But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.

Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.

Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that only 10% of beneficiaries switched Medicare Advantage plans in 2019.

Once open enrollment ends, there are limited options for a do-over. People in Medicare Advantage plans can go to another Advantage plan or back to the original, government-run Medicare from January through March. And the Centers for Medicare & Medicaid Services has expanded the criteria for granting a “special enrollment period” to make changes in drug or Advantage plans anytime.

But most seniors will generally allow their existing policy to renew automatically, like it or not.

Keeping her doctor was not Du Bois’ only reason for switching plans, though. With help from Senior PharmAssist, a Durham nonprofit that advises seniors about Medicare, she found a Humana Medicare Advantage plan that would not only be accepted by her providers but also cover her medications — saving her more than $14,000 a year, said Gina Upchurch, the group’s executive director.

Senior PharmAssist is one of the federally funded State Health Insurance Assistance Programs, known as SHIPs, available across the country to provide unbiased assistance during the open enrollment season and year-round to help beneficiaries appeal coverage denials and iron out other problems.

“Many people are simply overwhelmed by the calls, ads, the sheer number of choices, and this ‘choice overload’ contributes to decision-making paralysis,” said Upchurch. Seniors in Durham have as many as 74 Advantage plans and 20 drug-only plans to choose from, she said.

Upchurch said the big insurance companies like the way the system works now, with few customers inclined to explore other plans. “They call it ‘stickiness,’” she said. “If we had fewer and clear choices — an apple, orange, grape, or banana — most people would review options.”

In Washington state, one woman switched from a plan she had had for more than a decade to one that will cover all her drugs and next year will save an estimated $7,240, according to Tim Smolen, director of the state’s SHIP, Statewide Health Insurance Benefits Advisors.

In Northern California, another woman changed drug plans for the first time since 2012, and her current premium of $86 will plummet to 40 cents a month next year, an annual savings of about $1,000, said Pam Smith, a local director for California’s SHIP, called the Health Insurance Counseling & Advocacy Program.

And in Ohio, a woman sought help after learning that her monthly copayment for the blood thinner Eliquis would rise from $102 to $2,173 next year. A counselor with Ohio’s SHIP found another plan that will cover all her medications for the year and cost her just $1,760. If she stuck with her current plan, she would be paying an additional $24,852 for all her drugs next year, said Chris Reeg, who directs that state’s program.

In some cases, CMS tries to persuade beneficiaries to switch. Since 2012, it has sent letters every year to thousands of beneficiaries in poorly performing Advantage and drug plans, encouraging them to consider other options. These are plans that have received less than three out of five stars for three years from CMS.

“You may want to compare your plan to other plans available in your area and decide if it’s still right for you,” the letter says.

CMS allows low-scoring plans to continue to operate. In an unusual move, officials recently found that one plan had such a terrible track record that they will terminate its contract with government health programs next December.

CMS also contacts people about changing plans during open enrollment if they get a subsidy — called “extra help” — that pays for their drug plan’s monthly premium and some out-of-pocket expenses. Because some premiums will be more expensive next year, CMS is warning beneficiaries that they could be in for a surprise: a monthly bill to cover cost increases the subsidy doesn’t cover.

But many beneficiaries receive no such nudge from the government to find out if there is a better, less expensive plan that meets their needs and includes their health care providers or drugs.

That leaves many people with Medicare drug or Advantage plans on their own to decipher any changes to their plans while there is still time to enroll in another. Insurers are required to alert members with an “annual notice of change,” a booklet often more than two dozen pages long. Unless they plow through it, they may discover in January that their premiums have increased, the provider network has changed, or some drugs are no longer covered. If a drug plan isn’t offered the next year and the beneficiary doesn’t pick a new one, the insurer will select a plan of its choosing, without considering costs or needed drug coverage.

“Every year, our call volume skyrockets in January when folks get invoices for that new premium,” said Reeg, the Ohio program director. At that point, Medicare Advantage members have until March 30 to switch to another plan or enroll in government-run Medicare. There’s no similar grace period for people with stand-alone drug plans. “They are locked into that plan for the calendar year.”

One cost-saving option is the government’s Medicare Savings Program, which helps low-income beneficiaries pay their monthly premium for Medicare Part B, which covers doctor visits and other outpatient services. The Biden administration’s changes in eligibility for subsidies announced in September will extend financial assistance to an estimated 860,000 people — if they apply. In the past, only about half of those eligible applied.

Fixing a mistake after the open enrollment period ends Dec. 7 is easy for some people. Individuals who receive “extra help” to pay for drug plan premiums and those who have a subsidy to pay for Medicare’s Part B can change drug plans every three months.

At any time, beneficiaries can switch to a Medicare Advantage plan that earns the top five-star rating from CMS, if one is available. “We’ve been able to use those five-star plans as a safety net,” said Reeg, the Ohio SHIP director.

Other beneficiaries may be able to get a “special enrollment period” to switch plans after the open enrollment ends if they meet certain conditions. Local SHIP offices can help people make any of these changes when possible.

Reeg spends a lot of time trying to ensure that unwelcome surprises — like a drug that isn’t covered — don’t happen in the first place. “What we want to do is proactively educate Medicare patients so they know that they can go to the doctors and hospitals they want to go to in the upcoming year,” she said.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.

The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process.

Insurance companies’ advertising campaigns kick into high gear every fall, when seniors can buy policies that take effect Jan. 1. People with traditional government Medicare coverage can add or change a prescription drug plan or join a Medicare Advantage plan that combines drug and medical coverage. Although private Advantage plans offer extra benefits not available under the Medicare program, some services require prior authorization and beneficiaries are confined to a network of health care providers that can change anytime. Beneficiaries in traditional Medicare can see any provider. The open enrollment season ends Dec. 7.

Catching Medicare Advantage plans that step out of line isn’t the only reason to keep an eye out for marketing scams. Accurate plan information can help avoid enrollment traps in the first place.

Although insurers and advocates for older adults have generally welcomed the new truth-in-advertising rules, compliance is the big challenge. Expecting beneficiaries to monitor insurance company sales pitches is asking a lot, said Semanthie Brooks, a social worker and advocate for older adults in northeast Ohio. She’s been helping people with Medicare sort through their options for nearly two decades. “I don’t think Medicare beneficiaries should be the police,” she said.

Choosing a Medicare Advantage plan can be daunting. In Ohio, for example, there are 224 Advantage and 21 drug plans to choose from that take effect next year. Eligibility and benefits vary among counties across the state.

“CMS ought to be looking at how they can educate people, so that when they hear about benefits on television, they understand that this is a promotional advertisement and not necessarily a benefit that they can use,” Brooks said. “If you don’t realize that these ads may be fraudulent, then you won’t know to report them.”

The agency relies on beneficiaries to help improve services, Meena Seshamani, CMS’ Medicare director, told KFF Health News in a written statement. “The voices of the people we serve make our programs stronger,” she said. Beneficiary complaints prompted the government’s action. “That’s why, after hearing from our community, we took new critical steps to protect people with Medicare from confusing and potentially misleading marketing.”

Although about 31 million of the 65 million people with Medicare are enrolled in Medicare Advantage, even that may not be enough people to monitor the tsunami of advertising on TV, radio, the internet, and paper delivered to actual mailboxes. Last year more than 9,500 ads aired daily during the nine-week marketing period that started two weeks before enrollment opened, according to an analysis by KFF. More than 94% of the TV commercials were sponsored by health insurers, brokers, and marketing companies, compared with only 3% from the federal government touting the original Medicare program.

During just one hourlong Cleveland news program in December, researchers found, viewers were treated to nine Advantage ads.

For the first time, CMS asked insurance and marketing companies this year to submit their Medicare Advantage television ads, to make sure they complied with the expanded rules. Officials reviewed 1,700 commercials from May 1 through Sept. 30 and nixed more than 300 deemed misleading, according to news reports. An additional 192 ads out of 250 from marketing companies were also rejected. The agency would not disclose the total number of TV commercials reviewed and rejected this year or whether ads from other media were scrutinized.

