The annual regulatory proposal, known as the payment parameters rule, also seeks to expand access to adult dental coverage in Affordable Care Act marketplaces and would require states to hold open enrollment periods for Obamacare plans at the same time of year. It’s likely one of the last major ACA policy efforts of President Joe Biden’s first term — and, if he loses reelection, could represent his final touches on the landmark health program created when he was vice president.

Biden has been a staunch supporter of Obamacare and has taken steps during his own first term in the White House to expand the program through rules and legislation, including measures that increased premium subsidies. In part because of those subsidies, enrollment has increased steadily and hit records under his watch.

The proposal for 2025 would continue administration efforts to expand coverage, making it easier for states to offer plans that include adult dental care. The rules also set additional guardrails on the growing number of states that have chosen to run their own ACA marketplaces.

The rules need to be finalized in the spring and would affect plans starting in January 2025, not long before Inauguration Day.

So expect some controversy.

Already, the ACA has entered the political debate, with the current GOP front-runner, former President Donald Trump, taking to his Truth Social site on Thanksgiving weekend to call the failure of the GOP to repeal the ACA “a low point for the Republican Party.”

Trump also said he was “seriously” considering alternatives, which harked back to his presidency when he frequently promised an Obamacare replacement was soon to be revealed. It never was.

Biden quickly seized on Trump’s comments, saying on Nov. 27 that “my predecessor has once again — God love him — called for cuts that could rip away health insurance for tens of millions of Americans.”

Many of the changes made during Biden’s term, especially to rules that spell out how the law is to be implemented, could be altered if a Republican wins the White House — just as occurred in the transition from the Obama administration to the Trump term and, again, when Biden took office.

When Trump came into office, for example, he made a number of moves to roll back ACA rules set by the program’s namesake, President Barack Obama, including sharply reducing funding for enrollment assistance, shortening the annual sign-up period, and allowing less expensive but less protective short-term plans to cover longer periods of time. Biden’s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans, which don’t cover many of the benefits included in ACA plans and are often called “junk insurance” by critics.

“If the past is any guide, and the next administration is different, the first thing they will do is roll things back,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Politics may be one reason the administration’s latest proposal doesn’t include larger changes to the ACA. Doing anything more aggressive in an election year “might disrupt a program that Biden fully supports,” said Joseph Antos, senior fellow at the American Enterprise Institute, a right-leaning think tank.

But the proposal from the Department of Health and Human Services does respond to concerns about “network adequacy,” or whether insurers’ doctor and hospital networks are large enough to meet demand. The rules would require states to set numerical standards, such as a maximum “time and distance” that patients must travel to access in-network care, that are at least as rigorous as federal limits that kicked in this year.

The proposal would affect the 18 states, plus the District of Columbia, that run their own ACA marketplaces.

While many of them already set some network parameters, the standards vary. The administration’s latest proposal notes that 25% of existing state rules fail to set any quantitative requirements, such as how long or far a patient might have to drive to find a participating provider, or the acceptable ratio of the number of enrollees in a plan to the number of covered medical providers.

Requiring standards at least as tough as federal exchange rules across all states “would enhance consumer access to quality, affordable care,” the document says.

Some states “may not be doing enough to ensure compliance,” said Corlette. “States will have to step up their game.”

States would also have to review insurer networks to see if they meet the standards before giving the go-ahead to sell their plans. While the federal marketplace will, beginning in 2025, require insurers to meet new rules aimed at limiting patients’ wait times for appointments, especially for primary care and behavioral health, state marketplaces won’t yet have to impose similar standards.

More prescriptive state requirements for ACA insurers might draw some pushback during the public comment period for the rules, which runs through Jan. 8. They could also be a target for change if the GOP wins the White House, said Chris Condeluci, a health law attorney who worked as counsel to the Senate Finance Committee when the ACA was drafted.

“On the one hand, it makes sense to have standardized rules so everyone is working off the same song sheet,” said Condeluci. But he said there’s support for the idea that state marketplaces were not “to be nationally run or overly prescriptive from a federal government regulatory perspective.”

The HHS proposal also seeks to expand access to routine adult dental coverage by eliminating a prohibition against states including the care as an “essential health benefit” in their benchmark plans. The rules would also standardize open enrollment periods across all states, requiring them to begin Nov. 1 and run through at least Jan. 15. Most states already do that, although Idaho’s period currently begins Oct. 15 and ends Dec. 15, and New York’s begins Nov. 16 and ends Jan. 31.

The payment parameter notices, though dryly named, are a big deal not only for insurers, who plan their benefits and set their rates based in part on such rules, but also for consumers.

The ACA marketplaces “cover millions of people and it’s very important to make sure they are working and people understand what they are buying,” said Bethany Lilly, executive director of public policy at the Leukemia & Lymphoma Society.

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.

USE OUR CONTENT

This story can be republished for free (details).

As part of the ambitious five-year initiative, called CalAIM, the state is supposed to offer the sickest and costliest patients a personal care manager and new services ranging from home-delivered healthy meals to help paying rental security deposits.

But a quarter of the health care insurers, nonprofit organizations, and others responsible for implementing the program don’t know enough about it to serve those in need, and many are not equipped to refer and enroll vulnerable patients, according to research by the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The survey found that only about half of primary care providers and hospital discharge planners are very or somewhat familiar with the initiative, even though they are essential to identifying patients and referring them for services.

“These workers are on the front lines and if they don’t know about it, that’s a pretty easy win to educate them so they can help more people,” said Melora Simon, an associate director at the foundation, which conducted the survey between July 21 and Sept. 12. The initiative debuted in January 2022.

“These workers are most likely to see people in the hospital, in crisis,” she added, and “have the opportunity to do something about it.”

The roughly two dozen managed care insurance companies serving patients in Medi-Cal, California’s Medicaid program for low-income people, are responsible for identifying and enrolling patients into the program, and providing the new services. To make this happen, they contract with local government agencies, community nonprofit groups, social service organizations, hospitals, community clinics, and more. Those organizations can also make referrals and link patients to new services. The foundation surveyed 1,196 of these so-called implementers.

Most of the respondents said state payment rates do not cover the cost of providing expensive social services, and half say the workforce they need to deliver them is “tapped out and overwhelmed.”

About 44% also cited inconsistencies and different rules imposed by managed care plans, making participation very or somewhat challenging. For example, some insurers provide on-the-spot Uber rides for doctor appointments while others offer only a bus pass. Plus, not all plans offer the same services.

The survey did pinpoint some early successes. For instance, about half of respondents said the initiative has enabled them to serve more people, and that their ability to manage the comprehensive needs of patients has gotten better.

Tony Cava, a spokesperson for the state Department of Health Care Services, which administers Medi-Cal, acknowledged that the survey findings “resonate” and said the state is working to streamline and standardize patient referrals and authorizations.

“Implementers are on board with the core goals, and we are seeing improvements. But there is room to increase familiarity with CalAIM and broaden and deepen networks,” Cava said.

He said CalAIM represents a major shift in how Medi-Cal delivers care, and that the “kind of seismic system change that we are undergoing takes time.”

“Rather than reactive, we are moving toward a system that is proactive and considers all factors affecting health — the social drivers of health — and not simply what may happen inside of a medical facility,” he added.

The department provides financial and technical assistance to implementers, though only about one-third of survey respondents have found the training, technical guidance, and other resources adequate.

Van Do-Reynoso, chief healthy equity officer for CenCal Health, the Medi-Cal health insurer serving Santa Barbara and San Luis Obispo counties, acknowledged that it has been difficult to provide a full complement of CalAIM services. She cited a variety of obstacles such as inadequate reimbursement, lack of housing, and working with social services agencies unfamiliar with the health care system.

Nearly 3,000 CenCal enrollees are receiving CalAIM services, she said, many of them housing- and homelessness-related.

