Tag: Advantage

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Humana’s Bruce Broussard touts upside to Medicare Advantage cuts

Humana’s Bruce Broussard touts upside to Medicare Advantage cuts

The health and fitness insurance coverage business at big could be marshaling its forces to battle proposed cuts to Medicare Edge premiums upcoming calendar year, but a single CEO won’t look far too concerned.

Humana would really benefit from reduce costs and has in the earlier, President and CEO Bruce Broussard stated during a TD Cowen conference in Boston on Tuesday. “We discovered in decades that there is force on the charge discover, we do much improved,” he said. “I feel that 2024 will be that way.”

Humana is the next-biggest Medicare Benefit carrier with 5.1 million members, or 18{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of the sector, whilst the primary insurance provider, UnitedHealthcare, has 7.1 million policyholders and a 29{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} sector share.

The Facilities for Medicare and Medicaid Products and services issued a proposal previous month to minimize Medicare Gain premiums by 2.3{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in 2024, but danger adjustment and other variables will outcome in disparate outcomes between insurers. The insurance plan market has characterised the draft policy as a minimize, but CMS asserts it would outcome in an typical 1{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} increase in Medicare Gain revenue for insurers. The agency plans to finalize Medicare Edge prices by April 3. In addition, CMS declared very last month it would reclaim $4.7 billion around 10 yrs from Medicare Edge carriers the company concluded ended up overpaid.

Humana would likely see an total rate reduce of 1{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} less than the proposed rate recognize, TD Cowen running director for health care and senior equity analysis analyst Gary Taylor claimed at the convention.

The possibility-adjustment and oblique clinical instruction elements of CMS’ proposal are of minimal period and would not affect Medicare Advantage expansion around time, Broussard mentioned. Humana has large enrollment, favorable excellent scores and favourable associations with insurance policies brokers, which will edge the firm over opponents whether CMS cuts prices or retreats from its proposal, he stated.

The wellbeing coverage trade association AHIP and UnitedHealth Team are considerably less sanguine about the proposed rate reductions and other modern plan announcements.

“We keep on being concentrated on strengthening and enhancing Medicare Benefit and urge the administration to pull again its flawed payment design revisions for 2024,” AHIP CEO Matt Eyles explained in a news release Tuesday. UnitedHealthcare also believes CMS ought to withdraw its level recognize, a spokesperson wrote in an e mail.

Broussard echoed claims from AHIP and other individuals that vulnerable Medicare beneficiaries, such as individuals also eligible for Medicaid, may perhaps endure from reduced benefits if premiums had been trimmed. Similarly, insurers and companies engaged in benefit-based payment preparations and those people working in battling marketplaces may well be harmed, he mentioned.

Humana recommitted to Medicare Gain as its core line of organization very last month when it introduced it would halt gross sales of professional insurance guidelines, which Broussard described as a “distraction” from its govt-sponsored business enterprise. The corporation mulled providing its commercial functions to a different insurer but opted to only shut it down, he reported. “We resolved we really wanted to exit it as a final result of not becoming competitive in the marketplace and also the possibility price it experienced for us as an business,” he stated.

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How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions

How Medicare Advantage Plans Dodged Auditors and Overcharged Taxpayers by Millions

In April 2016, government auditors requested a Blue Cross Medicare Gain wellness plan in Minnesota to switch around healthcare documents of individuals taken care of by a podiatry exercise whose owner had been indicted for fraud.

Medicare had compensated the Blue Cross approach much more than $20,000 to deal with the care of 11 sufferers noticed by Aggeus Health care, a chain of podiatry clinics, in 2011.

Blue Cross stated it could not find any records to justify the payments for the reason that Aggeus shut down in the wake of the indictment, which provided costs of falsifying client clinical documents. So Blue Cross asked the Facilities for Medicare & Medicaid Services for a “hardship” exemption to a rigid need that well being strategies keep these documents in the function of an audit.

CMS granted the request and auditors eradicated the 11 sufferers from a random sample of 201 Blue Cross prepare associates whose documents have been reviewed.

A evaluate of 90 authorities audits, introduced solely to KHN in response to a Freedom of Information Act lawsuit, reveals that wellness insurers that issue Medicare Advantage programs have consistently experimented with to sidestep regulations demanding them to document clinical problems the governing administration compensated them to treat.