The new restrictions also apply to salespeople, whether their pitch is in an ad, written material, or a one-on-one conversation.

Under one important new rule, the salesperson must explain how the new plan is different from a person’s current health insurance before any changes can be made.

That information could have helped an Indiana woman who lost coverage for her prescription drugs, which cost more than $2,000 a month, said Shawn Swindell, the State Health Insurance Assistance Program supervisor of volunteers for 12 counties in east-central Indiana. A plan representative enrolled the woman in a Medicare Advantage plan without telling her it didn’t include drug coverage because the plan is geared toward veterans who can get drug coverage through the Department of Veterans Affairs instead of Medicare. The woman is not a veteran, Swindell said.

In New York, the Medicare Rights Center received a complaint from a man who had wanted to sign up just for a prepaid debit card to purchase nonprescription pharmacy items, said the group’s director of education, Emily Whicheloe. He didn’t know the salesperson would enroll him in a new Medicare Advantage plan that offered the card. Whicheloe undid the mistake by asking CMS to allow the man to return to his previous Advantage plan.

Debit cards are among a dizzying array of extra nonmedical perks offered by Medicare Advantage plans, along with transportation to medical appointments, home-delivered meals, and money for utilities, groceries, and even pet supplies. Last year, plans offered an average of 23 extra benefits, according to CMS. But some insurers have told the agency only a small percentage of patients use them, although actual usage is not reportable.

This month, CMS proposed additional Advantage rules for 2025, including one that would require insurers to tell their members about available services they haven’t used yet. Reminders will “ensure the large federal investment of taxpayer dollars in these benefits is actually making its way to beneficiaries and are not primarily used as a marketing ploy,” officials said in a fact sheet.

Medicare Advantage members are usually locked into their plans for the year, with rare exceptions, including if they move out of the service area or the plan goes out of business. But two years ago, CMS added an escape hatch: People can leave a plan they joined based on misleading or inaccurate information, or if they discovered promised benefits didn’t exist or they couldn’t see their providers. This exception also applies when unscrupulous plan representatives withhold information and enroll people in an Advantage policy without their consent.

Another new rule that should prevent enrollments from going awry prohibits plans from touting benefits that are not available where the prospective member lives. Empty promises have become an increasing source of complaints from clients of Louisiana’s Senior Health Insurance Information Program, said its state director, Vicki Dufrene. “They were going to get all these bells and whistles, and when it comes down to it, they don’t get all the bells and whistles, but the salesperson went ahead and enrolled them in the plan.”

So expect to see more disclaimers in advertisements and mailings like this unsolicited letter an Aetna Medicare Advantage plan sent to a New York City woman: “Plan features and availability may vary by service area,” reads one warning packed into a half-page of fine print. “The formulary and/or pharmacy network may change at any time,” it continues, referring to the list of covered drugs. “You will receive notice when necessary.”

However, the rules still allow insurers to boast about their ratings from CMS — five stars is the top grade — even though the ratings do not reflect the performance of the specific plan mentioned in an ad or displayed on the government’s Medicare plan finder website. “There is no way for consumers to know how accurately the star rating reflects the specific plan design, specific provider network, or any other specifics of a particular plan in their county,” said Laura Skopec, a senior researcher at the Urban Institute who recently co-authored a study on the rating system.

And because ratings data can be more than a year old and plans change annually, ratings published this year don’t apply to 2024 plans that haven’t even begun yet — despite claims to the contrary.

How to spot misleading Medicare Advantage and drug plan sales pitches (and what to do about it)

The Centers for Medicare & Medicaid Services has new rules cracking down on misleading or inaccurate advertising and promotion of Medicare Advantage and drug plans. Watch out for pitches that:

• Suggest benefits are available to all who sign up when only some individuals qualify.
• Mention benefits that are not available in the service area where they are advertised (unless unavoidable because the media outlet covers multiple service areas).
• Use superlatives like “most” or “best” unless claims are backed up by data from the current or prior year.
• Claim unrealistic savings, such as $9,600 in drug savings, which apply only in rare circumstances.
• Market coverage without naming the plan.
• Display the official Medicare name, membership card, or logo without CMS approval.
• Contact you if you’re an Advantage or drug plan member and you told that plan not to notify you about other health insurance products.
• Pretend to be from the government-run Medicare program, which does not make unsolicited sales calls to beneficiaries.

If you think a company is violating the new rules, contact CMS at 800-MEDICARE, its 24-hour information hotline. If you believe you chose a plan based on inaccurate information and want to change plans, contact CMS or your State Health Insurance Assistance Program: www.shiphelp.org or 877-839-2675. For more information about protecting yourself from marketing violations, go to www.shiphelp.org/about-medicare/blog/protecting-yourself-marketing-violations.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Funcionarios de los Centros de Servicios de Medicare y Medicaid (CMS) le han pedido a las personas mayores y a otros miembros de la comunidad que sean detectives contra el fraude, denunciando tácticas de venta engañosas al 800-MEDICARE, la línea de información las 24 horas de la agencia.

Entre los productos sospechosos se encuentran las tarjetas postales diseñadas para que parezcan del gobierno y los anuncios de televisión con famosos que prometen prestaciones y tarifas bajas que sólo están disponibles para algunas personas en ciertos condados.

Las nuevas normas, vigentes desde el 30 de septiembre, describen lo que las aseguradoras pueden decir en anuncios y otros materiales promocionales, y durante el proceso de inscripción.

Las campañas publicitarias de las aseguradoras se lanzan cada otoño, cuando los adultos mayores pueden comprar pólizas que comienzan el 1 de enero. Las personas con cobertura tradicional de Medicare pueden añadir o cambiar un plan de medicamentos recetados o inscribirse en un plan Medicare Advantage, que combina cobertura médica y de fármacos.

Aunque los planes privados Advantage ofrecen prestaciones adicionales no disponibles en el Medicare tradicional, algunos servicios requieren autorización previa y los beneficiarios están limitados a una red de proveedores de salud que puede cambiar en cualquier momento.

Los beneficiarios de Medicare tradicional pueden acudir a cualquier proveedor. La temporada de inscripción abierta termina el 7 de diciembre.

Los planes Medicare Advantage que cruzan alguna línea no son la única razón para estar atentos a los fraudes comerciales. La información precisa del plan puede ayudar a evitar trampas en la inscripción.

Aunque, en general, las aseguradoras y los profesionales que abogan por las personas mayores han acogido con satisfacción las nuevas normas de veracidad en la publicidad, que se cumplan es el gran reto.

Esperar que los beneficiarios controlen los argumentos de venta de las aseguradoras es pedir demasiado, afirmó Semanthie Brooks, trabajadora social y defensora de los adultos mayores en el noreste de Ohio. Lleva casi dos décadas ayudando a beneficiarios de Medicare a analizar sus opciones. “No creo que los afiliados deban hacer de policías”, dijo.

Elegir un plan de Medicare Advantage puede ser abrumador. En Ohio, por ejemplo, hay 224 y 21 planes de medicamentos para elegir que entrarán en vigencia el año que viene. La elegibilidad y las prestaciones varían según los condados.

“Los CMS deberían estudiar cómo educar a las personas para que cuando oigan hablar de las servicios en televisión, entiendan que se trata de un anuncio promocional y no necesariamente de una prestación que podrían utilizar”, señaló Brooks. “Si no se dan cuenta de que estos anuncios pueden ser fraudulentos, entonces no sabrán que deben denunciarlos”.

La agencia confía en los beneficiarios para ayudar a mejorar los servicios, declaró por escrito a KFF Health News Meena Seshamani, directora de Medicare en los CMS. “Las voces de las personas a las que servimos hacen que nuestros programas sean más fuertes”, dijo.

Las quejas de los beneficiarios motivaron la intervención del gobierno. “Es por eso que, después de escuchar a nuestra comunidad, tomamos nuevas medidas para proteger a las personas con Medicare del marketing confuso y potencialmente engañoso”, agregó.