“We are working hard to better engage with hospital CEOs, community providers, and medical providers,” Do-Reynoso said. “People are getting housed. They’re practicing sobriety. It has only whetted our appetite to continue doing this work.”

When Newsom launched CalAIM, the Democratic governor promised it would transform Medi-Cal. The goal, his administration said, is to improve health and prevent people from winding up in costly institutions like the emergency room and jail, and to help move homeless people into housing.

It’s unclear how many of the 15.2 million Californians enrolled in Medi-Cal are eligible for new services and benefits, but several large populations qualify, including homeless Californians, people leaving jail or prison, foster children, people with severe mental illness or addiction, and older nursing home residents who want to transition home.

So far, about 141,000 Medi-Cal patients have a personal care manager through CalAIM, according to Cava, though hundreds of thousands more likely qualify. About 76,000 patients are receiving other social services, which are optional for plans to offer, he said.

In some cases, qualified Medi-Cal enrollees are turning down new services because they are being offered at the wrong time or by the wrong person, Simon said. For instance, a homeless person might not accept services from a police or code enforcement officer.

Insurers say they want to do more but need more help from the state.

“I am very hopeful that a year from now, we are going to be able to demonstrate even greater strides,” Do-Reynoso said. “What we hear often is what is reflected in the survey. We need higher rates, more communication, a more streamlined approval process.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Former president and current 2024 Republican front-runner Donald Trump is aiming to put a repeal of the Affordable Care Act back on the political agenda, much to the delight of Democrats, who point to the health law’s growing popularity.

Meanwhile, in Texas, the all-Republican state Supreme Court this week took up a lawsuit filed by more than two dozen women who said their lives were endangered when they experienced pregnancy complications due to the vague wording of the state’s near-total abortion ban.

This week’s panelists are Julie Rovner of KFF Health News, Joanne Kenen of Johns Hopkins University and Politico Magazine, Victoria Knight of Axios, and Sarah Karlin-Smith of the Pink Sheet.

Panelists

Among the takeaways from this week’s episode:

• The FDA recently approved another promising weight loss drug, offering another option to meet the huge demand for such drugs that promise notable health benefits. But Medicare and private insurers remain wary of paying the tab for these very expensive drugs.
• Speaking of expensive drugs, the courts are weighing in on the use of so-called copay accumulators offered by drug companies and others to reduce the cost of pricey pharmaceuticals for patients. The latest ruling called the federal government’s rules on the subject inconsistent and tied the use of copay accumulators to the availability of cheaper, generic alternatives.
• Congress will revisit government spending in January, but that isn’t soon enough to address the end-of-the-year policy changes for some health programs, such as pending cuts to Medicare payments for doctors.
• “This Week in Medical Misinformation” highlights a guide by the staff of Stat to help lay people decipher whether clinical study results truly represent a “breakthrough” or not.

Also this week, Rovner interviews KFF Health News’ Rachana Pradhan, who reported and wrote the latest “Bill of the Month” feature, about a woman who visited a hospital lab for basic prenatal tests and ended up owing almost $2,400. If you have an outrageous or baffling medical bill you’d like to share with us, you can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: KFF Health News’ “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get,” by Katheryn Houghton, Rachana Pradhan, and Samantha Liss.

Joanne Kenen: KFF Health News’ “She Once Advised the President on Aging Issues. Now, She’s Battling Serious Disability and Depression,” by Judith Graham.  

Victoria Knight: Business Insider’s “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God,” by Lauren Vespoli.

Sarah Karlin-Smith: ProPublica’s “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It,” by Maya Miller and Robin Fields.

Also mentioned in this week’s episode:

• KFF Health News’ “Progressive and Anti-Abortion? New Group Plays Fast and Loose to Make Points,” by Darius Tahir.
• ProPublica’s “Some Republicans Were Willing to Compromise on Abortion Ban Exceptions. Activists Made Sure They Didn’t,” by Kavitha Surana.

KFF Health News’ ‘What the Health?’Episode Title: Trump Puts Obamacare Repeal Back on AgendaEpisode Number: 324Published: Nov. 30, 2023

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 30, at 10 a.m. As always, news happens fast, and things might’ve changed by the time you hear this. So, here we go.

We are joined today via video conference by Sarah Karlin-Smith of the Pink Sheet.

Sarah Karlin-Smith: Hi, Julie.

Rovner: Victoria Knight of Axios News.

Victoria Knight: Hello, everyone.

Rovner: And Joanne Kenen of the Johns Hopkins University and Politico Magazine.

Joanne Kenen: Hi, everybody.

Rovner: Later in this episode we’ll have my interview with my colleague Rachana Pradhan about the latest KFF Health News-NPR “Bill of the Month.” This month’s patient fell into an all-too-common trap of using a lab suggested by her doctor’s office for routine bloodwork without realizing she might be left on the hook for thousands of dollars. But first, this week’s news — and last week’s, too, because we were off.

Because nothing is ever gone for good, the effort to repeal and replace Obamacare is back in the news, and it’s coming primarily from the likely Republican presidential nominee, Donald Trump. Just to remind you, in case you’ve forgotten, Trump, during his presidency, even in the two years that Republicans controlled the House and the Senate, was unable to engineer a repeal of the Affordable Care Act, nor did his administration even manage to unveil an alternative. So what possible reason could he have for thinking that this is going to help him politically now?

Knight: My takeaway is that I think it’s a personal grudge that former President Trump still has, that he failed at this. And I think, when you talk to people, he’s still mad that Sen. John McCain did his famous thumbs-down when the rest of the Republican Party was on board. So I’m not sure that there is much political strategy besides wanting to just make it happen finally, because upset it didn’t happen.

Rovner: Is this part of his revenge tour?

Knight: I mean, I think somewhat. Because if you ask House Freedom Caucus people, they will say, “Yeah, we should repeal it.” But if you ask some more moderate Republican members, they’re like, “We’ve already been through that. We don’t want to do it again.” So I don’t think the Republican Party on the Hill has an appetite to do that, even if Congress goes to Republicans in both chambers.

Kenen: Trump never came up with a health plan and repeal died in the Senate, but remember, it was a struggle to even get anything through the House, and what the House Republicans finally voted for, they didn’t even like. So I don’t know if you call this a revenge tour, but it’s checking a box. But I think it’s important to remember that if you look closely at what Republican policies are, they don’t call it repeal, they don’t say, “We are going to repeal it.” That didn’t go so well for them, and it probably cost them an election.

But they still do have a lot of policy ideas that would water down or de facto repeal many key provisions of Obamacare. So they haven’t tried to go that route, and I’m not sure they would ever try a full-out repeal, but there are lots of other things they could do, some of which would have technical names: community rating and things like that, that voters might not quite understand what they were doing, that could really undermine the protections of Obamacare.

Rovner: Yeah, I mean, I was going to say the Republican Party, in general, this has been the running joke since they started “repeal and replace” in 2010, is that they haven’t had the “replace” part of “repeal and replace” at all. Trump kept saying he was going to have a great plan, it’s coming in two weeks, and, of course, now he’s saying he’s going to have a great plan. We’ve never seen this great plan because the Republicans have never been able to agree on what should come next. Aside from, as Joanne says, tinkering around with the Affordable Care Act.

Kenen: Some of that tinkering would be significant.

Rovner: It could be.

Kenen: I mean there are things that they could tinker that wouldn’t be called repeal, but would actually really make the ACA not work very well.

Rovner: But most of the things that the Republicans wanted to do to the ACA have already been done, like repealing the individual mandate, getting rid of a lot of the industry-specific taxes that they didn’t like.

Kenen: Right. So they ended up getting rid of the spinach and they end up with the stuff that even Republicans, they might not say they like the ACA, but they’re being protected by it. And the individual mandate was the single-most unpopular, contentious part of the law and even a lot of Democrats didn’t like it. And so that target of the animus is gone. So by killing part of it, they also made it harder to do things in the future. They could do damage, though.