The audits, the most modern types the company has completed, sought to validate payments to Medicare Edge health ideas for 2011 through 2013.

As KHN noted late last month, auditors uncovered millions of dollars in poor payments — citing overcharges of a lot more than $1,000 per client a calendar year on regular — by just about two dozen health designs.

The hardship requests, with each other with other documents received by KHN by way of the lawsuit, shed light-weight on the secretive audit approach that Medicare depends on to keep accountable the ever more well-liked Medicare Advantage wellbeing programs — which are an different to first Medicare and generally run by big insurance coverage providers.

Reacting to the audit results, Sen. Chuck Grassley (R-Iowa) known as for “aggressive oversight” to recoup overcharges.

“CMS will have to aggressively use just about every device at its disposal to make certain that it’s proficiently figuring out Medicare Edge fraud and doing the job with the Justice Division to prosecute and recuperate improper payments,” Grassley claimed in a composed assertion to KHN.

Medicare reimburses Medicare Edge plans employing a complicated system known as a risk score that computes increased prices for sicker individuals and reduced types for more healthy persons.

But federal officers almost never demand documentation to confirm that clients have these disorders, or that they are as major as claimed. Only about 5{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of Medicare Advantage ideas are audited yearly.

When auditors came contacting, the earlier hidden CMS records exhibit, they typically observed tiny or no aid for diagnoses submitted by the Edge plans, these types of as long-term obstructive pulmonary disease, diabetes, or vascular sickness. Even though auditors appear at the records of a rather tiny sample of patients, they can extrapolate the mistake charge to the broad populace of individuals in the Medicare Benefit health and fitness plan and estimate tens of millions of dollars in overpayments.

Overall, CMS auditors flagged diagnostic billing codes — which display what people have been dealt with for — as invalid a lot more than 8,600 occasions. The audits included data for 18,090 clients about the three-12 months time period.

In quite a few circumstances, auditors identified that the health-related qualifications of the well being care company who built the analysis ended up unclear, the documents delivered have been unacceptable, or the history lacked a signature as expected. Other data files bore the completely wrong patient’s name or had been missing altogether.

The costs of billing codes rejected by auditors diverse broadly across the 90 audits. The price of invalid codes topped 80{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} at Touchstone Health, a defunct New York HMO, in accordance to CMS information. The firm also was demonstrated to have the highest common annual overcharges — $5,888 for each individual billed to the governing administration.

By contrast, seven well being programs had fewer than 10{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of their codes flagged.

Registering Excuses

One Medicare Benefit overall health strategy submitted 57 hardship requests, much more than any other insurance provider, however CMS accepted only 6. In three conditions, the overall health strategies explained the documents had been destroyed in floods. One more cited a warehouse hearth, and two stated the records couldn’t be turned in excess of for the reason that a health care provider had been convicted for his job in illegally distributing tens of millions of oxycodone capsules by his network of discomfort clinics.

Other Medicare Edge health and fitness ideas argued they experienced no luck retrieving clinical information from medical practitioners who had moved, retired, died — and in some conditions been arrested or lost their licenses for misconduct.

CMS uncovered most excuses seeking, telling wellbeing strategies they granted exceptions only in “truly remarkable situations.” CMS stated it receives about 100 of these requests for each individual calendar year it audits and approves about 20{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of them.

The Medicare Benefit plan issued by Minnesota Blue Cross gained its attraction following it relied on Aggeus Health care for diagnoses of vascular condition for 11 of its patients who got podiatry treatment.

Dr. Yev Grey, a Chicago podiatrist who owned the Aggeus chain that operated in additional than a dozen states, was indicted on federal fraud costs in Missouri in Oct 2015.

The indictment accused him of building an electronic health-related file that fraudulently added billing codes for therapy of health-related ailments people did not necessarily have, together with vascular illness.

Grey pleaded responsible in Could 2017 to rates of conspiracy to defraud the United States and generating wrong statements related to overall health care matters. He was sentenced to 90 months in jail.

Blue Cross said it “terminated” its network agreements with Aggeus about two weeks right after studying of the indictment. Jim McManus, director of community relations for Blue Cross and Blue Protect of Minnesota, had no remark on the circumstance but reported the insurance company “is dedicated to investigating credible instances of fraud, squander, and abuse.”