Aunque alrededor de 31 millones de los 65 millones de personas con Medicare están inscritas en Medicare Advantage, esta gran cantidad de personas podría no ser suficiente para controlar el tsunami de publicidad en la televisión, la radio, Internet y el papel que llega a los buzones.

El año pasado hubo más de 9,500 anuncios diarios durante el período de comercialización de planes de nueve semanas, según un análisis de KFF. Más del 94% de los anuncios televisivos estaban patrocinados por aseguradoras, brokers y empresas de marketing, frente a sólo un 3% del gobierno federal que promocionaba el programa tradicional de Medicare.

Según los investigadores, durante una hora del noticiero de Cleveland en diciembre, los telespectadores vieron nueve anuncios de Advantage.

Por primera vez, los CMS pidieron este año a las compañías de seguros y de marketing que les presentaran sus anuncios televisivos de Medicare Advantage, para asegurarse de que cumplían las nuevas normas.

Entre el 1 de mayo y el 30 de septiembre, los funcionarios revisaron 1,700 anuncios, y rechazaron más de 300 por considerarlos engañosos, según informes de la prensa. También se rechazaron otros 192 anuncios, de un total de 250, de empresas de marketing. La agencia no reveló si se analizaron otros medios.

Las nuevas restricciones se aplican también a los vendedores, ya sea en un anuncio, en material escrito o en una conversación cara a cara.

Según una norma nueva e importante, el vendedor debe explicar en qué se diferencia el nuevo plan del actual seguro médico de una persona antes de que se pueda realizar cualquier cambio.

Esa información podría haber ayudado a una mujer de Indiana que perdió la cobertura de sus medicamentos recetados, que le cuestan más de $2,000 al mes, indicó Shawn Swindell, supervisor de voluntarios del Programa Estatal de Asistencia sobre Seguros de Salud para 12 condados del centro-este del estado.

Un representante inscribió a la mujer en un plan de Medicare Advantage sin decirle que no incluía cobertura de medicamentos porque el plan está dirigido a veteranos que pueden obtener esa cobertura a través del Departamento de Asuntos de Veteranos en lugar de Medicare. La mujer no es veterana, añadió Swindell.

En Nueva York, el Centro de Derechos de Medicare recibió una queja de un hombre que solo quería inscribirse para obtener una tarjeta de débito prepagada para comprar productos farmacéuticos no recetados, contó Emily Whicheloe, directora de educación de la organización. No sabía que el vendedor lo inscribiría en un nuevo plan de Medicare Advantage que ofrecía la tarjeta. Whicheloe reparó el error pidiendo a los CMS que permitieran al hombre volver a su plan Advantage anterior.

Las tarjetas de débito forman parte de la vertiginosa gama de ventajas adicionales no médicas que ofrecen los planes Medicare Advantage, junto con el transporte a las citas médicas, las comidas a domicilio y el dinero para servicios públicos, comestibles e incluso artículos para mascotas. El año pasado, los planes ofrecieron un promedio de 23 prestaciones adicionales, según los CMS. Sin embargo, algunas aseguradoras han comunicado a la agencia que sólo un pequeño porcentaje de pacientes las utiliza, aunque el uso real no se reporta.

Este mes, los CMS propusieron normas adicionales sobre Advantage para 2025, incluida una que obligaría a las aseguradoras a informar a sus afiliados sobre los servicios disponibles que aún no hayan utilizado. Los recordatorios “garantizarán que la gran inversión federal de dinero de los contribuyentes en estos beneficios llegue realmente a los beneficiarios y no se utilice principalmente como una estratagema de marketing”, según señalan las autoridades en una hoja informativa.

Por lo general, los afiliados a Medicare Advantage permanecen vinculados a sus planes durante todo el año, salvo raras excepciones, como el traslado fuera del área de servicio o la quiebra del plan.

Pero hace dos años, los CMS agregaron una vía de escape: las personas pueden abandonar un plan al que se han afiliado basándose en información engañosa o inexacta, o si descubren que las prestaciones prometidas no existen o no pueden ver a sus proveedores. Esta excepción también se aplica cuando representantes del plan, sin escrúpulos, ocultan información e inscriben a personas en una póliza Advantage sin su consentimiento.

Otra nueva norma, que debería evitar que las inscripciones salgan mal, prohíbe a los planes promocionar prestaciones que no están disponibles en el lugar donde vive el potencial afiliado. Las promesas vacías se han convertido en una fuente creciente de quejas de los clientes del Programa de Información sobre Seguros de Salud para Mayores de Louisiana, según Vicki Dufrene, su directora estatal. “Iban a tener todas estas opciones y estos extras, y cuando llega el momento, no tienen ni opciones ni extras, pero el vendedor siguió adelante y les inscribió en el plan”.

Así que esperamos ver más cláusulas de exención de responsabilidad en anuncios y correos como esta carta no solicitada que un plan Aetna Medicare Advantage envió a una mujer de Nueva York: “Las características y la disponibilidad del plan pueden variar según el área de servicio”, dice una advertencia incluida en letra chica. “El formulario y/o la red de farmacias pueden cambiar en cualquier momento”, continúa, refiriéndose a la lista de medicamentos cubiertos. “Recibirá un aviso cuando sea necesario”.

Sin embargo, las normas siguen permitiendo a las aseguradoras presumir de sus calificaciones de los CMS —cinco estrellas es la máxima—, aunque estas no reflejen el rendimiento del plan mencionado en un anuncio o mostrado en el sitio web del gobierno para encontrar planes de Medicare.

“No hay forma de que los consumidores sepan con qué exactitud la calificación por estrellas refleja el diseño específico del plan, la red de proveedores concreta o cualquier otro aspecto específico de una póliza en su condado”, afirmó Laura Skopec, investigadora del Urban Institute y coautora de un estudio reciente sobre el sistema de calificación.

Y como los datos de las calificaciones pueden tener más de un año de antigüedad y los planes cambian cada año, las publicadas este año no se aplican a los planes de 2024 que ni siquiera han empezado, a pesar de las afirmaciones en sentido contrario.

Cómo detectar argumentos de venta engañosos de Medicare Advantage y planes de medicamentos (y qué hacer al respecto)

Los Centros de Servicios de Medicare y Medicaid tienen nuevas reglas que toman medidas enérgicas contra la publicidad y promoción engañosas o inexactas de Medicare Advantage y los planes de medicamentos. Hay que tener cuidado con los avisos que:

• Los beneficios sugeridos están disponibles para todos los que se registren cuando solo algunas personas califican.
• Menciona los beneficios que no están disponibles en el área de servicio donde se anuncian.
• Utiliza superlativos como “la mayoría” o “mejor”, a menos que estos datos estén respaldados por datos del año actual o anterior.
• Reclama ahorros poco realistas, como $9,600 en ahorros en medicamentos, que se aplican sólo en circunstancias excepcionales.
• Habla de cobertura sin nombrar el plan.
• Muestra el nombre oficial de Medicare, la tarjeta de membresía o el logotipo sin la aprobación de los CMS.
• Contacta al miembro de un plan Advantage o de medicamentos sobre otros productos sin autorización.
• Finge ser del programa Medicare administrado por el gobierno, que no realiza llamadas de ventas no solicitadas a los beneficiarios.

Si crees que una empresa está violando las nuevas reglas, comuníquese con CMS al 800-MEDICARE, su línea directa de información las 24 horas. Si cree que eligió un plan basándose en información inexacta y desea cambiar de plan, comuníquese con CMS o con su Programa estatal de asistencia sobre seguros médicos: http://www.shiphelp.org o al 877-839-2675. Para obtener más información sobre cómo protegerse de las infracciones de marketing, visite http://www.shiphelp.org/about-medicare/blog/protecting-yourself-marketing-violations.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. Both are part of UnitedHealth Group. NaviHealth analyzes data to help UHC and other insurance companies make coverage decisions.

Its proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long.

