February 24, 2024
Uncle Sam wants you to help stop insurers' fraudulent Medicare Advantage sales tactics


People gathered at the US Capitol in Washington, DC, at a rally organized by the Center for Medicare Advocacy in July. He protested the denials and delays in private Medicare Advantage plans.

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Alex Wong/Getty Images

People gathered at the US Capitol in Washington, DC, at a rally organized by the Center for Medicare Advocacy in July. He protested the denials and delays in private Medicare Advantage plans.

Alex Wong/Getty Images

Following an unprecedented crackdown on deceptive advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to bring to the forefront a special weapon to make sure companies comply with the new rules: you.

Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting deceptive or misleading sales tactics to the agency’s 24-hour reporting hotline, 800-MEDICARE. Suspects include postcards designed to appear as if they were government and TV ads featuring celebrities promising benefits and low fees that are only available to certain people in certain counties.

Specifically, you should keep an eye on sales pitches:

  • suggest The benefit is available to everyone who signs up while only a select number of 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 Superlative words such as “most” or “best” unless the claims are supported by current or prior year data.
  • Claim Unrealistic savings, such as $9,600 in medication savings, that apply only in rare circumstances.
  • market Coverage without specifying the name of the plan.
  • Display Official Medicare name, membership card or logo without the approval of CMS, the federal agency in charge of Medicare.
  • Contact If you are a member of an Advantage or drug plan and you have asked that plan not to notify you about other health insurance products.
  • To make excuses Being from the government-run Medicare program, which does not make unsolicited sales calls to beneficiaries.

If you believe a company is violating the new rules, contact CMS at 800-MEDICARE, its 24-hour reporting hotline. If you believe you chose a plan based on incorrect information and want to change a plan, contact CMS or your state health insurance assistance program: www.shiphelp.org or 877-839-2675. Visit ShipHelp.org for more information on protecting yourself from marketing violations.

Medicare’s open enrollment season ends Dec. 7.

New limits on advertising

The new rules, which took effect Sept. 30, close some loopholes in the existing requirements by limiting what insurers can say in advertisements and other promotional materials as well as during the enrollment process.

Insurance companies’ advertising campaigns ramp up every fall, when seniors can purchase policies that take effect Jan. 1. People with traditional government Medicare coverage can add or change prescription drug plans or join a Medicare Advantage plan that combines drug and Medicare coverage. ,

Although Private Advantage plans offer additional benefits that are not available under the Medicare program, some services require prior authorization and beneficiaries are limited to a network of health care providers that may change at any time. In traditional Medicare, beneficiaries can see any provider.

Catching Medicare Advantage plans that are 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 rules for truth in advertising, compliance remains a major challenge. Semanthi Brooks, a social worker and advocate for older adults in northeast Ohio, says it’s too much of an ask to expect beneficiaries to monitor the insurance company’s sales pitches. She has been helping people with Medicare navigate their options for nearly two decades. “I don’t think Medicare beneficiaries should be the police,” she says.

Challenging range of options

Choosing a Medicare Advantage plan can be difficult. For example, in Ohio, there are 224 Advantage and 21 drug plans to choose from that will take effect next year. Eligibility and benefits vary in counties across the state.

Brooks says, “CMS should look at how they can educate people, so that when they hear about the benefits on television, they understand it’s a promotional ad and not necessarily a benefit they can use.” Can do.” “If you don’t realize that these ads may be fraudulent, you won’t know to report them.”

CMS Medicare Director Meena Seshamani told KFF Health News in a written statement that the agency relies on beneficiaries to help improve services. “The voices of the people we serve strengthen our programs,” she writes. Beneficiaries’ complaints prompted government action. “That’s why, after hearing from our community, we took new important steps to protect people with Medicare from misleading and potentially deceptive marketing.”

Although about 31 million of the 65 million people with Medicare are enrolled in Medicare Advantage, even that number may not be enough to monitor the tsunami of ads on TV, radio, the Internet and on paper delivered to physical mailboxes. More than 9,500 ads aired daily during a nine-week marketing period that began two weeks before enrollment opened last year, according to an analysis by KFF. Over 94% of the TV ads were sponsored by health insurers, brokers, and marketing companies, while only 3% of ads from the federal government promoted the Original Medicare program.