Dara Corrigan, a CMS deputy administrator, reported that as a “general make any difference,” its Medicare Edge audits “are not created to detect fraud, nor are they supposed to identify all inappropriate analysis submissions.”

Preserving Taxpayers

The expenses to taxpayers from inappropriate payments have mushroomed around the earlier decade as extra seniors choose Medicare Advantage plans. CMS has estimated the whole overpayments to wellbeing designs for the 2011-2013 audits at $650 million, however how substantially it will eventually claw back again continues to be unclear.

Payment faults continue on to be a drain on the federal government program. CMS has estimated internet overpayments to Medicare Advantage programs induced by unconfirmed healthcare diagnoses at $11.4 billion for 2022.

“This is not a partisan issue,” said Sen. Sherrod Brown (D-Ohio). “I’ve requested a approach from CMS as to how they approach to recoup these taxpayer-funded overpayments and stop long term overbilling.”

Leslie Gordon, an performing director of wellness care for the Authorities Accountability Place of work, said CMS requires to pace up the audit and appeals course of action to get more rapidly results.

“That is income that must be recovered,” Gordon instructed KHN.

As Medicare Advantage faces mounting criticism from federal government watchdogs and in Congress, the business has tried to rally seniors to its aspect although disputing audit findings and research that asserts the application expenditures taxpayers a lot more than it should really.

AHIP, an insurance policies industry trade team, criticized KHN’s reporting on the newly launched audits as “misleading,” while the professional-field group Superior Medicare Alliance stated the audits were “in some conditions, more than a decade previous.”

Jeff De Los Reyes, a senior vice president at GHG Advisors wellness treatment consulting team, explained he thinks the health and fitness designs have enhanced their documentation in latest many years. But, he stated, “coding is in no way 100{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} best and there will be glitches irrespective of the most effective of intentions.”

Rep. Katie Porter, a Democrat from Southern California and a critic of Medicare Edge, countered: “When massive insurance policy expenditures taxpayers for treatment it by no means intends to provide, it is thieving our tax bucks.”

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Medicare Advantage plans overcharged Medicare by millions : Shots

Medicare Advantage plans overcharged Medicare by millions : Shots
A review of 90 government audits, released exclusively to KHN in response to a Freedom of Information Act lawsuit, reveals that some health insurers issuing Medicare Advantage plans have tried to sidestep regulations requiring them to document medical conditions the government paid them to treat.
A review of 90 government audits, released exclusively to KHN in response to a Freedom of Information Act lawsuit, reveals that some health insurers issuing Medicare Advantage plans have tried to sidestep regulations requiring them to document medical conditions the government paid them to treat.

In April 2016, government auditors asked a Blue Cross Medicare Advantage health plan in Minnesota to turn over medical records of patients treated by a podiatry practice whose owner had been indicted for fraud.

Medicare had paid the Blue Cross plan more than $20,000 to cover the care of 11 patients seen by Aggeus Healthcare, a chain of podiatry clinics, in 2011.

Blue Cross said it couldn’t locate any records to justify the payments because Aggeus shut down in the wake of the indictment, which included charges of falsifying patient medical files. So Blue Cross asked the Centers for Medicare & Medicaid Services for a “hardship” exemption to a strict requirement that health plans retain these files in the event of an audit.

CMS granted the request and auditors removed the 11 patients from a random sample of 201 Blue Cross plan members whose records were reviewed.

A review of 90 government audits, released exclusively to KHN in response to a Freedom of Information Act lawsuit, reveals that Blue Cross and a number of other health insurers issuing Medicare Advantage plans have tried to sidestep regulations requiring them to document medical conditions the government paid them to treat.

The audits, the most recent ones the agency has completed, sought to validate payments to Medicare Advantage health plans for 2011 through 2013.

Hidden audits reveal millions in overcharges by Medicare Advantage plans

As KHN reported late last month, auditors uncovered millions of dollars in improper payments — citing overcharges of more than $1,000 per patient a year on average — by nearly two dozen health plans.

The hardship requests, together with other documents obtained by KHN through the lawsuit, shed light on the secretive audit process that Medicare relies on to hold accountable the increasingly popular Medicare Advantage health plans — which are an alternative to original Medicare and primarily run by major insurance companies.

Reacting to the audit findings, Sen. Chuck Grassley, R-Iowa, called for “aggressive oversight” to recoup overcharges.