But patients, providers, and patient advocates in several states said they have noticed a suspicious coincidence: The tool often predicts a patient’s date of discharge, which coincides with the date their insurer cuts off coverage, even if the patient needs further treatment that government-run Medicare would provide.

“When an algorithm does not fully consider a patient’s needs, there’s a glaring mismatch,” said Rajeev Kumar, a physician and the president-elect of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “That’s where human intervention comes in.”

The federal government will try to even the playing field next year, when the Centers for Medicare & Medicaid Services begins restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.

Medicare Advantage plans, an alternative to the government-run, original Medicare program, are operated by private insurance companies. About half the people eligible for full Medicare benefits are enrolled in the private plans, attracted by their lower costs and enhanced benefits like dental care, hearing aids, and a host of nonmedical extras like transportation and home-delivered meals.

Insurers receive a monthly payment from the federal government for each enrollee, regardless of how much care they need. According to the Department of Health and Human Services’ inspector general, this arrangement raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits.” Nursing home care has been among the most frequently denied services by the private plans — something original Medicare likely would cover, investigators found.

After UHC cut off her nursing home coverage, Sullivan’s medical team agreed with her that she wasn’t ready to go home and provided an additional 18 days of treatment. Her bill came to $10,406.36.

Beyond her mobility problems, “she also had a surgical wound that needed daily dressing changes” when UHC stopped paying for her nursing home care, said Debra Samorajczyk, a registered nurse and the administrator at the Bishop Wicke Health and Rehabilitation Center, the facility that treated Sullivan.

Sullivan’s coverage denial notice and nH Predict report did not mention wound care or her inability to climb stairs. Original Medicare would have most likely covered her continued care, said Samorajczyk.

Sullivan appealed twice but lost. Her next appeal was heard by an administrative law judge, who holds a courtroom-style hearing usually by phone or video link, in which all sides can provide testimony. UHC declined to send a representative, but the judge nonetheless sided with the company. Sullivan is considering whether to appeal to the next level, the Medicare Appeals Council, and the last step before the case can be heard in federal court.

Sullivan’s experience is not unique. In February, Ken Drost’s Medicare Advantage plan, provided by Security Health Plan of Wisconsin, wanted to cut his coverage at a Wisconsin nursing home after 16 days, the same number of days naviHealth predicted was necessary. But Drost, 87, who was recovering from hip surgery, needed help getting out of bed and walking. He stayed at the nursing home for an additional week, at a cost of $2,624.

After he appealed twice and lost, his hearing on his third appeal was about to begin when his insurer agreed to pay his bill, said his lawyer, Christine Huberty, supervising attorney at the Greater Wisconsin Agency on Aging Resources Elder Law & Advocacy Center in Madison.

“Advantage plans routinely cut patients’ stays short in nursing homes,” she said, including Humana, Aetna, Security Health Plan, and UnitedHealthcare. “In all cases, we see their treating medical providers disagree with the denials.”

UnitedHealthcare and naviHealth declined requests for interviews and did not answer detailed questions about why Sullivan’s nursing home coverage was cut short over the objections of her medical team.

Aaron Albright, a naviHealth spokesperson, said in a statement that the nH Predict algorithm is not used to make coverage decisions and instead is intended “to help the member and facility develop personalized post-acute care discharge planning.” Length-of-stay predictions “are estimates only.”

However, naviHealth’s website boasts about saving plans money by restricting care. The company’s “predictive technology and decision support platform” ensures that “patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions.”

New federal rules for Medicare Advantage plans beginning in January will rein in their use of algorithms in coverage decisions. Insurance companies using such tools will be expected to “ensure that they are making medical necessity determinations based on the circumstances of the specific individual,” the requirements say, “as opposed to using an algorithm or software that doesn’t account for an individual’s circumstances.”

The CMS-required notices nursing home residents receive now when a plan cuts short their coverage can be oddly similar while lacking details about a particular resident. Sullivan’s notice from UHC contains some identical text to the one Drost received from his Wisconsin plan. Both say, for example, that the plan’s medical director reviewed their cases, without providing the director’s name or medical specialty. Both omit any mention of their health conditions that make managing at home difficult, if not impossible.

The tools must still follow Medicare coverage criteria and cannot deny benefits that original Medicare covers. If insurers believe the criteria are too vague, plans can base algorithms on their own criteria, as long as they disclose the medical evidence supporting the algorithms.

And before denying coverage considered not medically necessary, another change requires that a coverage denial “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue.”

Jennifer Kochiss, a social worker at Bishop Wicke who helps residents file insurance appeals, said patients and providers have no say in whether the doctor reviewing a case has experience with the client’s diagnosis. The new requirement will close “a big hole,” she said.

The leading MA plans oppose the changes in comments submitted to CMS. Tim Noel, UHC’s CEO for Medicare and retirement, said MA plans’ ability to manage beneficiaries’ care is necessary “to ensure access to high-quality safe care and maintain high member satisfaction while appropriately managing costs.”

Restricting “utilization management tools would markedly deviate from Congress’ intent in creating Medicare managed care because they substantially limit MA plans’ ability to actually manage care,” he said.

In a statement, UHC spokesperson Heather Soule said the company’s current practices are “consistent” with the new rules. “Medical directors or other appropriate clinical personnel, not technology tools, make all final adverse medical necessity determinations” before coverage is denied or cut short. However, these medical professionals work for UHC and usually do not examine patients. Other insurance companies follow the same practice.

David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS will enforce the rules since it doesn’t mention specific penalties for violations.

CMS’ deputy administrator and director of the Medicare program, Meena Seshamani, said that the agency will conduct audits to verify compliance with the new requirements, and “will consider issuing an enforcement action, such as a civil money penalty or an enrollment suspension, for the non-compliance.”

Although Sullivan stayed at Bishop Wicke after UHC stopped paying, she said another resident went home when her MA plan wouldn’t pay anymore. After two days at home, the woman fell, and an ambulance took her to the hospital, Sullivan said. “She was back in the nursing home again because they put her out before she was ready.”

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

Los defensores de Medicare que realizan un seguimiento del fraude han observado un aumento de quejas entre los beneficiarios que recibieron pruebas que nunca solicitaron.

Una señal de que alguien podría estar utilizando (y podría seguir haciéndolo) la información de Medicare para facturar ilegalmente al gobierno federal.

La Oficina del Inspector General (OIG) del Departamento de Salud y Servicios Humanos ha recibido quejas de todo el país sobre pruebas facturadas a Medicare que nunca se pidieron, según declaró un investigador.

A principios de este año, la OIG publicó una advertencia de fraude en su sitio web, instando a los consumidores a denunciar toda estafa relacionada con covid.

“Desgraciadamente, la mayoría de estas estafas son el resultado del robo de información de beneficiarios de Medicare”, dijo Scott Lampert, inspector general adjunto de investigaciones, a KFF Health News.

El hecho de haber sido objeto de estafa una vez hace que esa persona sea más vulnerable en el futuro.

Un número de Medicare robado puede utilizarse repetidamente para obtener pagos por todo tipo de cosas, o venderse a otros estafadores, dijo María Álvarez, que supervisa la Senior Medicare Patrol del estado de Nueva York, parte de un programa nacional que ayuda a identificar y educar a los beneficiarios sobre el fraude a Medicare.

“Si tienes el número de Medicare de alguien, puedes facturar a Medicare por procedimientos, pruebas, medicamentos, servicios y equipos médicos”, explicó Álvarez. “En la web profunda (dark web), los números de Medicare son más valiosos que los de las tarjetas de crédito o el Seguro Social”.

Un beneficiario de Indiana sospechó que algo iba mal cuando recibió 32 resultados de pruebas no solicitadas en un período de 10 días, contó Nancy Moore, directora del programa estatal Senior Medicare Patrol.

Ninguna de las personas que presentaron una queja recordaba haber dado su número de Medicare, añadió Moore.