Rovner: Yeah. Or they could take on entitlements which, of course, is where the real money is. But we’ll get to that in a minute. Sarah, we have not seen you in a while, so we need to catch up on a bunch of things that are FDA-related. First, a couple of payment items since you were last here. The FDA has, as expected, approved a weight loss version of the diabetes drug Mounjaro that appears to be even more effective than the weight loss version of Ozempic. But insurers are still very reluctant to pay for these drugs, which are not only very expensive, they appear to need to be consumed very long-term, if not forever. Medicare has so far resisted calls to cover the drugs, despite some pressure from members of Congress, but that might be about to change.

Karlin-Smith: I think Medicare is getting a lot of pressure. They’re going to have to probably re-look at it at some point. What I found interesting is recently CMS [the Centers for Medicare and Medicaid Services] regulates other types of health plans as well, and in the ACA space they seem to be pushing for coverage of these obesity drugs. And I think they’re thinking around that. They note that the non-coverage allowance for these ACA plans was based on … they were following what Medicare was doing and there’s some acknowledgment that maybe the non-Medicare population is different from the Medicare population. But I think it’s also worth thinking about some of their other reasoning for coverage there, including that these drugs are different than some of the older weight loss drugs that provided more minimal weight loss, had worse side effects, and it came at a time when weight loss was seen as more of a cosmetic issue. So if that ACA provision rule goes through, I think that does help the case for people pushing for coverage in Medicare Part D of these drugs.

Rovner: Yeah, I mean this seems to be one of these “between a rock and a hard place” … that the demand for these drugs is huge. The evidence suggests that they work very well and that they work not just to help people lose weight, but perhaps when they lose weight to be less likely to have heart attacks and strokes and all that other stuff that you don’t want people to have. On the other hand, at the moment, they are super expensive and would bankrupt insurance companies and Medicare.

Karlin-Smith: Right. I mean, we’ve seen this before where people worry there’s a new class of expensive drugs that a lot of people seem like they will need and it’s going to bankrupt the country, and oftentimes that doesn’t happen even whether it is, in theory, more coverage to some extent. We saw that with hep C. There was a new class of cholesterol drugs that came out a few years ago that just haven’t taken off in the way people worried they would. Some of these obesity drugs, they do work really well, not everybody really tolerates them as well as you would think. So there’s questions about whether that demand is really there. Sen. [Bill] Cassidy [R-La.] has made some interesting points about “Is there a way to use these drugs initially for people and then come up with something more for weight maintenance that wouldn’t be as expensive?”

Rovner: We should point out that Sen. Cassidy is a medical doctor.

Karlin-Smith: But I think the pressure is coming on the government. Recently, I got to hear the head of OPM [Office of Personnel Management], who deals with the insurance coverage for federal government employees, and they have a really permissible coverage of obesity drugs. Basically, they require all their health insurance plans to cover one of these GLP-1 drugs, and they have some really interesting language I’ve seen used by pharmaceutical companies to say, “Look, this part of the federal government has said obesity is a disease. It needs to be treated,” and so forth. So I don’t think the federal government is going to be able to use this argument of, “This is not a medical condition, and these are expensive, we’re not going to cover it.” But there’s definitely going to be tensions there in terms of costs.

Rovner: Well, definitely more to come here. Meanwhile, CMS is also looking at changing the rules, again, for some pharmacy copay assistance programs, which claim to assist patients but more often seem to enrich drug companies and payers. What is this one about? And can you explain it in English? Because I’m not sure I understand it.

Karlin-Smith: So most people, when you get a prescription for a drug, have some amount of copay, so your insurance company pays the bulk of the cost and you pay maybe $10, $20, $30 when you pick up your prescription. For really high-cost drugs, pharmaceutical companies and sometimes third-party charities often offer copay support, where they will actually pay your copay for you.

The criticism of these charities and pharma support is that it lets the companies keep the prices higher. Because once you take away the patient feeling the burden of the price, they can still keep that higher percentage that goes to your health plan and into your premiums that you don’t think about. And so health insurance companies have said, “OK, well we’re not going to actually count this coupon money towards your copay, your out-of-pocket max for the year, because you’re not actually paying it.”

So that doesn’t end up doing the patient much good in the end because, while you might get the drug for free the first part of the year, eventually you end up having to pay the money. The courts have weighed in, and the latest ruling was that the effect of it was essentially telling CMS, “You need to re-look at your rules. We don’t think your logic is consistent,” and they seem to potentially suggest that CMS should only allow copay accumulators if there’s a cheaper drug a patient could take.

So, basically, they’re saying it’s unfair to put this burden on patients and not let them benefit from the coupons if this is the only drug they can take. But if there’s a generic drug they should be taking, that’s the equivalent then, OK, insurance company, you can penalize them there. But interestingly, CMS has basically pushed back on the court ruling. They’re asking them for basically more information about what they’re exactly directing them to do and signaling that they want to keep their broader interpretation of the law.

It’s a tricky situation, I think, policy-wise, because there’s this tension of, yes, the drug prices are really high. The insurance companies have a point of how these coupons create these perverse incentives in the system, and, on the other hand, the person that gets stuck in the middle, the patient is not really the fair pawn in this game. And when talking about a similar topic with somebody recently, they brought up what happened with surprise billing and they made this parallel of we need to think about it as, OK, you big corporate entities need to figure out how to duke out this problem, but stop putting the patient in the middle because they’re the one that gets hurt. And that’s what happened in surprise billing. I’m not sure if there’s quite that solution of how you could do that in this pharmaceutical space though.

Rovner: I was just going to say that this sounds exactly like surprise billing, but for prescription drugs. Well, while we are talking about Capitol Hill, let’s turn to Capitol Hill, where the big news of the week is that House Republican conservatives, the so-called Freedom Caucus, have apparently agreed to abide by the deal they agreed to abide by earlier this year. At least that’s when it comes to the overall total for the annual spending bills. Then-Speaker [Kevin] McCarthy’s attempt to adhere to that deal is one of the things that led to his ouster. The conservatives had wanted to cut spending much more deeply than the deal that was cut, I think it was in May. Although I feel compelled to add: Cutting the appropriations bills, which is what we’re talking about here, doesn’t really do very much to help the federal budget deficit. Most of the money that the federal government spends doesn’t go through the appropriations process. It’s automatic, like Social Security and Medicare.

But I digress. Victoria, what prompted the Freedom Caucus to change their minds and what does that portend for actually getting some of these spending bills done before the next cutoff deadline, which is mid-January?

Knight: I mean, I think it’s the Freedom Caucus just facing reality and that it’s really hard to do budget cuts, and a lot of these bills, the cuts are very deep. For the Labor-HHS bill, which is the bill that funds the Department of Health and Human Services, the cut is 18%. To the CDC [Centers for Disease Control and Prevention], 12% to the department itself. Those are really big cuts. And all the bills, you look at them, they all have really deep cuts.

The agriculture bill has deep cuts to the Department of Agriculture that some moderate Republicans don’t like. So all of the bills have these issues, and so I think they’re realizing it is just not possible to get what they want. Some of them didn’t vote for the Fiscal Responsibility Act, which was the deal that former Speaker McCarthy did with the debt limit that set funding levels. So they’re not necessarily going back on something that they voted for.

Rovner: They’re going back on something that the House voted for.

Knight: Yeah. So yeah, I think they’re just realizing the appropriations process, it’s difficult to make these deep spending cuts. I’ve also heard rumors that there might still be a big omnibus spending bill in January. Despite all this talk of doing the individual appropriations bills, I’ve heard that it may end up, despite all the efforts of the Republican Caucus, it may end where they have to just do a big bill because this is the easiest thing to do and then move on to the rest of the business of Congress for the next year. So we’ll see if that happens. But I have heard some rumors already swirling around that.

