Medicare Advantage (MA) – the offshoot of traditional Medicare that’s administered by private insurance companies – has recently caught a lot of flak.
As it pertains to home health care specifically, MA plans have been criticized for their cumbersome prior authorization requirements and provider reimbursement rates that are typically far below fee-for-service Medicare.
What’s more, MA home health patients generally have worse functional outcomes compared to traditional Medicare patients, partly because they often receive fewer visits, according to a 2024 study from the Department of Rehabilitation Medicine at University of Washington.
Similar MA grievances can be heard from beyond home health care as well.
In response to the mounting criticism, the U.S. Centers for Medicare & Medicaid Services (CMS) has been collecting feedback on the MA program through a request for information (RFI) process. The public comment period attached to that RFI – largely focused on MA data policies and procedures – officially ended on Wednesday.
“Recommendations regarding MA data included calls for CMS to collect and release more MA data on key areas of concern, such as supplemental benefit costs and utilization, value-based payment arrangements between providers and plans, utilization management and prior authorization including denials and appeals and access to inpatient services and post-acute care, network adequacy and provider directory accuracy, competitive forces in the market such as the effects of market shifts and vertical integration and consolidation on consumers, care outcomes, and Medicare Loss Ratios (MLRs),” CMS noted in its RFI.
Overall, the RFI received hundreds of comments from MA stakeholders.
In one, a commenter summarized how they had seen multiple patients discharged from home health services after patients had changes necessitating continued visits. In the same comment, the individual explained how appealing for continued services was extremely difficult.
“These are next to impossible to get approved and the patient pays the price,” the commenter wrote. “I am so glad this is being evaluated.”
Home health care was brought up in a number of other comments, too.
“My consulting firm works with all levels of home-based services, but the Medicare agencies in highly impacted areas of Medicare Advantage plans are struggling and many now cannot take the patients on the plans because they pay far below the cost with overhead,” another commenter wrote. “This means that many Medicare patients now cannot get the services that they need.”
Broadly, commenters also raised data considerations on topics such as MA marketing activity, especially predatory behavior, care outcomes and data available in MA compared to fee-for-service Medicare.
Moving forward, the feedback will be used to guide future rulemaking, according to CMS.
“This RFI is an extension of our ongoing work on MA data as we solicit feedback from the public on how best to meet the shared goals of enhancing data capabilities to have better insight into our programs, consider areas to increase MA data transparency and propose future rulemaking,” CMS wrote in the RFI. “Our eventual goal is to have, and make publicly available, MA data commensurate with data available for Traditional Medicare to advance transparency across the Medicare program, and to allow for analysis in the context of other health programs like accountable care organizations, the Marketplace, Medicaid managed care, integrated delivery systems, among others.”
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