En Ohio, Medicare pagó por pruebas que beneficiarios nunca recibieron, señaló Lisa Dalga, gerente estatal de Senior Medicare Patrol.

“La información es la mercancía del siglo XXI”, apuntó Moore, quien recomienda a los beneficiarios proteger sus números de Medicare.

Junto con los de Nueva York, Indiana y Ohio, los directores de las Senior Medicare Patrol de Tennessee, Texas y Utah dijeron a KFF Health News que habían observado un aumento de quejas sobre pruebas no deseadas a medida que se acercaba la fecha límite del beneficio.

Álvarez observó que últimamente los proveedores de pruebas se habían “vuelto más agresivos”, llamando y enviando correos electrónicos a personas mayores —algo que no hacen los representantes legítimos de Medicare—, además de publicar anuncios engañosos en Internet.

Cuando el 11 de mayo finalizó la emergencia de salud pública por covid-19, Medicare dejó de pagar las pruebas sin receta, aunque sigue cubriendo las que se realizan en una clínica, consultorio médico o en otro centro de salud y son procesadas por un laboratorio.

Algunos planes privados de Medicare Advantage pueden seguir pagando las pruebas a domicilio.

Medicare gastó $900,800 millones en proporcionar cobertura sanitaria a 64 millones de beneficiarios en 2021. Pero el programa pierde hasta $90,000 millones al año por reclamos fraudulentos. Algunas de las estafas más conocidas han involucrado equipos médicos como sillas de ruedas eléctricas.

Sara Lonardo, vocera de los Centros de Servicios de Medicare y Medicaid (CSM), confirmó que Medicare recibió quejas sobre pruebas no solicitadas, pero dijo que procedían sólo de “una pequeña parte” de los beneficiarios de Medicare que recibieron pruebas.

El año pasado, la administración del presidente Joe Biden ofreció a todos los hogares un número limitado de pruebas caseras gratuitas, aumentando el acceso a las pruebas como parte de su esfuerzo para combatir covid-19.

Más tarde, en abril de 2022, los CMS decidieron pagar ocho pruebas al mes a quienes tuvieran cobertura ambulatoria de la Parte B de Medicare, millones de personas mayores, uno de los grupos más susceptibles a morir a causa del virus. Era la primera vez que la agencia accedía a cubrir los productos sin receta y de venta libre sin costo alguno para los beneficiarios.

En un comunicado del mes pasado, autoridades policiales federales afirmaron que “los infractores supuestamente intentaron aprovecharse del programa suministrando repetidamente a los pacientes o, en algunos casos, a pacientes fallecidos, docenas de pruebas de covid-19 que no querían ni necesitaban”.

Hasta ahora, los fiscales del Departamento de Justicia sólo han confirmado un caso relacionado con la estafa de las pruebas.

Un médico de Florida y un proveedor de pruebas de Georgia han sido acusados de pagar ilegalmente a una empresa de marketing de Virginia no identificada unos $85,000 para obtener los números “de miles de beneficiarios de Medicare en todo Estados Unidos”, según una denuncia presentada por el Departamento de Justicia en abril y obtenida por KFF Health News.

La denuncia alegaba que esta dupla presentó más de $8,4 millones en reclamos fraudulentos por pruebas de covid “independientemente de si los beneficiarios de Medicare habían solicitado o necesitaban las pruebas”.

Lampert no quiso decir cuántos reclamos recibió la OIG, y agregó: “Puede haber o no otras investigaciones en curso de las que no podemos hablar todavía”.

Los detalles de varios avisos a los beneficiarios sobre los servicios recibidos, obtenidos por KFF Health News, muestran que Medicare pagó a los proveedores $94,08 por pruebas caseras de covid utilizando un código de facturación para “una sola prueba”.

La mayoría de las farmacias minoristas venden un paquete de dos pruebas por unos $24.

Lonardo dijo que Medicare pagó hasta $12 para una prueba y que el número de pruebas cubiertas se limitó para reducir “el riesgo de facturación abusiva”. No explicó por qué los resúmenes de Medicare indicaban un pago de $94,08.

Los beneficiarios pueden ser los mejores detectives contra el fraude para prevenir el robo de identidad médica. Los programas Senior Medicare Patrol los animan a revisar los resúmenes de  prestaciones para detectar cualquier artículo o servicio que Medicare haya pagado pero que ellos nunca hayan recibido.

Si Medicare ha pagado un artículo una vez, aunque haya sido un fraude, es posible que los beneficiarios no puedan obtenerlo cuando realmente lo necesiten.

Diane Borton, de 72 años, de New Smyrna Beach, Florida, ha tirado a la basura algunas de las pruebas caducadas que recibió y que nunca había pedido, pero aún le quedan 25. Dice que llamó dos veces a la línea de ayuda 1-800-MEDICARE sobre los tests no deseados, pero le dijeron que no se podía hacer nada.

Borton no pagó por las pruebas, pero no es eso lo que le preocupa. “No quiero que mi gobierno pague por algo que no voy a usar y que no he pedido”, explicó. “Me parece un despilfarro de dinero”.

Las personas con Medicare o planes privados de Medicare Advantage que reciben suministros médicos que no pidieron pueden ponerse en contacto con el Senior Medicare Patrol Resource Center llamando al 1-877-808-2468.

Esta historia fue producida por KFF Health News, conocido antes como Kaiser Health News (KHN), una redacción nacional que produce periodismo en profundidad sobre temas de salud y es uno de los principales programas operativos de KFF, la fuente independiente de investigación de políticas de salud, encuestas y periodismo. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Medicare advocates around the country who track fraud noticed an eleventh-hour rise in complaints from beneficiaries who received tests — sometimes by the dozen — that they never requested. It’s a signal that someone may have been using, and could continue to use, seniors’ Medicare information to improperly bill the federal government.

The U.S. Department of Health and Human Services’ Office of Inspector General has received complaints from around the country about unsolicited tests being billed to Medicare, said a top investigator. Earlier this year, the office posted a fraud warning on its website, urging consumers to report this and other covid-related scams.

“Unfortunately, most of these schemes are the result of bad actors receiving stolen Medicare beneficiary information,” Scott Lampert, assistant inspector general for investigations, told California Healthline.

Being targeted once can mean a person is vulnerable to future scams. A stolen Medicare number can be used repeatedly to get payment for all kinds of things or sold to other fraudsters, said María Alvarez, who oversees New York state’s Senior Medicare Patrol. The organization helps identify and educate beneficiaries about Medicare fraud throughout the country.

“If you have someone’s Medicare number, you can bill Medicare for procedures, tests, drugs, services, and durable medical equipment,” Alvarez said. “On the dark web, Medicare numbers are more valuable than credit card or Social Security numbers.”

One beneficiary in Indiana suspected something was amiss after receiving 32 unrequested tests over a 10-day period, said Nancy Moore, the Senior Medicare Patrol program director for Indiana. None of the people who submitted a complaint recalled giving out their Medicare number, she said.

In another variation of the problem, Medicare paid for tests for some Ohio beneficiaries who never received them, said Lisa Dalga, project manager for the state’s Senior Medicare Patrol.

“Information is the commodity of the 21st century,” said Moore, who said she urges beneficiaries to guard their Medicare numbers.

It is possible that some unwanted packages were a mistake, after pharmacies or other suppliers turned a one-time request into a continuing monthly order, a switch allowed under the program’s rules that beneficiaries were responsible for correcting.

Along with those from New York, Indiana, and Ohio, Senior Medicare Patrol directors in Tennessee, Texas, and Utah told California Healthline they noted a rise in complaints about the unwanted tests as the benefit’s cutoff date approached.

Alvarez said lately test suppliers had “gotten more aggressive,” calling and emailing seniors — something legitimate Medicare representatives do not do — as well as running misleading internet ads.

When the covid-19 public health emergency ended on May 11, Medicare stopped paying for over-the-counter tests, though it continues to cover those provided in a clinic, doctor’s office, or other health care setting and processed by a laboratory. Some private Medicare Advantage plans may continue paying for the at-home tests.