Rovner: I mean the idea they have now “agreed” to a spending limit that should have been done in the budget in April, which would’ve given them several months to work on the appropriations bills coming in under that level. And, of course, now we’re almost three months into the new fiscal year, so I mean they’re going to be late starting next year unless they resolve this pretty soon. But in the meantime, one thing that won’t happen is that we won’t get a big omnibus bill before Christmas because the deadline is now not until January, and that’s important for a bunch of health issues because we have a lot of policies that are going to end at the end of the year. Things like putting off cuts in Medicare payments to doctors, which a lot of people care about, including, obviously, all the doctors. Is there a chance that some of these “extender provisions” will find their way onto something else, maybe the defense authorization bill that I think they do want to finish before Christmas?

Knight: Yeah, I think that’s definitely possible. I’ve also heard they can retroactively do that, so even if they miss the deadline, it will probably be fixed. So it doesn’t seem like too big a worry,

Rovner: Although those doctor cuts, I mean, what happens is that CMS pens the claims, they don’t pay the claims until it’s been fixed retroactively. They have done it before, it’s a mess.

Kenen: And it’s bad for the doctors because they don’t get paid. It takes even longer to get paid because they’re put in a hold pile, which gets rather large.

Rovner: It does. Not that the defense bill doesn’t have its own issues around defense, but while we’re on the subject of defense, it looks like Alabama Republican Sen. Tommy Tuberville might be ready to throw in the towel now on the more than 400 military promotions he’s been blocking to protest the Biden administration’s policy allowing members of active-duty military and their dependents to travel to other states for an abortion if it’s banned where they are stationed. This has been going on since February. My impression is that it’s his fellow Republicans who are getting worried about this.

Kenen: Yeah. They’re as fed up as the Democrats are now. Not 100% of them are, but there’s a number who’ve come out in public and basically told him to cut it out. And then there are others who aren’t saying it in public, but there are clearly signs that they’re not crazy about this either. But we keep hearing it’s about to break. We’ve been hearing for several weeks it’s about to be resolved, and until it’s resolved, it’s not resolved. So I think clearly there’s movement because the pressure has ramped up from his fellow Republicans.

Rovner: Well, to get really technical, I think that the Senate Rules Committee passed a resolution that could get around this whole thing-

Kenen: But they don’t really want to, I mean the Republicans would rather not confront him through a vote. They’d rather just stare him down and get him to pretend that he won and move on. And that’s what we’re waiting to see. Is it a formal action by the Senate or is there some negotiated way to move forward with at least a large number of these held-up nominations.

Rovner: It’s the George Santos-Bob Menendez health issue. In other words, they would like him to step down himself rather than have to vote to take it down, but they would definitely like him to back off.

Kenen: I mean, not confusing anybody but they’re not talking about expelling her from the Senate. They’re [inaudible] talking about “Cut this out and let these people get their promotions,” because some of them are very serious. These are major positions that are unfilled.

Rovner: Yes, I mean it’s backing up the entire military system because people can’t move on to where they’re supposed to go and the people who are going to take their place can’t move on to where they’re supposed to go, and it’s not great for the Department of Defense. All right, well, while we are on the subject of abortion, at least tangentially, the Texas Supreme Court this week heard that case filed by women who had serious pregnancy complications for which they were unable to get medical care because their doctors were afraid that Texas’ abortion ban would be used to take their medical licenses and/or put them in jail.

Kenen: For 99 years!

Rovner: Yeah, the Texas officials defending against the lawsuit say the women shouldn’t be suing the state. They should be suing their doctors. So what do we expect to happen here? This hearing isn’t even really on the merits. It’s just on whether the exceptions the lower court came up with will be allowed to take effect, which at the moment they’re not.

Kenen: The exception-by-exception policy, where things get written in, is problematic because it’s hard to write a law allowing every possible medical situation that could arise and then that would open it to all other litigation because people would disagree about is this close to death or not? So the plaintiffs want a broader, clearer exception where it’s up to the doctors to do what they think is correct for their patients’ health, all sorts of things can go wrong with people’s bodies.

It’s hard to legislate, which is OK and which isn’t. So the idea of suing your doctor, I mean, that’s just not going to go anywhere. I mean, the court is either going to clarify it or not clarify it. Either way, it’ll get appealed. These issues are not going away. There’s many, many, many documented cases of people not being able to get standard of care. Pregnancy complications are rare, but they’re serious and the state legislatures have been really resistant so far to broadening these exemptions.

Rovner: It’s not just Texas. ProPublica published an investigation this week that found that none of the dozen states with the strictest abortion bans broadened exceptions even after women and their doctors complained that they were being put at grave risk, as Joanne just pointed out. When we look at elections and polls, it feels like the abortion rights side very much has the upper hand, but the reverse seems to be the case in actual state legislatures. I mean, it looks like the anti-abortion forces who want as few exceptions as possible are still getting their way. At least that’s what ProPublica found.

Kenen: Right. One of the other points that the ProPublica piece made was many of these laws were trigger laws. They were written before Roe was toppled. They were written as just in case, if the Supreme Court lets us do this, we’ll do it. So they were symbolic and they were not necessarily written with a lot of medical input. And they were written by activists, not physicians or obstetricians.

And the resistance to changing them is coming from the same interest groups that want no abortions, who say it’s just not ever medically necessary or so rarely medically necessary, and it is medically necessary at times. I mean, there are people who, and this line saying, “Well, if you’re in trouble, you can’t have an abortion. But if you’re close to death you can,” that can happen in split seconds. You can be in trouble and then really be in real trouble. You can’t predict the course of an individual, and it’s tying the hands for physicians to do what needs to be done until it might be too late.

Knight: I think a lot of them don’t realize, until it starts happening, how many times it is sometimes medically necessary. It’s not even that a woman necessarily wants to get an abortion, it’s just something happens, and it’s safer for her to do that in order to save her life.

Karlin-Smith: And you’ve seen in some of these states, sometimes Republican women prominently coming out and pushing for this and trying to explain why it’s necessary. In some cases, they also have made the argument, too, that sometimes to preserve a woman’s fertility, these procedures are necessary given the current situations they face.

Kenen: There was a quote in that ProPublica story, and it’s not necessarily everybody on the anti-abortion rights side, but this individual was quoted as saying that the baby’s life is more important than the mother’s life. So that’s a judgment that a politician or activist is making. Plus, if the mother dies, the fetus can die too. So it doesn’t even make sense. It’s not even choosing one. I mean, in many cases if the pregnant person dies, the fetus will die.

Rovner: Well, finally this week, I want to give a shout-out to a story by my KFF Health News colleague Darius Tahir, who, by the way, became a father this week. Congratulations, Darius. The story’s about a group called the Progressive Anti-Abortion Uprising that purports to be both anti-abortion and progressively leftist and feminist. One of its goals appears to be to get courts to overturn the federal law that restricts protests in front of abortion clinics. The Freedom of Access to Clinic Entrances Act, known as FACE, is I think the only explicitly abortion rights legislation that became law in the entire 1990s, which makes you wonder if this group is really as leftist and feminist as it says it is, or if it’s just a front to try and go after this particular law.

Kenen: It sets limits of where people can be and tries to police it somewhat. But in Darius’ story, his reporting showed that they did, at least some of them, had ties to right-wing groups. So that they’re calling themselves leftist and progressive … it’s not so clear how accurate that is for everybody involved.

Rovner: Yeah, it was an interesting story that we will link to in the show notes. All right, now it is time for “This Week in Health Misinformation,” and it’s good news for a change. I chose a story from Stat News called “How to Spot When Drug Companies Spin Clinical Trial Results.” It’s actually an update of a 2020 guide that STAT did to interpret clinical trial results, and it’s basically a glossary to help understand company jargon and red flags, particularly in press releases, to help determine if that new medical “breakthrough” really is or not. It is really super helpful if you’re a layperson trying to make sense of this.

OK that is this week’s news, and I now will play my “Bill of the Month” interview with Rachana Pradhan, and then we will come back with our extra credits.

