Washington, D.C. — The Medicare Advantage (MA) program has grown dramatically and now accounts for more than half of all Medicare enrollment. The Center for American Progress estimates MA plans are overpaid by 22 percent to 39 percent, with overpayments in 2024 alone estimated to total between $83 billion and $127 billion. The Biden-Harris administration has taken important steps to bring more accountability and transparency to the MA program, but critical data gaps remain that make it challenging to fully assess the program’s quality, oversee MA plan performance, identify and address disparities, and ensure Medicare enrollees have the information they need to make informed choices.
A new column summarizes recommendations CAP elevated in response to a recent Centers for Medicare and Medicaid Services (CMS) request for information on MA data transparency. CAP highlights that CMS must fill remaining data gaps in six key areas:
- Broker and agent financial arrangements: Nearly one-third of all Medicare enrollees receive guidance from brokers or agents—who can financially benefit by directing enrollees to certain plans—when choosing a plan. Brokers should have to publicize if and how they are compensated by MA plans.
- Network adequacy and directory accuracy: Prospective MA enrollees should know with certainty whether they will have access to a range of in-network providers upon signing up for an MA plan. CMS should strengthen marketing restrictions on MA plans so enrollees are confident in their network options.
- Prior authorization (PA): When making enrollment decisions, enrollees should know how heavily individual plans use PA in making care or reimbursement decisions. CMS should publicize data on PA use so that prospective enrollees can consider that information when deciding between plans.
- Supplemental benefits use and spending: CMS should collect and publish complete, disaggregated data on utilization and out-of-pocket (OOP) spending for all supplemental benefits, at both the plan and beneficiary level, as well as complete data on PA use and outcomes for supplemental benefits.
- MA plan disenrollment rates: Understanding the demographic and health characteristics of MA enrollees who switch between MA plans or disenrolled MA plans is important for spotting alarming trends in plan coverage. CMS should make this data publicly available at the MA plan level.
- Enrollee out-of-pocket cost expenditures: CMS should publish actual out-of-pocket spending information as part of MA encounter data to help enrollees compare plans and help researchers study how out-of-pocket spending varies between MA and traditional Medicare enrollees.
“To ensure the Medicare Advantage program is functioning as intended and meeting the needs of Medicare enrollees and providers, CMS must fill remaining data gaps related to MA broker compensation, network adequacy and accuracy, prior authorization, supplemental benefits, disenrollment, and enrollee OOP cost expenditures,” said Andrea Ducas, vice president of Health Policy and co-author of the column.
Read the column: “6 Medicare Advantage Data Gaps That the Centers for Medicare and Medicaid Services Must Fill” by Brian Keyser and Andrea Ducas
For more information or to speak with an expert, please contact Sarah Nadeau at [email protected].