“CMS must aggressively use every tool at its disposal to ensure that it’s efficiently identifying Medicare Advantage fraud and working with the Justice Department to prosecute and recover improper payments,” Grassley said in a written statement to KHN.

Medicare reimburses Medicare Advantage plans using a complex formula called a risk score that computes higher rates for sicker patients and lower ones for healthier people.

But federal officials rarely demand documentation to verify that patients have these conditions, or that they are as serious as claimed. Only about 5{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of Medicare Advantage plans are audited yearly.

Medicare Advantage's cost to taxpayers has soared in recent years, research finds

When auditors came calling, the previously hidden CMS records show, they often found little or no support for diagnoses submitted by the Advantage plans, such as chronic obstructive pulmonary disease, diabetes or vascular disease. Though auditors look at the records of a relatively small sample of patients, they can extrapolate the error rate to the broad population of patients in the Medicare Advantage health plan and calculate millions of dollars in overpayments.

Overall, CMS auditors flagged diagnostic billing codes — which show what patients were treated for — as invalid more than 8,600 times. The audits covered records for 18,090 patients over the three-year period.

In many cases, auditors found that the medical credentials of the health care provider who made the diagnosis were unclear, the records provided were unacceptable, or the record lacked a signature as required. Other files bore the wrong patient’s name or were missing altogether.

The rates of billing codes rejected by auditors varied widely across the 90 audits. The rate of invalid codes topped 80{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} at Touchstone Health, a defunct New York HMO, according to CMS records. The company also was shown to have the highest average annual overcharges — $5,888 per patient billed to the government.

By contrast, seven health plans had fewer than 10{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of their codes flagged.

Health insurers had a wide range of excuses for why records couldn’t be turned over to auditors

One Medicare Advantage health plan submitted 57 hardship requests, more than any other insurer, though CMS approved only six. In three cases, the health plans said the records were destroyed in floods. Another cited a warehouse fire, and two said the records couldn’t be turned over because a doctor had been convicted for his role in illegally distributing millions of oxycodone pills through his network of pain clinics.

Other Medicare Advantage health plans argued they had no luck retrieving medical records from doctors who had moved, retired, died — and in some cases been arrested or lost their licenses for misconduct.

CMS found most excuses wanting, telling health plans they granted exceptions only in “truly extraordinary circumstances.” CMS said it receives about 100 of these requests for each year it audits and approves about 20{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of them.

Medicare Advantage Insurer Settles Whistleblower Suit For $32 Million

The Medicare Advantage plan issued by Minnesota Blue Cross won its appeal after it relied on Aggeus Healthcare for diagnoses of vascular disease for 11 of its patients who got podiatry care..

Dr. Yev Gray, a Chicago podiatrist who owned the Aggeus chain that operated in more than a dozen states, was indicted on federal fraud charges in Missouri in October 2015.

The indictment accused him of creating an electronic medical record that fraudulently added billing codes for treatment of medical conditions patients didn’t necessarily have, including vascular disease.

Gray pleaded guilty in May 2017 to charges of conspiracy to defraud the United States and making false statements related to health care matters. He was sentenced to 90 months in prison.

Blue Cross said it “terminated” its network agreements with Aggeus about two weeks after learning of the indictment. Jim McManus, director of public relations for Blue Cross and Blue Shield of Minnesota, had no comment on the case but said the insurer “is committed to investigating credible cases of fraud, waste, and abuse.”

Dara Corrigan, a CMS deputy administrator, said that as a “general matter,” its Medicare Advantage audits “are not designed to detect fraud, nor are they intended to identify all improper diagnosis submissions.”

Protecting taxpayers: ‘That is money that should be recovered’

The costs to taxpayers from improper payments have mushroomed over the past decade as more seniors pick Medicare Advantage plans. CMS has estimated the total overpayments to health plans for the 2011-2013 audits at $650 million, yet how much it will eventually claw back remains unclear.

Payment errors continue to be a drain on the government program. CMS has estimated net overpayments to Medicare Advantage plans triggered by unconfirmed medical diagnoses at $11.4 billion for 2022.

“This isn’t a partisan issue,” said Sen. Sherrod Brown D-Ohio. “I’ve requested a plan from CMS as to how they plan to recoup these taxpayer-funded overpayments and prevent future overbilling.”

Leslie Gordon, an acting director of health care for the Government Accountability Office, said CMS needs to speed up the audit and appeals process to get quicker results.