I am pleased to welcome back to the podcast my colleague Rachana Pradhan, who reported and wrote the latest KFF Health News-NPR “Bill of the Month” installment. Always great to see you, Rachana.

Rachana Pradhan: Thanks for having me, Julie.

Rovner: So this month’s patient fell into what’s an all-too-common trap. She went to a lab for routine bloodwork suggested by her doctor without realizing she could be subjected to thousands of dollars in bills she’s expected to pay. Tell us who she is and how she managed to rack up such a big bill for things that should not have cost that much.

Pradhan: So our patient is Reesha Ahmed. She lives in Texas, just in a suburb of the Dallas-Fort Worth area, and what happened to Reesha is she found out she was pregnant and she went to a doctor’s office that she had never gone to before for a standard prenatal checkup, and she also had health insurance. I want to underscore that that is an important detail in this story. So the nurse recommended that Reesha get routine blood tests just down the hall in a lab that was in the adjoining hospital. And it was routine. There was nothing unusual about the blood tests that Reesha received. So what she was advised to do is after her checkup, she was told, “Well, here’s the bloodwork you need, and just go down the hallway here, into the hospital,” to get her blood drawn.

Rovner: How convenient, they have their own lab.

Pradhan: Exactly. And Reesha did what she was told. She got bloodwork done. And then, soon after that, she started getting bills. And they first were small amounts, like there was a bill for $17, and she thought, “OK, well that’s not so bad.” Then she got a bill for over $300 and thought, “That’s unusual. Why would I get billed this?” Then came the huge one. It was over $2,000. In total, Reesha’s overall lab work bills were close to $2,400 for, again, standard bloodwork that every pregnant woman gets when they find out that they’re pregnant. And so she, needless to say, was shocked and immediately actually started trying to investigate herself as to how it was possible for her to get billed such astronomical amounts.

Rovner: And so what did she manage to find out?

Pradhan: She tried taking it up with the hospital and her insurance company. And she just got passed around over and over again. She appealed to her insurance. They denied her appeal saying that, “Well, this bloodwork was diagnostic and not preventive, so it was coded correctly based on the claim that was submitted to us,” and the hospital even sent her to collections for this bloodwork. Unfortunately for Reesha, this pregnancy ended in a miscarriage, and so it was particularly difficult. She was dealing with all the emotional, physical ramifications of that, and then on top of that, having to deal with this billing nightmare is just a lot for any one person to handle. It’s too much, honestly.

Rovner: So we, the experts in this, what did we discover about why she got billed so much?

Pradhan: You can get bloodwork at multiple places in our health system. You could get it maybe within a lab just in your doctor’s office. You can go to an outside lab, like an independent commercial one, to get bloodwork done and you can sometimes get labs within a hospital building. They may not look any different when you’re actually in there, but there’s a huge difference as to how much they will charge you.

Research has shown that if a patient is getting blood tests done, things that are relatively routine and just as a standalone service, hospital outpatient department labs charge much, much more. There’s research that we cite in the story about Reesha that … she lives in Texas … bloodwork in Texas, if it’s done in a hospital outpatient department is at least six times as expensive compared to if you get those same tests in a doctor’s office or in an independent commercial lab.

Rovner: To be clear, I would say it’s not just bloodwork. It’s any routine tests that you get in a hospital outpatient department.

Pradhan: That research, in particular, was looking at blood tests actually, in particular, just any lab work that you might get done. So the conclusion of that is really that there’s no meaningful quality difference. There’s really no difference at all when you get them in a doctor’s office versus a hospital or a lab, and yet the prices you pay will vary dramatically.

Rovner: Yeah, there should be a big sign on the door that says: “This may be more convenient, but if you go somewhere else, you might pay a lot less and so will your insurance.” What eventually happened with Reesha’s bill?

Pradhan: Well, eventually, the charges were waived and zeroed out and she was told that she would not have to pay anything and all the accounts would be zeroed out to nothing.

Rovner: Eventually, after we started asking questions?

Pradhan: Yes. It was a day after I had sent a litany of questions about her billing that they gave her a call and said, “You now won’t have to pay anything.” So it’s a big relief for her.

Rovner: Obviously this was not her fault. She did what was recommended by the nurse in her doctor’s office, but there are efforts to make this more transparent.

Pradhan: Yeah. I think in health care policy world, the issue that she experienced is a reflection of something called site-neutral payment, which essentially means if payment is site-neutral for a health care provider, it means that you get a service and regardless of where you get that service, there is no difference in the amount that you are paying. There are efforts in Congress and even in state legislatures to institute site-neutral pay for certain services.

Bloodwork is one that is not necessarily being targeted, at least in Congress. But I will say, I think one of the big takeaways about what patients can do is if they do get paperwork from your doctor’s office saying, “OK, you need to get some blood tests done,” you can always take that bloodwork request and get it done at an independent lab where the charges will be far, far less than in a hospital-based lab, to avoid these charges.

Rovner: Think of it like a prescription.

Pradhan: Exactly. It might not be as convenient in that moment. You might have to drive somewhere, you can’t just walk down a hallway and get your blood tests and labs done, but I think you will potentially avoid exorbitant costs, especially for bloodwork that is very standard and is not costly.

Rovner: Yet another cautionary tale. Rachana Pradhan, thank you very much.

Pradhan: Thanks for having me, Julie.

Rovner: OK. We are back and it’s time for our extra-credit segment. That’s when we each recommend a story we read this week we think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Sarah, you offered up the first extra credit this week. Why don’t you go first?

Karlin-Smith: Sure. I took a look at a ProPublica piece by Maya Miller and Robin Fields, “Insurance Executives Refused to Pay for the Cancer Treatment That Could Have Saved Him. This Is How They Did It.” And it tells the story of a Michigan man who had cancer, and the last resort treatment for him was CAR-T, which is a cellular therapy where they basically take some of your cells, reengineer them, and put them back into your body, and it is quite expensive and it can come with a lot of expensive side effects as well.

FDA considers it a drug, and Michigan state law requires cancer drugs be covered. The insurance company of this man, basically on a technicality, denied it, describing it as a gene therapy, and he did die before he was able to fully push this battle with the insurance company and get access to the treatment and so forth. But I think the piece raises these broader issues about [how] few states are able to proactively monitor whether insurance plans are properly implementing the laws around what is supposed to be covered and not covered.

Few people really have the knowledge or skill set, particularly when you’re dealing with devastating diseases like cancer, which are just taking all of your energy just to go through the treatment, to figure out how to fight the system. And it really demonstrates the huge power imbalances people face in getting health care, even if there are laws that, in theory, seem like they’re supposed to be protected.

I also thought there’s some really interesting statistics in the story about, yes, even though the price tag for these products are really expensive, that the health insurance company actually crunched the numbers and found that if they shifted the cost to premiums in their policyholders, it would lead to, like, 17 cents a month per premium. So I thought that was interesting, as well, because it gives you a sense of, again, where their motivation is coming from when you boil it down to how the costs actually add up.

Rovner: And we will, I promise, talk about the growing backlash against insurance company behavior next week. Victoria.

Knight: So my extra-credit article is a Business Insider story in which I’m quoted, but the title is “Washington’s Secret Weapon Is a Beloved Gen Z Energy Drink With More Caffeine Than God.” And it basically talks about the phenomenon of Celsius popping up around the Hill. So it’s an energy drink that contains 200 milligrams of caffeine. It tastes like sparkling water, it’s fruity, but it’s not like Monster or Red Bull. It tastes way better than them, which I think is partly why it’s become so popular.

But anyways, I’ve only been on the Hill reporting for about a year and in the past couple months it has really popped up everywhere. It’s all around in the different little stores within the Capitol complex, there’s machines devoted to it. So it talks about how that happened. And I personally drink almost one Celsius a day. I’m trying to be better about it, but the Hill is a hard place to work, and you’re running around all the time, and it just gets you as much caffeine as you need in a quick hit. But the FDA does recommend about 400 milligrams a day. So if you drink two, then you’re not going over the recommendation.