Medicare spent $900.8 billion providing health coverage to 64 million beneficiaries in 2021. But the program loses as much as $90 billion a year to fraudulent claims. Some of the more well-known scams have involved medical equipment like power wheelchairs.

Sara Lonardo, a spokesperson for the Centers for Medicare & Medicaid Services, confirmed Medicare received complaints about unwanted tests but said they came from only “a small portion” of Medicare beneficiaries who received tests.

Last year, President Joe Biden’s administration offered all households a limited number of at-home tests for free, increasing access to testing as part of its effort to combat covid-19.

A few months later, in April 2022, CMS decided to pay for eight tests per month for those with Medicare Part B outpatient coverage, including tens of millions of seniors, one of the groups most susceptible to severe illness and death from the virus. It was the first time the agency agreed to cover non-prescription, over-the-counter products at no cost to beneficiaries.

In a statement last month, federal law enforcement officials said “wrongdoers allegedly sought to exploit the program by repeatedly supplying patients or, in some instances, deceased patients, with dozens of COVID-19 tests that they did not want or need.”

So far, prosecutors at the Department of Justice have confirmed only one case involving the testing scam. A doctor in Florida and a test supplier in Georgia face charges after they were accused of illegally paying an unnamed Virginia marketing company approximately $85,000 to obtain beneficiary numbers “for thousands of Medicare beneficiaries throughout the United States,” according to an indictment filed by the Department of Justice last month and obtained by California Healthline.

The indictment said the pair submitted more than $8.4 million in fraudulent claims for covid tests “regardless of whether the Medicare beneficiaries had requested or needed the tests.”

Lampert declined to say how many complaints the OIG had received, adding, “There may or may not be some other ongoing investigations that we just cannot discuss yet.”

The details of several Medicare Summary Notices — quarterly statements of services beneficiaries received — obtained by California Healthline show Medicare paid suppliers $94.08 for at-home covid testing using a billing code for “a single test.” Most retail pharmacies sell a two-pack of tests for about $24.

Lonardo said Medicare paid up to $12 for one test and that the number of covered tests was limited to reduce “the risk of abusive billing.” She declined to explain why the Medicare Summary Notices indicated a payment of $94.08.

Beneficiaries may be the best fraud detectives for preventing medical identity theft. Senior Medicare Patrol programs encourage them to look for any items on their benefits statements — like back braces and lab tests — that Medicare paid for but that they never received.

If Medicare has paid for an item once, beneficiaries may not be able to get it when they really need it — regardless of whether they actually received it.

Diane Borton, a 72-year-old from New Smyrna Beach, Florida, has thrown out some of the expired tests she received but never asked for, yet she still has 25 tests. She said she called the 1-800-MEDICARE helpline twice about the unwanted packages but was told nothing could be done to stop them.

Borton didn’t pay for her supply, but that’s not why she’s concerned. “I don’t want my government paying for something that I’m not going to use and I didn’t ask for,” she said. “I feel like it is such a waste of money.”

People with Medicare or private Medicare Advantage plans who receive medical supplies they didn’t order can contact the Senior Medicare Patrol Resource Center at 1-877-808-2468.

This article was produced by KFF Health News, formerly known as Kaiser Health News (KHN), a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Congress approved in August a $35 cap on what seniors will pay for insulin as part of the Inflation Reduction Act, along with free vaccines and other Medicare improvements. But the change came too late to add to the Medicare plan finder, the online tool that helps beneficiaries sort through dozens of drug and medical plans for the best bargain.

Officials say the problem affects only 2023 plans.

To fix anticipated enrollment mistakes, Medicare officials will give beneficiaries who use insulin a chance to switch plans next year. They can make one change after Dec. 8 and throughout 2023 through a special enrollment period for “exceptional circumstances.” Typically, people are locked in for an entire year.

The Centers for Medicare & Medicaid Services provided initial details of the opportunity in a document distributed to the State Health Insurance Assistance Program, or SHIP, which assists Medicare enrollees in every state. Although Medicare did not publicize the document, beneficiaries can get more information by contacting their local SHIP office. CMS officials would not answer questions about whether the ability to change plans will be granted automatically.

“We are pleased that CMS is offering the special enrollment period that will allow insulin users to change plans in 2023,” said Chris Reeg, director of the Ohio Senior Health Insurance Information Program.

In some cases, a special enrollment period can be avoided, said Janet Stellmon, director of the Montana State Health Insurance Assistance Program. If the plan charges more than a $35 copayment for a member’s insulin, a SHIP counselor can ask the plan to correct the mistake. “Plans usually try to make it right quickly,” said Stellmon, who helped one beneficiary save $565 a month on insulin.

Medicare patients spent $1 billion in 2020 on insulin products — four times the amount in 2007, with some paying as much as $116 a month out-of-pocket, KFF has found. Americans paid an average of five to 10 times as much for insulin in 2018 than in other countries, according to a recent study. About 3.3 million people with Medicare rely on one or more insulin products to control blood sugar levels.

The $35 copay for injectable insulin products takes effect Jan. 1, and July 1 for patients who use an insulin pump.

When beneficiaries who use insulin now check the plan finder, the price could show up as thousands of dollars a year instead of the maximum $420 stipulated by law. An inaccurate price could also distort the costs of other drugs, which depend on what coverage phase patients reach. For example, once both the plan and the patient spend a total of $4,660 for all drugs next year, the member pays no more than 25% of the cost for non-insulin drugs.

It’s extremely difficult for consumers to evaluate policy options without the plan finder. One plan might have the lowest price for one drug but not another. Or a plan might have the lowest premium but higher drug prices. Or a preferred pharmacy in one plan may be excluded in another.

Medicare officials caution consumers about the problem. “This new $35 cap may not be reflected when you compare plans,” according to a warning that pops up during a plan finder search. “You should talk to someone for help comparing plans,” it says, pointing readers to the Medicare help line — 800-633-4227 — or a counselor with SHIP. It doesn’t mention the option of changing plans after the Dec. 7 enrollment deadline.

But both SHIP counselors and representatives answering the Medicare help line rely on the same flawed plan finder.

Georgia Gerdes at AgeOptions in Oak Park, Illinois, trains people across the state to assist Medicare beneficiaries. She said she searches for policies without adding insulin to a client’s medication list and separately searches plans that cover the type of insulin the client takes. Then she reviews those lists to see which ones on the insulin list are also on the list of non-insulin drugs and manually adds the $35 monthly insulin cost before making recommendations.

Medicare beneficiaries filled prescriptions for at least 114 kinds of insulin in 2020, and those who did not get low-income subsidies paid on average $572 out-of-pocket, according to the KFF study.

But drug plans do not have to cover all injectable insulins, said Tatiana Fassieux, an education and training specialist at California Health Advocates. “It’s all about the formulary,” she added, referring to the plans’ covered drugs.

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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That’s because, under current law, Medicare can pay for limited dental care only if it is medically necessary to safely treat another covered medical condition. In July, officials proposed adding conditions that qualify and sought public comment. Any changes could be announced in November and take effect as soon as January.

The review by the Centers for Medicare & Medicaid Services follows an unsuccessful effort by congressional Democrats to pass comprehensive Medicare dental coverage for all beneficiaries, a move that would require changes in federal law. Sen. Bernie Sanders (I-Vt.) sought in vain to add that to the Democrats’ last major piece of legislation, the Inflation Reduction Act, which passed in August. As defeat appeared imminent, consumer and seniors’ advocacy groups along with dozens of lawmakers urged CMS to take independent action.

Dr. Biana Roykh, senior associate dean for clinical affairs at Columbia University’s College of Dental Medicine, called CMS’ proposal “a step in the right direction.” But she cautioned that it doesn’t yet address the full extent of dental needs among seniors. “We’re not solving the problems upstream” by tackling the causes of dental decay, including a lack of routine care, she said.