“That is money that should be recovered,” Gordon told KHN.

GAO Audit: Feds Failed To Rein In Medicare Advantage Overbilling

As Medicare Advantage faces mounting criticism from government watchdogs and in Congress, the industry has tried to rally seniors to its side while disputing audit findings and research that asserts the program costs taxpayers more than it should.

AHIP, an insurance industry trade group, criticized KHN’s reporting on the newly released audits as “misleading,” while the pro-industry group Better Medicare Alliance said the audits were “in some cases, more than a decade old.”

Jeff De Los Reyes, a senior vice president at GHG Advisors health care consulting group, said he believes the health plans have improved their documentation in recent years. But, he said, “coding is never 100{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} perfect and there will be errors despite the best of intentions.”

Rep. Katie Porter, a Democrat from Southern California and a critic of Medicare Advantage, countered: “When big insurance bills taxpayers for care it never intends to deliver, it is stealing our tax dollars.”

KHN (Kaiser Health News) is a national, editorially independent program of KFF (Kaiser Family Foundation).

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Medicare Advantage health plans overcharged taxpayers millions, dodged U.S. auditors

Medicare Advantage health plans overcharged taxpayers millions, dodged U.S. auditors

In April 2016, government auditors asked a Blue Cross Medicare Advantage health plan in Minnesota to turn over medical records of patients treated by a podiatry practice whose owner had been indicted for fraud.

Medicare had paid the Blue Cross plan more than $20,000 to cover the care of 11 patients seen in 2011 by Aggeus Healthcare, a chain of podiatry clinics that was owned by Dr. Yev Gray, a Chicago podiatrist.

Blue Cross said it couldn’t locate any records to justify the payments because Aggeus shut down in the wake of the indictment, which included charges of falsifying patient medical files. So Blue Cross asked the federal Centers for Medicare & Medicaid Services for a “hardship” exemption to a strict requirement that health plans retain these files in the event of an audit.

CMS granted the request, and auditors removed the 11 patients from a random sample of 201 Blue Cross plan members whose records were reviewed.

A review of 90 government audits, released exclusively to KHN in response to a Freedom of Information Act lawsuit, reveals that health insurers that offer Medicare Advantage health plans have repeatedly tried to sidestep regulations that require them to document medical conditions the government paid them to treat.

The audits, the most recent ones the agency has completed, sought to validate payments to Medicare Advantage plans for 2011 through 2013.

As KHN reported last month, auditors uncovered millions of dollars in improper payments — citing overcharges of, on average, more than $1,000 per patient a year — by nearly two dozen health plans.

The hardship requests, together with other documents obtained by KHN through the lawsuit, shed light on the secretive audit process that Medicare relies on to hold accountable the increasingly popular Medicare Advantage health plans — which are an alternative to original Medicare and primarily run by major insurance companies.

‘Aggressive oversight’ needed

Reacting to the audit findings, U.S. Sen. Chuck Grassley, R-Iowa, called for “aggressive oversight” to recoup overcharges.

“CMS must aggressively use every tool at its disposal to ensure that it’s efficiently identifying Medicare Advantage fraud and working with the Justice Department to prosecute and recover improper payments,” Grassley said in a written statement.

U.S. Sen. Chuck Grassley, R-Iowa, who says the federal government “must aggressively use every tool at its disposal to ensure that it’s efficiently identifying Medicare Advantage fraud and working with the Justice Department to prosecute and recover improper payments.”

U.S. Sen. Chuck Grassley, R-Iowa, says the federal government “must aggressively use every tool at its disposal to ensure that it’s efficiently identifying Medicare Advantage fraud and working with the Justice Department to prosecute and recover improper payments.”

Anna Moneymaker / Getty Images

Medicare reimburses Medicare Advantage plans using a complex formula called a risk score that computes higher rates for sicker patients and lower ones for healthier people.

But federal officials rarely demand documentation to verify that patients have these conditions — or that they are as serious as claimed. Only about 5{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of Medicare Advantage plans are audited yearly.

When government auditors came calling, the previously hidden CMS records show, they often found little or no support for diagnoses submitted by the Advantage plans, such as chronic obstructive pulmonary disease, diabetes and vascular disease. Though the auditors look at the records of a relatively small sampling of patients, they can extrapolate the error rate to the broad population of patients in the Medicare Advantage health plan and calculate millions of dollars in overpayments.