Rovner: Well, you can’t drink anything else with caffeine if you drink two.

Knight: That’s true. And I do drink coffee in the morning, but it has some funny quotes to our members of Congress and chiefs of staff and reporters about how we all rely on this energy drink to get through working on the Hill.

Rovner: I just loved this story because, forever, people wonder how these things happen in the middle of the night. It’s not the members, it’s the staff who are going 16 and 20 hours a day, and they’ve always had to rely on something. So, at least now, it’s something that tastes better.

Knight: It does taste better.

Rovner: That’s why it amused me, because it’s been ever thus that you cannot work the way Capitol Hill works without some artificial help, shall we say. Joanne.

Kenen: We used to just count how many pizza boxes were being delivered to know how long a night it was going to be. I guess now you count how many empty cans of Celsius.

Knight: Exactly.

Rovner: I personally ran more on sugar than caffeine.

Kenen: OK. This is a piece by Judy Graham of KFF Health News, and the headline is “A Life-Changing Injury Transformed an Expert’s View on Disability Services.” And it’s about a woman many of us know, actually Julie and I both know: Nora Super. I’ve known her for a long time. She’s an expert on aging. She ran one of the White House aging conferences. She worked at Milken for a long time. She worked at AARP for a while.

She’s in her late 50s now, and in midlife, she started having really severe episodes of depression, and she became very open about it, she became an advocate. Last summer, she had another episode and she couldn’t get an appointment for the treatment she needed quickly enough. And while she was waiting, which is the story of American health care right now, and while she was waiting for it, she did try to take her own life. She survived, but she now has no sensation from the waist down.

And her husband is a health economist, and I should disclose, my former boss at one point, I worked for and with Len for two years, Len Nichols. So this is a story about how she has now become an advocate for disability. And this is a couple with a lot of resources. I mean both knowledge, connections, and they’re not gazillionaires, but they have resources, and how hard it has been for them even with their resources and connections. And so now Nora who, when she’s well, she’s this effervescent force of nature, and this is how she is turning — her prognosis, it could get better, they don’t know yet — but clearly an extraordinarily difficult time. And she has now taken this opportunity to become not just an advocate for the aging and not just an advocate for people with severe depression, but now an advocate for people with severe disability.

Rovner: Yeah, I mean, it’s everything that’s wrong with the American health care system, and I will say that a lot of what I’ve learned about health policy over very many years came from both Len Nichols and Nora, his wife. So they do know a lot. And I think what shocked me about the story is just how expensive some of the things are that they need. And, again, this is a couple who should be well enough off to support themselves, but these are costs that basically nobody could or should have to bear.

Kenen: Even … it was just a lift to get her into their car, just that alone was $6,500. And there are many, many, many things like that. And then another thing that they pointed out in the article is that most physicians don’t have a way of getting somebody from a wheelchair onto the examining table other than having her 70-year-old husband hoist her. So that was one of the many small revelations in this story. Obviously, it’s heartbreaking because I know and like her, but it’s also another indictment of why we just don’t do things right.

Rovner: Yes. Where we are. Well, my story is yet another indictment of not doing things right. It’s by my colleagues Katheryn Houghton, Rachana Pradhan, who you just heard, and Samantha Liss, and it’s called “Medicaid ‘Unwinding’ Makes Other Public Assistance Harder to Get.” And it’s just an infuriating story pointing out that everything we’ve talked about all year with state reviews of Medicaid eligibility, the endless waits on hold with call centers, lost applications, and other bureaucratic holdups, goes for more than just health insurance. The same overworked and under-resourced people who determine Medicaid eligibility are also the gatekeepers for other programs like food stamps and cash welfare assistance, and people who are eligible for those programs are also getting wrongly denied benefits.

Among the people quoted in the story was DeAnna Marchand of Missoula, Montana, who is trying to recertify herself and her grandson for both Medicaid and SNAP (food stamps), but wasn’t sure what she needed to present to prove that eligibility. So she waited to speak to someone and picking up from the story, “After half an hour, she followed prompts to schedule a callback, but an automated voice announced slots were full and instructed her to wait on hold again. An hour later, the call was dropped.” It’s not really the fault of these workers. They cannot possibly do what needs to be done, and, once again, it’s the patients who are paying the price.

All right, that is our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us, too. Special thanks this week to Zach Dyer for filling in as our technical guru while Francis [Ying] takes some much-deserved time off. Also, as always, you can email us your questions or comments. We are at whatthehealth@kff.org. Or you can still find me at X, for now, @jrovner, or @julierovner at Bluesky and Threads. Joanne.

Kenen: I’m mostly at Threads, @joannekenen1. Occasionally I’m still on X, but not very often, that’s @JoanneKenen.

Rovner: Sarah.

Karlin-Smith: I am @SarahKarlin, or @sarahkarlin-smith, depending on the platform.

Rovner: Victoria.

Knight: I am @victoriaregisk [on X and Threads]. Still mostly on X, but also on Threads at the same name.

Rovner: We’re all trying to branch out. We will be back in your feed next week. Until then, be healthy.

Credits

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

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.

USE OUR CONTENT

This story can be republished for free (details).

And Haun was about $800 short.

When she couldn’t book the gigs she needed, Haun, with husband Johnston’s help, came up with a plan: to crowdfund enough money to make their own movie starring Haun, called “Ellen Needs Insurance.”

In this episode of “An Arm and a Leg,” host Dan Weissmann speaks with Haun and Johnston about their short film, how they were affected by the 2023 SAG-AFTRA strike, and their ongoing quest to stay insured.

Credits

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there. OK, here’s something I never expected to say — I’ve got a funny, kind of sweet story about health insurance. OK, maybe sweet and sour. Here it is …

As we record this, it’s November, which means it’s open enrollment for lots of people — time to get next year’s health insurance figured out, both on the Obamacare exchanges and at lots of workplaces. A year ago, Ellen Haun and her husband Dru Johnston were HUSTLING to get their health insurance set up for 2023. In the most creative possible way … by crowdfunding a creative project. They posted a video of course.

Ellen: Hi, I’m Ellen, and I need health insurance. 

Dru: And I’m Dru, and I also need health insurance.

Dan: Ellen and Dru work in Hollywood — acting and writing — and folks in that industry get their insurance through the unions. But only if they’ve racked up enough wages for union work over a 12-month period. They’d been on Ellen’s insurance through the actors’ union, SAG. But last fall, as they explained in their crowdfunding video, that union insurance wasn’t looking like a sure thing for the coming year.

Dru: Right now, Ellen is $804 short. So we’re making a short film. 

Ellen: And that short film is called “Ellen Needs Insurance.”

Dan: The video outlined their plan: to employ not just Ellen but other actors who also needed a little help getting over the finish line to qualify.

Dru: Also, which brings up the next point, are you an actor that’s close to hitting your health insurance? Then please get in touch.

Ellen: Yes, we want to cast you. We want you to have insurance.

Dru: And if we raise more money than our goal, we will use all of that only

towards casting more actors and getting them insurance. 

Ellen: We’ll add parts. We don’t care.

Dru: Yeah, this isn’t Shakespeare. This is a script we wrote. We’ll add parts.

Ellen: We can … We’ll make them up.

Dan: That was a year ago. And spoiler: They did make the film. Of course now they need insurance for 2024. And Ellen’s union spent a lot of 2023 on strike, which has narrowed down the opportunities to earn that insurance again. So… I wanted to talk with them!

[“An Arm and a Leg” theme music plays.]

This is “An Arm and a Leg” — a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge.

So the job we’ve picked here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.

[“An Arm and a Leg” theme music ends.]

Ellen and Dru met at a wedding.

Ellen: I was friends with the bride and Drew was friends with the groom. And at the bachelorette party, Emily had been, like, talking about all the single guys that were going to be at the wedding, but she had forgot to include Dru on that list. So I was like, just, I was like, why is this guy talking to me so much? He’s probably got a girlfriend somewhere.