Among the dental procedures Medicare already covers are wiring teeth to repair a fractured jaw, a dental exam before a kidney transplant, and extraction of infected teeth before radiation treatment for certain neck and head cancers.

But if a patient needs another kind of organ transplant, Medicare won’t cover the eradication of a dental infection so that the transplant can proceed. Or, if a patient with breast cancer has an infected tooth, Medicare will cover chemotherapy and radiation, but not the tooth extraction needed before that treatment can be provided.

CMS hinted at what dental services might be covered by asking for comments on whether additional organ transplants and cardiac valve replacement or repairs should be eligible for related dental exams and treatment. It also asked for examples of “other types of clinical scenarios” in which dental services would be “substantially related and integral to the clinical success” of other covered medical treatments.

If CMS receives sufficient medical evidence, officials said, dental services could be covered to detect and eradicate infections before total hip or knee replacement surgeries.

One possibility CMS pointedly does not mention is dental care for diabetes patients, said Dr. Judith A. Jones, an adjunct professor at the University of Detroit Mercy School of Dentistry. Medicare pays for insulin and other diabetic care supplies but not related dental care. “The data are really quite clear if you improve periodontal disease, for example, blood sugar control is improved,” she said. More than a quarter of people 65 and older had diabetes — or an estimated 16 million — in 2019, according to the Centers for Disease Control and Prevention.

CMS is also contemplating the creation of a system to review requests for additional kinds of dental treatment needed to improve the outcome of other covered medical care.

The proposed changes would be particularly important for patients undergoing treatments that weaken the immune system, giving any dental infections the opportunity to spread, Jones said. “So if you have infection anywhere in the body, it can become rampant when you suppress the immune system,” she said.

CMS is considering extending coverage to dental services that are “inextricably linked” to the success of other covered medical procedures, Dr. Meena Seshamani, a CMS deputy administrator and the director of the Center for Medicare, said in a statement. If the proposal is finalized, Medicare Advantage plans would be required to expand coverage as well, she said. And Medicare supplemental or Medigap policies would have to pay for the patient’s share of the cost.

Officials say the potential changes come after receiving criticism that the current definition of medically necessary dental care is too “restrictive, which may contribute to inequitable distribution of dental services for Medicare beneficiaries,” according to the proposal. It also cites a 2021 report on oral health from the National Institutes of Health, which found that almost 3 in 5 older adults experience severe periodontal or gum disease. Older adults also have the highest out-of-pocket dental costs.

Leading dental care, patients, and seniors’ advocacy organizations along with congressional Democrats largely support the proposal. But at the same time, they criticized its shortcomings.

“This new rule merely expands coverage to align with the most recent medical literature and accepted standards of care,” Rep. Lloyd Doggett (D-Texas), who chairs the Ways and Means health subcommittee and who has advocated for comprehensive coverage, said in a statement to KHN. “It is not a panacea.”

In June, Doggett spearheaded a letter signed by more than 100 colleagues pressing CMS to expand dental services for certain medical conditions. In July, 22 Senate Democrats also urged CMS to expand dental coverage.

The proposal has been criticized because it omits follow-up dental care. Extracting infected teeth has consequences, even when it’s needed to eliminate an infection that would otherwise jeopardize potentially lifesaving treatment. “If you remove the teeth, patients cannot chew and continue to nourish themselves properly,” said Dr. Dave Preble, chief strategy officer at the American Dental Association. “You’ve created another medical problem for the patient.” Full or partial dentures are not covered under Medicare. Overall, the ADA supports the proposal, although it has asked CMS for more information.

Additional details to be worked out include a big one: “How do you reimburse properly for things that haven’t been covered before?” asked Preble. He questioned how CMS would calculate dentists’ payments and whether they would cover ancillary expenses such as supplies, utilities, and equipment. The ADA’s concerns about Medicare payments and the funding of extra benefits are among the reasons it did not support legislation for more comprehensive coverage.

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.

“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother’s nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.

Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home.

Half of the nearly 65 million people with Medicare are enrolled in the private health plans called Medicare Advantage, an alternative to the traditional government program. The plans must cover — at a minimum — the same benefits as traditional Medicare, including up to 100 days of skilled nursing home care every year.

But the private plans have leeway when deciding how much nursing home care a patient needs.

“In traditional Medicare, the medical professionals at the facility decide when someone is safe to go home,” said Eric Krupa, an attorney at the Center for Medicare Advocacy, a nonprofit law group that advises beneficiaries. “In Medicare Advantage, the plan decides.”

Mairead Painter, a vice president of the National Association of State Long-Term Care Ombudsman Programs who directs Connecticut’s office, said, “People are going to the nursing home, and then very quickly getting a denial, and then told to appeal, which adds to their stress when they’re already trying to recuperate.”

The federal government pays Medicare Advantage plans a monthly amount for each enrollee, regardless of how much care that person needs. This raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits,” according to an April analysis by the Department of Health and Human Services’ inspector general. Investigators found that nursing home coverage was among the most frequently denied services by the private plans and often would have been covered under traditional Medicare.

The federal Centers for Medicare & Medicaid Services recently signaled its interest in cracking down on unwarranted denials of members’ coverage. In August, it asked for public feedback on how to prevent Advantage plans from limiting “access to medically necessary care.”

The limits on nursing home coverage come after several decades of efforts by insurers to reduce hospitalizations, initiatives designed to help drive down costs and reduce the risk of infections.

Charlene Harrington, a professor emerita at the University of California-San Francisco’s School of Nursing and an expert on nursing home reimbursement and regulation, said nursing homes have an incentive to extend residents’ stays. “Length of stay and occupancy are the main predictor of profitability, so they want to keep people as long as possible,” she said. Many facilities still have empty beds, a lingering effect of the covid-19 pandemic.

When to leave a nursing home “is a complicated decision because you have two groups that have reverse incentives,” she said. “People are probably better off at home,” she said, if they are healthy enough and have family members or other sources of support and secure housing. “The resident ought to have some say about it.”

Jill Sumner, a vice president for the American Health Care Association, which represents nursing homes, said her group has “significant concerns” about large Advantage plans cutting off coverage. “The health plan can determine how long someone is in a nursing home typically without laying eyes on the person,” she said.

The problem has become “more widespread and more frequent,” said Dr. Rajeev Kumar, vice president of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “It’s not just one plan,” he said. “It’s pretty much all of them.”

As Medicare Advantage enrollment has spiked in recent years, Kumar said, disagreements between insurers and nursing home medical teams have increased. In addition, he said, insurers have hired companies, such as Tennessee-based naviHealth, that use data about other patients to help predict how much care an individual needs in a skilled nursing facility based on her health condition. Those calculations can conflict with what medical teams recommend, he said.

UnitedHealthcare, which is the largest provider of Medicare Advantage plans, bought naviHealth in 2020.

Sumner said nursing homes are feeling the impact. “Since the advent of these companies, we’ve seen shorter lengths of stays,” she said.

In a recent news release, naviHealth said its “predictive technology” helps patients “enjoy more days at home, and health care providers and health plans can significantly reduce costs.”

UnitedHealthcare spokesperson Heather Soule would not explain why the company limited coverage for the members mentioned in this article. But, in a statement, she said such decisions are based on Medicare’s criteria for medically necessary care and involve a review of members’ medical records and clinical conditions. If members disagree, she said, they can appeal.

When the patient no longer meets the criteria for coverage in a skilled nursing facility, “that does not mean the member no longer requires care,” Soule said. “That is why our care coordinators proactively engage with members, caregivers, and providers to help guide them through an individualized care plan focused on the member’s unique needs.”

She noted that many Advantage plan members prefer receiving care at home. But some members and their advocates say that option is not always practical or safe.

Patricia Maynard, 80, a retired Connecticut school cafeteria employee, was in a nursing home recovering from a hip replacement in December when her UnitedHealthcare Medicare Advantage plan notified her it was ending coverage. Her doctors disagreed with the decision.

