At the annual meeting Doctors At a conference in Las Vegas on Monday, a Medicare Advantage policy research analyst sounded the alarm about the fundamental shift in attitudes toward MA at the federal level. It’s a combination of several factors: deep concerns about overpayments and fraud, leading to legislative and political scrutiny of insurers; 3 million seniors lose their MA coverage in 2026 because health insurers have pulled out of their counties; and large and small public insurance companies are doing poorly on the stock market.
Especially at the Centers for Medicare and Medicaid Services, overpayments have become a sticking point.
“CMS has started to take, I think, a more confrontational posture in terms of how they view Medicare Advantage,” said Tom Kornfield, founder and CEO of MAST Health Policy Solutions. “And that’s before we even get into what happens during election time, which is when the rhetoric is turned up to 11, to quote Spinal Tap.”
THE Doctors Conference brings together health care and life insurance brokers, agents, brokerage owners as well as independent marketing organizations and field marketing organizations that serve as a liaison between an insurance company and an agent. Participants are united by the sole goal of understanding the needs of older adults and meeting those needs by selling them insurance products, whether medical or financial. The conference also attracts agents and companies involved in the Affordable Care Act market.
Kornfield said CMS’s scrutiny also focuses on chronic care plans aimed at special needs.
“CMS’ concern about them is that they circumvent some of the requirements of the dual-eligible special needs plan,” he said. “So I think we might see some activity on that front.”
He added that, depending on the outcome of the midterm elections – especially if Democrats win – he expects to see a lot of activity in terms of regulations and legislative changes affecting MA.
While more seniors are enrolled in MA plans today compared to traditional Medicare, enrollment in MA plans is slowing across the board, except in special needs plans or SNPs. In 2021, master’s enrollment was 11%; in 2026 it was 3%.
Whether CMS and other federal agencies focus on fraud or control overpayments, most of the negative headlines about MA come from the fact that year after year, costs continue to rise. The last MedPAC The report shows that MA payments were $76 billion higher than what spending would have been if those same seniors had been enrolled in traditional Medicare.
And this is particularly difficult to digest given that when Medicare Advantage was legislatively designed, it was not only about providing more choices for seniors, but also about containing the costs of health care funded by taxpayer dollars.
But the scrutiny isn’t just on the cost of MA.
“So there are the MedPAC numbers that I mentioned, and the administration has also been under increased scrutiny of what they think is waste in Medicare Advantage plans or fraud, even with risk adjustment, data validation audits, where they look at the medical records, see if that diagnosis is supported by the medical record,” Kornfield pointed out.
Besides exploding costs, national bitterness over MA also has to do with the activity of health insurance marketing organizations, although Kornfield was careful not to castigate members of his audience, the overwhelming majority of whom were agents and brokers.
“During Covid, unfortunately, we’re not trying to shift the blame, but because of the issues probably with the call centers. [issues]“There have been a lot of complaints about the marketing and it has gotten people’s attention on the Hill and it’s a real problem,” he said. “And it might not be such a big deal now, but I think there’s still a hangover that comes from it.”
Overall, the MA market is in the midst of a fundamental shift.
“Medicare Advantage is really at an inflection point,” Kornfield said. “So it’s not really a difficult time. It’s not a cycle. It’s really a reset.”
Will this change in dynamic depend on the outcome of the midterm elections? Will it be better for brokers, insurers and the MA industry if Democrats win the midterm elections or if Republicans manage to hold on?
“I think the Democratic Congress would be much more active in bringing the health care plans there,” Kornfield said. “There are concerns about the size of these large companies, these insurers, UnitedHealthcare. There has been a lot of negative publicity about health insurers.”
But the moderator of the compliance debate in which Kornfield was speaking saw things differently. He found equal concern on both sides of the aisle.
“They want to see the taxpayer cost of Medicare Advantage as a program go down, and it’s Democrats and Republicans, guys are not wrong,” Steve Kaplan, chief legal, compliance and privacy officer at HealthPlanOne, told the audience. “And so they’re asking, ‘How can agents and brokers help?’ »
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