CMS takes aim at Medicare Advantage plans misrepresenting vision benefits

November 16, 2023
Medicare’s latest proposed rule builds on efforts to rein back Medicare Advantage plans with the AOA contributing comments that reiterate the need to eliminate plans’ barriers to care and promote transparency.
Guardrails on a mountain road

Administrators propose routine notices of unused supplemental benefits as Medicare Advantage (MA) plans continue to draw the ire of optometry’s advocates, concerned over plans’ misrepresentation of vision benefits.

In a proposed rule issued on Nov. 6, the Centers for Medicare & Medicaid Services (CMS) published its Contract Year 2025 Policy and Technical Changes to the Medicare Advantage (MA) and Medicare Prescription Drug Benefit Programs that would implement certain “guardrails” to protect beneficiaries and promote a competitive MA marketplace. Among those proposals, CMS specifically looks to increase utilization and appropriateness of supplemental benefits, such as vision care. Such proposals reflect concerns flagged by the AOA and other physician and patient organizations concerning MA plans in recent years.

Chiquita Brooks-LaSure, CMS administrator, notes the proposed rule furthers Medicare’s efforts to curb predatory marketing and maintain high-quality health care coverage choices for enrollees.

“People with Medicare deserve to have accurate and unbiased information when they make important decisions about their health coverage,” Brooks-LaSure says.

Mid-Year Enrollee Notification of Unused Supplemental Benefits explained

Toward that end, CMS states an ever-increasing amount of federal funds are going toward MA plan rebates used to advertise a wide array of supplemental benefits. In fact, over 99% of MA plans offered at least one supplemental benefit in 2022—the median was 23 supplemental benefits—and the most frequently offered benefits included vision, hearing, fitness and dental. Yet, MA plans report enrollee utilization of these benefits remains “low.”

Such is the case, CMS proposes a new “Mid-Year Enrollee Notification of Unused Supplemental Benefits” be issued annually, personalized to each enrollee, that includes a list of any supplemental benefits not accessed during the first six months of the year. Additionally, the notice would state:

  • The scope of the benefit
  • Cost-sharing
  • Instructions on how to access the benefit
  • Any network application information for each available benefit
  • Customer service contact information for additional help if needed

Although a step in the right direction, the AOA contends that how plans phrase the availability of these supplemental benefits will be critical to the success of this proposal. Frustration and confusion are already high among beneficiaries as to what coverage they actually receive through supplemental vision benefits given MA plans’ misrepresentation of such benefits and occasional bait and switch tactics.

Limiting agent, broker compensation for prospective enrollee steering

Separately, CMS proposes erecting “guardrails” around plan compensation to agents and brokers to halt anti-competitive enrollee steering. As it stands, agents and brokers often receive financial incentives to steer beneficiaries toward large MA plans rather than recommending plans based on prospective enrollees’ best interests. While Medicare statute requires marketing standards that ensure agents and brokers are incentivized to steer patients toward a plan that best meets their health care needs, CMS proposes setting a clear, fixed amount to be paid regardless of the plan prospective beneficiaries choose. What’s more, CMS proposes a prohibition on contract terms between MA plans and “marketing middlemen” that result in volume-based bonuses for enrollment in certain plans.

The AOA’s comments to CMS will not only reiterate these points but also continue to point out concerns regarding the subcontracting of benefits to vision plans and the challenges created therein.

AOA’s advocacy with CMS results in MA plan changes in recent years

The latest proposed rule comes as CMS continues a years-long effort to regain control over MA plans. In each case, the AOA logs concerns over plans’ policies and tactics that create barriers to eye health and vision care, as well as cloud beneficiaries’ understanding of their own benefits.

In 2023, CMS announced its intent to collect data to better understand the utilization of supplemental benefits, which, if finalized, would include requiring MA plans to report utilization and cost data for all supplemental benefit offerings, including vision. Additionally, CMS proposed new controls on MA plans’ marketing to promote transparency and curb misleading or deceptive advertising. At that time, the AOA noted concerns with MA plans’ marketing in eye care, specifically noting plans’ proclivity to focus on supplemental benefits available without making clear that medical eye care covered under traditional Medicare is also a benefit for MA patients.

“To make matters worse, MA plan marketing misleads patients by overstating the scope of supplemental benefits—first by falsely suggesting that without supplemental benefits Medicare does not cover eye care, and second, by promising certain benefits as ‘free’ even though beneficiaries often have cost sharing,” noted an AOA letter to CMS.

The result is patient confusion and frustration that may inadvertently cause delayed medical eye care or deny the patient the full scope of care promised to them under Medicare, the AOA asserted.

Then again in 2022, CMS finalized expanded Medical Loss Ratio (MLR) reporting requirements, requiring MA organizations to report expenditures on supplemental benefit categories, including vision. The AOA once again brought forward concerns to bolster CMS’ case.

As demonstrated by the most recent proposed rule, CMS does hear the AOA’s concerns and is taking a close look at how these benefits are offered and managed.

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