During just one hour of a Cleveland news program in December, researchers found, viewers were shown nine Advantage ads.

reviewing ads

For the first time, CMS this year asked insurance and marketing companies to submit their Medicare Advantage television advertisements to ensure they comply with the expanded rules. According to news reports, officials reviewed 1,700 ads from May 1 to September 30 and removed more than 300 ads deemed misleading. An additional 192 out of 250 advertisements from marketing companies were also rejected. The agency would not disclose the total number of TV ads reviewed and rejected this year or whether ads in other media were examined.

The new restrictions also apply to salespeople, whether their pitch is in an advertisement, written material or face-to-face conversation.

Under a key new rule, the seller must explain how the new plan differs from a person’s current health insurance before making any changes.

That information could have helped an Indiana woman who lost coverage for her prescription drugs, which cost $2,000 a month, says Shawn Swindell, state health insurance assistance program supervisor of volunteers for 12 counties in east-central Indiana. Was more than. A plan representative enrolled the woman in a Medicare Advantage plan without telling her it did not include drug coverage because the plan is designed for veterans who can get drug coverage through the Department of Veterans Affairs rather than Medicare . Swindell says the woman is not experienced.

In New York, the Medicare Rights Center received a complaint from a person who wanted to sign up for a prepaid debit card just to buy non-prescription pharmacy items, says Emily Whichelo, the group’s education director. He didn’t know that the vendor would enroll him in the new Medicare Advantage plan the card offered. Whislow corrected the mistake by asking CMS to allow the person to return to his or her previous Advantage plan.

Debit cards are one of a range of additional non-medical benefits offered by Medicare Advantage plans, including transportation to medical appointments, home meals and utilities, groceries and even pet care. Also includes money for supplies. According to CMS, an average of 23 additional benefits were offered in plans last year. But some insurers have told the agency that only a small percentage of patients use them, although actual use is not reportable.

This month, CMS proposed additional Medicare Advantage rules for 2025 that would require insurers to tell their members about available services they have not yet used. “The reminders will ensure that the large federal investment of taxpayer dollars in these benefits is actually reaching beneficiaries and not used primarily as a marketing ploy,” officials said in a fact sheet.

A new escape hatch if you got a bomb steer last year

Medicare Advantage members are typically locked into their plans for the year, with rare exceptions in which they move out of the service area or the plan goes out of business. But two years ago, CMS added a loophole: People could drop a plan they joined based on misleading or inaccurate information, or if they discovered promised benefits didn’t exist or they missed their plan. Couldn’t see the providers. This exception also applies when dishonest plan representatives conceal information and enroll people in Advantage policies without their consent.

Another new rule that prevents enrollment from being rigged prohibits plans from touting benefits that are not available while the potential member is there. Vicki Dufresne, state director of Louisiana’s Senior Health Insurance Information Program, says empty promises have become a growing source of customer complaints. “They were supposed 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 seller went ahead and enrolled them in the plan.”

So expect to see more disclaimers in ads and mailings, like the unsolicited letter from an Aetna Medicare Advantage plan sent to a New York City woman: “Plan features and availability may vary by service area,” reads half a page of fines. A warning packaged in it says 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 required.”

However, the rules still allow insurers to boast about their rating from CMS – five stars is the top grade – even if the rating does not reflect the performance of the specific plan mentioned in an advertisement or displayed on the government’s Medicare Plan Finder website. Does it. “There is no way for consumers to know how accurately a star rating reflects a specific plan design, a specific provider network, or any other characteristic of a particular plan in their county,” Laura Skopek, a senior researcher at the Urban Institute, recently said. represents it.” Co-authored a study on the rating system.

And because ratings data can be more than a year old and plans change every year, ratings published this year do not apply to 2024 plans that haven’t even started yet – despite claims to the contrary.

@susanjaffe, [email protected]

kff health newsKaiser Health News (KHN), formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the main operating programs. KFF – Independent source for health policy research, polling and journalism.

Source: www.npr.org

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