaps a little bit differently among plans. But overall, I think when you compare what is available within the original Medicare program, we would not have seen the innovation and the additional benefits and the additional services. There’s just no real way for the government administered part of the program to deliver those benefits and services. That’s where this public-private partnership that you see through Medicare Advantage plans, working with community organizations, really do deliver a higher value offering that also can help bridge those gaps with respect to health equity and health disparities in a way that original Medicare just cannot.

Q: CMS has proposed adding more health equity standards to star ratings. What do you think of those rules, and in general, is the star rating program working effectively?

ME: I’d say by and large, yes. At the margins there are always issues with respect to how new star measures get added or weighting. Overall, the stars program is an important way to both signal to consumers, seniors and enrollees about quality, but also to communicate more broadly the value and quality that Medicare Advantage plans offer. 

With respect to the proposed changes in health equity, I know that we’re looking at the availability of the data there and how they’re rolling this out. We’re still digging into them and we’ll be putting out our comments very soon. 

Q: Medicaid redeterminations begin in April. What is AHIP doing to help prepare for this, and what can state agencies do to ensure as many people stay covered as possible? 

ME: AHIP and our member organizations are intensely focused on the Medicaid redeterminations process, and we’re supportive of the provisions that were included in the end-of-year omnibus that provide some additional clarity on how this will all play out. We’re working very collaboratively with CMS as they’re putting out guidance, working with other stakeholder organizations to make sure that we achieve the goal of keeping as many Americans covered as possible. 

Right now, we’re at historically low uninsured rates. We think it’s important to try and maintain the gains that we’ve seen through coverage in Medicaid, the Affordable Care Act marketplace, employer-sponsored insurance and others. 

We’re tracking what’s happening in all 50 states. Again, working with our members, we’ve been supportive of the role that Medicaid and health plans can play in terms of communicating with their enrollees, because they often have the latest, most current information about addresses, telephone numbers, and helping to navigate the redeterminations process. You’re going to see a lot of energy, activity and efforts by health plans through this process to make sure that as many Americans who have coverage today stay covered. 

Q: Many states are considering further regulations around prior authorization. From your perspective, why is prior authorization necessary, and are there areas where it can be improved to reduce burdens on providers? 

ME: Prior authorization plays an important role in delivering high quality, evidence-based, safe and effective care. When you look at care that’s being delivered, it does not always follow evidence-based guidelines. There may be just as effective, lower cost, even potentially less invasive options that are available to deliver care and we know that there’s an important role for it to play. 

That said, we also believe that there’s ways that we can improve the process. We’ve looked a lot at an expansion of the use of electronic prior authorization. About two years ago we launched an initiative called the fast path initiative to really better understand how electronic prior authorization could impact the process for both patients and providers. What we found is that electronic prior authorization can significantly reduce the time between a request and getting an authorization. 

We’re looking at the rules that have been recently proposed that cut across different markets by CMS. We’re encouraged that to the extent that electronic prior authorization is going to be part of it, that there are going to be incentives for physicians and providers to actually use this. We think that’s really important.

Q: What do you think the next 10 years look like for Medicare Advantage? What are the challenges to address in the future? 

ME: As we look to the future of Medicare Advantage, we think it’s important to keep the program very strong and as an important option for Medicare beneficiaries. The past 10 years have shown the value of Medicare Advantage, and the value is very clear to seniors because they’re actively choosing to enroll in Medicare Advantage when they have a choice.

I’d say over the next period of time, between demographic trends and also what we see by way of innovations and benefit offerings, we expect there to be continued growth in the program. 

Now, when we look longer term, I think we always need to keep in mind the economic environment and the fiscal environment that we’re operating in. We know there’s issues that are being discussed with respect to the debt ceiling, but … we know that it’ll be important to make sure that Medicare Advantage stays strong and as a really important option for seniors in the foreseeable future.