Medicare Rights Urges CMS to Increase Medicare Advantage Transparency and Accountability

Yesterday, the Medicare Rights Center submitted comments in response to a Centers for Medicare & Medicaid Services (CMS) Request for Information (RFI) on enhancing their Medicare Advantage (MA) data collection. According to CMS, the solicited information is intended to “support efforts for MA plans to best meet the needs of people with Medicare, for people with Medicare to have timely access to care, to ensure that MA plans appropriately use taxpayer funds, and for the market to have healthy competition.”

Our response focused on opportunities to improve program transparency, plan accountability, and the MA system through data collection and reporting in several key areas: equity, provider directories and plan networks, marketing, utilization management and appeals, supplemental benefits, dually eligible individuals and dual eligible special needs plans (D-SNPs), and favorable selection and risk adjustment.

Our recommendations center beneficiary needs and are grounded in our work helping MA enrollees navigate coverage and access care. Year after year, among the most frequent calls to Medicare Rights Helpline are those on or behalf of MA enrollees facing care complications or coverage barriers. Based on this experience, we know that MA is increasingly affecting the lives and finances of many people with Medicare, and the program itself. Over half of eligible beneficiaries are now enrolled in MA, and plans draw down billions of dollars from Medicare each year. Despite MA’s sizable and growing footprint, enrollees, advocates, researchers, families, and policymakers are often kept in the dark about important aspects of the program, including fundamentals like whether enrollees are getting the care they need and how plans are using program, beneficiary, and taxpayer funds.

These data gaps impact beneficiaries from the outset, as inadequate information undermines efforts to understand and choose optimal coverage. An increasingly cluttered MA marketplace, driven by burgeoning profits and rule changes allowing MA plans to proliferate, further hinders sound decision-making. More beneficiaries than ever before are experiencing these pitfalls. MA enrollment has more than doubled in the last decade and the share of beneficiaries enrolled in MA, currently around 50%, may hit 60% by 2030.

Payments to MA plans are also climbing. As a portion of total Medicare dollars, they ballooned from 26% in 2010 to 45% in 2020, and could reach 54% by 2030. Per person, Medicare spending is higher and growing faster for MA beneficiaries than for those with Original Medicare (OM). Medicare pays MA plans an estimated 6% more than OM for similar enrollees, translating to an extra $27 billion in 2023 alone. Higher payments per MA enrollee are expected to cost Medicare $183 billion in the coming years. These overpayments have system-wide consequences, raising taxpayer costs and Part B premiums across the board, while worsening Medicare sustainability for current and future enrollees.

These trajectories are additionally concerning because the data are unclear when it comes to MA quality and the beneficiary experience. Much of what we do know suggests room for improvement, and that plans are simply not being made to account for their use of public dollars. There is also a lack of reported demographic information, which undermines transparency and stymies equity advancement. Without these and other data points, it is impossible to know how well MA works for people with Medicare, including those from underserved communities. This, in turn, makes it difficult for beneficiaries to make fully informed enrollment choices or for policymakers to hold MA plans responsible for their spending, promises, and behaviors.

As a result, harmful plan practices—such as inappropriate denials, utilization management misuse, aggressive marketing, favorable selection and other gaming—can continue unabated, worsening health care access, outcomes, and disparities.

For these reasons, we welcome the RFI. From our perspective, it is evident that MA enrollment and costs are surging, that access issues abound, and that transparency is lacking. To ensure MA works well for those it is supposed to serve, in our comments we urged CMS to immediately and thoroughly collect and publish critical data elements.

While some of the information we request may be actionable for people with Medicare, we caution that CMS must neither expect the market to self-eradicate bad actors, nor overly rely on beneficiary reporting to ensure plan compliance. Instead, CMS-required data must form the basis of enhanced enforcement of Medicare’s statutes and regulations and be used to drive future policy improvements program-wide.

These data collections and any evidence-based reforms they yield are long overdue, and CMS is well within its authority to operationalize such changes. A foundational principle of Medicare is its public financing and associated duties. As private companies, Medicare Advantage Organizations (MAOs) are taking federal money from Medicare in exchange for providing necessary, and often legally required, care. CMS must hold plans accountable for the funding they receive and the promises they make.

Doing so will require additional data, oversight, and fortitude. CMS must not allow MAOs to hide behind claims of proprietary operations or otherwise limit access to Medicare-linked information. Instead, plan responses to agency data requests must be timely, correct, and publicly available. All such requirements must be strictly enforced, with appropriate consequences for inaccuracies and delays, including financial, enrollment, and contractual penalties.

We applaud CMS’s interest in this important issue and urge swift action. The need for enhanced MA plan oversight, transparency, and accountability will only grow as the program does.

Read the RFI and our comments.