“If I stayed, I would have to pay,” Maynard said. “Or I could go home and not worry about a bill.” Without insurance, the average daily cost of a semiprivate room at her nursing home was $415, according to a 2020 state survey of facility charges. But going home was also impractical: “I couldn’t walk because of the pain,” she said.

Maynard appealed, and the company reversed its decision. But a few days later, she received another notice saying the plan had decided to stop payment, again over the objections of her medical team.

The cycle continued 10 more times, Krupa said.

Maynard’s repeated appeals are part of the usual Medicare Advantage appeals process, said Beth Lynk, a CMS spokesperson, in a statement.

When a request to the Advantage plan is not successful, members can appeal to an independent “quality improvement organization,” or QIO, that handles Medicare complaints, Lynk said. “If an enrollee receives a favorable decision from the QIO, the plan is required to continue to pay for the nursing home stay until the plan or facility decides the member or patient no longer needs it,” she explained. Residents who disagree can file another appeal.

CMS could not provide data on how many beneficiaries had their nursing home care cut off by their Advantage plans or on how many succeeded in getting the decision reversed.

To make fighting the denials easier, the Center for Medicare Advocacy created a form to help Medicare Advantage members file a grievance with their plan.

When UnitedHealthcare decided it wouldn’t pay for an additional five days in the nursing home for Christopherson, she stayed at the facility and appealed. When she returned to her apartment, the facility billed her nearly $2,500 for that period.

After Christopherson made repeated appeals, UnitedHealthcare reversed its decision and paid for her entire stay.

Loomis said her family remains “mystified” by her mother’s ordeal.

“How can the insurance company deny coverage recommended by her medical care team?” Loomis asked. “They’re the experts, and they deal with people like my mother every day.”

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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If adopted, it would be the first time the federal government insists that nursing homes devote the majority of Medicaid dollars to caring for residents.

Three states have already set such mandates, and California lawmakers are considering one during the current session. The bill would require nursing homes to spend at least 85% of revenue from all payers on direct care for residents.

The strategy, which has not yet been formally proposed, is among several steps officials are considering after the covid-19 pandemic hit vulnerable nursing home residents especially hard. During the first 12 months of the pandemic, at least 34% of the people killed by the virus lived in nursing homes and other long-term care facilities even though residents of those facilities make up fewer than 1% of the U.S. population.

Medicaid, the federal-state health insurance program for low-income people, pays the bills for 62% of long-term care residents in nursing homes. In 2019, that totaled $50.8 billion. Medicare, which covers short-term nursing home visits for older adults or people with disabilities, spent $38.2 billion that year. (Officials have not included Medicare payments in their discussions of a direct care spending mandate.)

“The absolutely critical ingredient” for good care is sufficient staffing, Dan Tsai, a deputy administrator at the Centers for Medicare & Medicaid Services and Medicaid director, told KHN.

CMS requested public comments on a possible direct care spending mandate in its proposed update of nursing home payment policies and rates for next year. Tsai also spoke about it at a meeting with Illinois state officials, nursing home workers, residents, and relatives in Chicago in April.

Studies have found a strong connection between staffing levels and care. CMS doesn’t require specific numbers of nurses and other staff members, although some states do.

“We want to make sure that the dollars get to the direct care workforce to ensure high-quality care,” Tsai told KHN.

To receive a government paycheck, nursing homes must follow dozens of requirements aimed at ensuring high-quality care. They can be penalized for violations. But federal investigations have found that inspectors can miss serious problems and that inspections don’t consistently meet CMS standards. Infection control has been one of the most common violations.

In its request for public comment, CMS asked several questions, including: “Is there evidence that resources that could be spent on staffing are instead being used on expenses that are not necessary to quality patient care?”

The federal interest follows laws enacted in three states — Massachusetts, New Jersey, and New York — to mandate spending on care. Massachusetts requires nursing homes to spend at least 75% of revenue on residents’ care. New Jersey’s nursing homes must spend at least 90% of Medicaid payments on resident care, and no more than 5% can go to profits. New York mandates that at least 70% of nursing home revenue — including payments from Medicaid, Medicare, and private insurance — be used to care for residents and that at least 40% of the money for direct care pay for “resident-facing” staff. Profits are capped at 5%. All three states promise a boost in state Medicaid payments to facilities that comply with the laws.

The California Assembly last month approved legislation that would require nursing homes to spend at least 85% of all revenue on services that benefit residents, such as nursing staff, drugs, therapy, food, and laundry. Administrative costs, executive salaries, legal expenses, and profits would be excluded. The bill is now before the Senate.

“Currently, once they get that money, they’re free to spend it pretty much any way they want,” said Tony Chicotel, a senior staff attorney at California Advocates for Nursing Home Reform.

The bill, AB 2079, also would block nursing homes from classifying rent or lease payments as direct-care expenses. Industry lobbyist Jennifer Snyder told lawmakers during a March hearing that those expenses are “required to keep the doors open and the lights on.”

The measure, which would take effect July 1, 2023, would also require facilities to report how much they spent on direct and non-direct care, in addition to other disclosures. Lawmakers want to scrutinize these expenses because some nursing-home owners have been able to shift profits by contracting with other, related businesses they own. The homes’ financial reports would be audited every three years.

“When an operator sets up a related-party entity to charge rents, they’re not doing that to get the best possible rate,” said Assembly member Jim Wood (D-Santa Rosa), who authored the bill. “They’re doing that to get the most profit they can.”

In April, the National Academies of Sciences, Engineering, and Medicine endorsed the direct care spending strategy in a report about improving nursing home care.

“When you’re taking public dollars, those dollars should be put back into direct care,” said David Grabowski, a professor of health care policy at Harvard Medical School and a member of the committee that wrote the report. “We’re expecting that the nursing home will make the best judgment as to the right kind of share of spending on labor and materials and capital to really produce the highest level of quality, but that just hasn’t been the case. So this recommendation is really an opportunity to put up some guardrails.”

National nursing home industry groups oppose such requirements, which come at a challenging time since many facilities are facing staffing shortages. In New York, two trade associations and about half the state’s homes have filed two lawsuits to block the state’s spending directive.

Staffing is already “the No. 1 expense” for nursing homes, said Stephen Hanse, president and CEO of the New York State Health Facilities Association, which represents 350 nursing homes and spearheaded one of the lawsuits. “We’re a hands-on industry.”

The 239 nursing homes that joined the association’s lawsuit claim that if New York’s law had been in effect in 2019, the facilities would have been forced to provide residents with an additional $824 million in direct care or return that amount to the state.

Hanse objects to the state’s telling nursing home administrators how to do their jobs. “You can have an amazing dietary program, for example, and this law would mandate that you lay off dietary workers and hire front-line workers to meet the staffing requirement,” he said.

Groups bringing the lawsuits argue that forcing owners to spend more money on direct care leaves less money for maintaining their facilities and that the quality of care will suffer. They also claim Medicaid doesn’t cover the cost of caring for residents. Advocates for residents say facilities can hide their profits by overpaying related businesses they own, such as laundry or food-service companies.

Although a spending mandate is new for nursing homes in the three states, it has become routine for health insurers nationwide. Under the Affordable Care Act’s “medical loss ratio” provision, health insurance companies must spend at least 80% of premiums on beneficiaries’ medical care. A maximum of 20% can be spent on administrative costs, executive salaries, advertising, and profits. Companies that exceed the limit must refund the difference to beneficiaries.

In addition to a direct care spending mandate, Tsai said CMS is interested in a slightly different approach underway in Illinois, which made changes to nursing home regulations this year. Its nursing home rate reform law raises Medicaid funding and then requires each home to hire at least 70% of the staff that the state’s analysis shows the residents need. The state then uses payroll and other data to verify that the facility complied. If not, the difference will be deducted from its next payment.

“There are states across the country trying a range of approaches to make sure that dollars in the system from nursing facility reimbursement rates are actually — one way or another — getting to sufficient, high-quality staffing,” Tsai said. “That’s our primary goal.”

KHN senior correspondent Samantha Young contributed to this report from Sacramento.

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.