Dru: Turns out I didn’t. And then, uh, we ended up, uh, starting to date almost immediately after that wedding.

Dan: By then, Ellen was earning enough as an actor to qualify for health insurance, starting with an ad for Xfinity Internet and a recurring role as a law student on “How to Get Away with Murder.”

Viola Davis: Ms. Chapin, can you tell us what the Fifth Amendment is?

Ellen: The Fifth Amendment? Um, right.

It, um, assures your right to protection from self incrimination.

Viola Davis: Are you asking me?

Ellen: No, that’s my answer.

Viola Davis: And it’s a correct one.

Dan: Getting that insurance was a big professional milestone. More than 85 percent of SAG members do not book enough union work to qualify– it takes about 26 thousand dollars across a one-year period. (And, you know, of course most actors, Ellen included, pick up other work on the side, or even hold down a day job.) For most of the last few years, Ellen had no worries about making enough money to qualify for insurance. She’d been getting paid for a commercial that ran and ran, because it was so terrific. You may have seen it. Even I have seen it … and I kinda never watch TV. Ellen plays BOTH parts in it. She’s call center employee

Claire in Phoenix: This is Claire in Phoenix, can I help you? 

Dan: And she’s a woman who’s dialed in for customer support. 

Ellen as customer: Yes.

Claire in Phoenix: Great.

Ellen as customer: Correct.

Claire in Phoenix: Ma’am. This isn’t an automated computer.

Ellen as customer: Operator?

Claire in Phoenix: Ma’am? I’m here. I’m live.

Ellen as customer: Wait, you’re real?

Claire in Phoenix: Yeah! With Discover Card, you can talk to a real person.

Dan: Ellen had been getting a “holding fee” — to keep her from auditioning for commercials for competitors.

Ellen: And I kind of knew in the back of my mind that like, okay, eventually this holding fee is going to go away because this commercial isn’t running anymore.

Dan: And then last June, she got the call.

Ellen: My agent was like, Hey, they’re releasing you from the holds. Uh, you’re not getting that payment. You, um, you’re free to audition for other commercials.

And I was like, okay, but what about that health insurance?

Dan: This was in June. She needed to make another 6 thousand dollars, by the end of December, to keep her insurance.

Ellen: And I thought, okay, I’ve got half the year. Like that’s just booking like one other commercial.

Dan: But that wasn’t a sure thing. She’d done it for years and years, but she wanted to hedge her bets. She experimented with working as an extra.

Ellen: And I was getting like, pretty consistent work, but also background work does not pay very well.

Dan: $187 a day. More if there’s overtime, but still. It’s not that it’s not that much, especially if you’re trying to chip away at like a 6,000 balance.

I was like, I don’t know if I’m going to make this, um, I knew that it was definitely going to be down to the wire. So that’s when I was like, you know what, maybe we should think about making a movie about this.

Dan: Actually, this was an idea that had kind of been on Dru’s shelf for a few years. As a comedy writer for a TV talk show, Dru had gotten his insurance from the screenwriter’s union, the WGA. And then in 2018 the show got canceled. Lucky for Drew, he was married to Ellen by then, so they put him on her SAG insurance. And then after that saga had ended, he had a fun idea.

Dru: I was like, oh, you know what I should have done is I should have just made a web series called, “Dru Needs Insurance.” And then I was like, well, it’s too late. I guess that’s an idea that I’m never going to have to do. And then flash forward.

Dan: They’re in the same boat! all over again.

Except now, it’s Ellen who’s short, and nothing to fall back on. I asked if they remembered the day when they decided to try making the film. Dru was like, …

Dru: It was in the OBGYN’s office.

Dan: Yeah. They were pregnant! This was the first doctor visit.

Dru: We had gone to the ultrasound. We saw the baby. We heard the heartbeat. We were like, well, that we were having the baby. It’s coming.

Dan: Now they were gonna see the doctor, talk about next steps.

Dru: And we had about 20 minutes in that waiting room, just sitting there kind of going like, okay, our life’s gonna change.

We got to make some, some choices, or we got to, like, figure out, like, what room are we going to use? All that stuff. But also in the middle of that, we were like, oh, also our health insurance is going … is set to run out.

Dan: Actually, it was going to run out exactly one month before the baby’s due date.

Dru: And I was like, well, shit, we need that health insurance. Um, and, and that’s when Ellen said, I think I need to make a movie and we need to do that.

Dan: So they did! They banged out a script — and brought a friend’s production company on board. (The union doesn’t let you just pay yourself directly.) Which brings us to the point in the story when they made that crowdfunding video

[Bouncy music plays in the background.]

Dru: It’s a comedy about an actress named Ellen, and the things she does to get insurance.

Ellen: Things like begging my agent for a job, praying to the gods for a surprise residual check, and even background work.

Also, the movie’s just about how hard it is to navigate insurance in this country.

[Bouncy music ends.

Dan: How’d it come out? That’s next.

This episode of “An Arm and a Leg” is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health care in America. Their journalism is terrific– wins all kinds of awards every year– and I’m honored to work with them.

Dan: So, Ellen and Dru did raise the money: more than 33 thousand dollars. They actually did beat their goal. The movie is delightfully meta. It starts with Ellen-the-character in her kitchen in the middle of a conversation with her best friend …

Best Friend: Why can’t you just pay the difference?

Ellen: Oh yeah, I tried. But I called and they told me that’s not allowed.

Best Friend: I thought that was the whole thing about health insurance in this country. You have to pay for it.

Ellen: Apparently, not when you want to. If I want to keep my health insurance, I have to book another SAG job by the end of the year.

Best Friend: Couldn’t you cast yourself in something?

Ellen: Like in what, my own movie? Yeah. I mean, I’d have to get funding,

write a script, hire a production team, get a payroll company, …

Dan: So just like the real Ellen did, movie-Ellen decides to go all out to book another commercial. And if you ever thought it might be fun to take a crack at a career in acting, the audition scene — with Ellen and a casting director — that might dissuade you.

Casting director: Alright, we’ll start on action and, uh, remember, this determines whether or not you can see a doctor in the next year.

Dan: Soon, we see Ellen looking up COBRA — which you may have looked up yourself, like if you ever left a job without your next gig — and your next insurance — lined up.

COBRA pitch: Losing your health insurance?

Don’t worry. It happens all the time. Cobra is here for you. …

Dan: And if you’ve looked at it, you know: COBRA is EXPENSIVE. Like, average employer coverage for a family costs more than 20 thousand dollars a year. So that’s the price range for COBRA.

COBRA pitch: The fact that it’s named after a deadly and venomous snake is just part of the fun, and has nothing to do with the fact that it feels like death. You made less money, and now you have to pay more.

Dan: On her agent’s advice, Ellen tries background work, another case of art imitating life. And, in a scene that really highlights some of the peculiarities about how all of this works,  she debriefs with her friend, over drinks at a bar.

Best Friend: How is it?

Ellen: It’s not as bad as I thought, but it does not pay very well. You get a

lot more if you have a line.

Dan: And suddenly, another patron in the bar leans into the conversation… Bar patron: Excuse me, did you say you get more money if you have a line?

Ellen: Yeah.

Bar patron: Got it.

Dan: And another patron. Bar patron: Just one line?

Ellen: Yeah.

You get more if you have more than five lines, too.

Bar patron: Wow. Wow.

Dan:Now it’s everybody in the bar.

Bar patrons: Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow. Wow.

Dan: The bit about a pay bump is real, of course. Including the bump for more-than-five-lines. And just to expand on that for a minute here – Dru experienced the downside of that rule — ridiculously, painfully — when he did a one-shot appearance on Orange Is the New Black. It was a big meaty scene, but somehow wasn’t more than five lines.

