According to a new Government Accountability Office (GAO) report private insurers who offer Medicare Advantage plans need tougher oversight. 

“Federal investigators have found Medicare officials rarely enforce rules for private insurance plans intended to make sure beneficiaries will be able to see a doctor when they need care.

The U.S. Centers for Medicare and Medicaid Services, which oversees Medicare Advantage, requires the plans to have doctors in sufficient numbers and specialties who are near enough — in distance and travel time — so seniors can reach them. 

But the GAO found CMS checked the provider networks of less than 1 percent of the plans since 2013 — serving just 2 percent of Medicare Advantage members — and only when the plans expanded to a new county.” ... Kaiser Health News & Conn. Health I-Team 

In 2013, United Healthcare, which is the nation’s biggest health insurance company and a provider of private Medicare Advantage in Connecticut, dropped hundreds of health care providers and 1,200 doctors.  Medicare Advantage beneficiaries are restricted to a network of providers. If their provider leaves, they cannot change plans during the year. What happened in Connecticut is the perfect example of how MA plans have been allowed to skirt the rules, dropping providers thereby limiting coverage for seniors with little warning and leaving them with few options. 

“The GAO report shows Medicare ‘was not verifying network adequacy. That’s their job and they abdicated that responsibility,’ said U.S. Rep. Rosa DeLauro, D-New Haven, who requested the investigation along with other members of the Connecticut congressional delegation.”

Also this week, a new Brown University study shows that once medical care becomes costly for seniors in Medicare Advantage and no longer meets their needs beneficiaries are leaving the private MA plans.

"Our results raise questions about whether current Medicare Advantage regulations and payment formulas are designed to meet the needs of Medicare Advantage members who use post-acute and long-term care," wrote Momotazur Rahman, assistant professor (research) of health services, policy and practice in the Brown University School of Public Health, and colleagues in the October issue of the journal Health Affairs. "The unidirectional flow of these high-risk and often high-spending patients from Medicare Advantage to traditional Medicare appears to transfer responsibility to traditional Medicare just as patients enter a period of intensive health care needs." 

Private Medicare Advantage plans continue to see growth as they promise gym-memberships, limited optometric coverage or zero premium plans.  However, as predicted by many healthcare experts and indicated in the Brown study, seniors find that once they actually need help with more costly care, MA plans aren’t providing the coverage they need. 

Ultimately, this means that younger and healthier seniors are being lured into private insurers’ plans only to have to switch to traditional Medicare once they need coverage for more serious health issues (and isn’t that why we have health insurance in the first place – to cover when we get sick, not when we’re healthy?).  Meanwhile, private insurance companies continue to reap the benefits of annual federal subsidies to provide this limited coverage for healthier seniors – which are tax dollars that could have been used in traditional Medicare to serve all beneficiaries.