Dru: I was a lawyer and every line was about a half of a page of just legalese

Dru as Lawyer: based on copious witness testimony, the U. S. attorney has charged you and four others

[DUCKS UNDER: with inciting the riot. They allege that you created and maintained a secret riot bunker, and there’s also evidence that directly implicates you in the kidnapping and false imprisonment of Officer Desmond Piscatella…]

Dan: But that’s how a “line” gets defined in this situation: As long as nobody interrupts you, a monologue is just one line. A role with five lines or less gets called an “under-five”

Dru: And I was like, this is an under five? I was like, okay, well, there we go. I’ll just lecture for two pages.

Dru as Lawyer: I’ve negotiated a plea deal for you. If you admit to the riot charges, they’re willing to drop everything else. This is very good.

Dan: We have still not gotten to the end of Dru’s first line in this scene Dru as Lawyer: It’ll garner you the shortest possible sentence.

Dru as Lawyer: Do you understand?

Dan: Back in the film, the Ellen character is still freaking out when she shows up for a doctor’s appointment.

Dr Receptionist: Has your insurance changed?

Ellen: No, but it might soon, so I wanted to make sure that you all would still take it.

Dr. Receptionist: Well, we take most insurances, so I’m sure we’ll be fine.

Ellen: Great. Um, I was looking on the California Insurance Exchange. Dr Receptionist: Uh, no.

Ellen: Excuse me?

Dr. Receptionist: No, we, we don’t take that.

Dan: And in the doctor’s office– in another echo of Ellen and Dru’s story– Ellen-the-character gets an ultrasound.

Ellen: Congratulations.

Dan: And she flashes back to the first scene, with her friend…

Best Friend: Couldn’t you cast yourself in something?

Ellen: Like in what? My own movie? (echos) My own movie?

Dan: And of course, that’s where she decides. She’s gonna do this. On her way out, she tells the receptionist…

Ellen: My insurance is not going to change. You can count on it. 

Dr. Receptionist: Um, okay.

Dan: When I saw the movie, I did not know that Ellen Haun had been pregnant when they made it.

Dru: We never brought it up in crowdfunding. But then when we were making the movie, we were like, let’s just use real life. Not only was it real, it felt like the easiest way to explain it.

Dan: They shot the movie over three days in December 2022. Making this film on $33,000 and change was a feat on its own. They paid 15 actors, and a crew. There was a location to rent, and equipment…

Ellen: You’ve got to pay for food to feed your cast and crew. And especially, you know, everyone is kind of working a little bit under their rate so you want to buy them good food.

Dan: You’ve heard some of the results. I won’t spoil the rest. It’s a very-enjoyable 13 minutes. We’ll have a link wherever you’re listening to this. With the movie wrapped by New Years, Ellen qualified for her insurance, so she was on it when their baby Bruce was born a few weeks early.

Ellen: We spent three weeks in the NICU and the entire time that we were in the hospital with him, we just kept saying, I’m so glad we have insurance. I’m so glad we have insurance. I’m so glad we have insurance.

Dan: Just a few weeks after Bruce was born, Dru’s union– the Writer’s Guild– went on strike. Then Ellen’s union went on strike too.

Ellen: We took Bruce to his very first picket when he was like two months old. And I’ve been going, like, about, once a week to, to picket with him. So everybody knows him at 

the Disney Picket location. He’s a little union baby.

Dru: We say the joke, he went straight from labor to labor action.

Dan: No joke, though: the SAG strike meant there was less work for actors in 2023– fewer chances to earn money and qualify for insurance. The health plan extended a grace period to keep folks from getting cut off, and a new law in California lets workers who are on strike get subsidized insurance from the state’s Obamacare exchange. Meanwhile, Ellen managed to book another commercial — only TV shows and movies were targeted by the strike, not ads — so their family is set for next year too. 

It’s a happy ending … for now. 

But this seems like an exhausting merry-go-round to stay on for the rest of your life. I asked Ellen and Dru how they felt about it.

Ellen: So something that has been nice about the strike has been talking to a bunch of our friends about how hard it’s gotten over the last several years to make a living doing this.

I was like in my late twenties when I got the SAG health insurance for the first time. I thought, like, “Great.” Like, “this is it.”

Dan: That was almost ten years ago. But somehow getting consistent work actually got harder over time. And that felt personal.

Ellen: It was like feeling, like, emotionally, like there’s something wrong with me that I am not making the amount of money that I made earlier in my career. And so, honestly, that has been a nice part of the strike has been realizing that, hey, this is happening to all of us. It’s not just happening to me. It’s really hard.

Dan: But it’s not just hard for actors and writers.

Dru: My brother works in tech. Right. And like, I think the nature of employment, across many industries has changed. And like, there isn’t really that same job security that there used to be when, like, my parents were coming up.

Dan: Dru thinks back to the time, years ago, when he first quit his day job, to write and perform full-time. It was touch and go at first. Like, week to week, it could feel precarious.

Dru: I had a kind of a down week and I was like, maybe it’s time to get a real day job like my brother. And right that week, he got laid off. He’s found another job, he’s figured it out, but it was that moment where I was like, oh, there’s no job that you can just get and be like, now I’m set with health insurance. So that’s a long answer to say, I don’t think we’re leaving the entertainment industry anytime soon.

Ellen: Yeah, we’ve kind of put all of our chips on the table.

Dan: And like Dru said: Fewer of us these days have jobs where we don’t have to worry about where our health insurance is coming from, or if it’s gonna be any good. I mean, if more of us had that kind of security, I would literally never have started making this show. There would be no reason to make it. But of course, five years in, I do not expect to run out of material.

As we publish this episode, we’ve also just put out an installment of our First Aid Kit newsletter, this one sums up and updates all our best advice about how to pick the least-crappy health insurance for you.

I’ve learned a lot in five years. And we’re able to share what we’ve learned because you’ve been supporting us. And if you can, this is the absolute best moment to pitch in, because right now, every dollar you give — up to a thousand dollars per person! — get matched. Thanks to NewsMatch from the Institute for Nonprofit News, every dollar you give us counts for double. The place to go is arm and a leg show, dot com, slash support. That’s https://armandalegshow.com/support/.

We’ll be back in three weeks with part one of a big investigative story we’ve been working on … pretty much all year. Talk about learning a ton. It’s been a wild ride. We’ve been able to do that — and we’ll be able to share the results with you– because of your support, and I am super-thankful. I’ll leave you with that address one more time: arm and a leg show dot com, slash, support. Thanks! I’ll catch you in three weeks. Till then, take care of yourself.

This episode of “An Arm and a Leg” was produced by Emily Pisacreta and me, Dan Weissman and edited by Ellen Weiss.

Daisy Rosario is our consulting managing producer. 

Adam Raymonda is our audio wizard. 

Our music is by Dave Winer and Blue Dot Sessions.

Gabrielle Healy is our managing editor for audience. She edits the First Aid Kit Newsletter.

Bea Bosco is our consulting director of operations. 

Sarah Ballema is our operations manager.

“An Arm and a Leg” is produced in partnership with KFF Health News — formerly known as Kaiser Health News. That’s a national newsroom producing in-depth journalism about healthcare in America, and a core program at KFF — an independent source of health policy research, polling, and journalism. You can learn more about KFF Health News at: https://armandalegshow.com/about-x/partners-and-supporters/kaiserhealthnews/

Zach Dyer is senior audio producer at KFF Health News. He is editorial liaison to this show.

Big thanks to the Institute for Nonprofit News for serving as our fiscal sponsor, allowing us to accept tax-exempt donations. You can learn more about INN at INN.org

And now for one of my favorite parts of the gig … giving a shout out to some of the people who’ve come aboard to support this show in the last few weeks. Thanks at this time to our supporters (Dan lists donors.) Thank you so much! 

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and X, formerly known as Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KFF Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

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.

USE OUR CONTENT

This story can be republished for free (details).

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.

USE OUR CONTENT

This story can be republished for free (details).