Overall, CMS auditors flagged diagnostic billing codes — which show what patients were treated for — as invalid more than 8,600 times. The audits covered records for 18,090 patients over the three-year period.

In many cases, auditors found that the medical credentials of the health care provider who made the diagnosis were unclear, the records provided were unacceptable or the record lacked a required signature. Other files bore the wrong patient’s name or were missing altogether.

The rates of billing codes rejected by auditors varied widely across the 90 audits. The rate of invalid codes topped 80{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} at Touchstone Health, a defunct New York HMO, according to the CMS records. The company also was shown to have the highest average annual overcharges — $5,888 per patient billed to the government.

By contrast, seven health plans had fewer than 10{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of their codes flagged.

Excuses, exceptions usually denied

One Medicare Advantage health plan submitted 57 hardship requests, more than any other insurer, though CMS approved only six. In three cases, the health plans said the records were destroyed in floods. Another cited a warehouse fire, and two said the records couldn’t be turned over because a doctor had been convicted for his role in illegally distributing millions of oxycodone pills through his network of pain clinics.

Other Medicare Advantage health plans argued they had no luck retrieving medical records from doctors who had moved, retired, died — and in some cases been arrested or lost their licenses for misconduct.

CMS — which is part of the federal Department of Health and Human Services — found most of the excuses wanting, telling health plans they granted exceptions only in “truly extraordinary circumstances.” It said it receives about 100 of these requests for each year it audits and approves about 20{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of them.

The Medicare Advantage plan issued by Minnesota Blue Cross won its appeal after it relied on Aggeus Healthcare for diagnoses of vascular disease for 11 of its patients who got podiatry care.

Gray, the Chicago podiatrist who owned the Aggeus chain that operated in more than a dozen states, was indicted on federal fraud charges in Missouri in October 2015.

The federal Department of Health and Human Services’ Office of Inspector General’s announcement on Facebook of Dr. Yev Gray’s sentencing.

The federal Department of Health and Human Services’ Office of Inspector General’s announcement on Facebook of Dr. Yev Gray’s sentencing.

According to the indictment, he created an electronic medical record that fraudulently added billing codes for treatment of medical conditions patients didn’t necessarily have, including vascular disease.

Gray pleaded guilty in May 2017 to charges of conspiracy to defraud the United States and making false statements related to health care matters. He was sentenced to 90 months in prison.

Blue Cross said it “terminated” its network agreements with Aggeus about two weeks after learning of the indictment. Jim McManus, director of public relations for Blue Cross and Blue Shield of Minnesota, wouldn’t comment on the case. He said the insurer “is committed to investigating credible cases of fraud, waste and abuse.”

Dara Corrigan, a CMS deputy administrator, said, as a “general matter,” its Medicare Advantage audits “are not designed to detect fraud, nor are they intended to identify all improper diagnosis submissions.”

Dara Corrigan, deputy administrator and director, Center for Program Integrity, U.S. Centers for Medicare and Medicaid Services.

Dara Corrigan, deputy administrator and director, Center for Program Integrity, U.S. Centers for Medicare and Medicaid Services.

Hundreds of millions in overpayments

The costs to taxpayers from improper payments have mushroomed over the past decade as more seniors pick Medicare Advantage plans. CMS has estimated the total overpayments to health plans for the 2011-2013 audits at $650 million. But how much it will eventually be able to get back remains uncertain.

Payment errors continue to be a drain on the government program. CMS has estimated net overpayments to Medicare Advantage plans triggered by unconfirmed medical diagnoses at $11.4 billion for 2022.

U.S. Sen. Sherrod Brown, D-Ohio.

U.S. Sen. Sherrod Brown, D-Ohio (left), wants to know how the Medicare program’s administrators “plan to recoup these taxpayer-funded overpayments and prevent future overbilling.”

Drew Angerer / Getty Images

Leslie Gordon, an acting director of health care for the federal Government Accountability Office, said CMS needs to speed its audit and appeals process to get quicker results.

“That is money that should be recovered,” Gordon said.

Leslie Gordon, acting director of health care for the federal Government Accountability Office, wants Medicare administrators to move more quickly on Medicare Advantage plan audits to get back overpayments: “That is money that should be recovered.”

Leslie Gordon, acting director of health care for the federal Government Accountability Office, wants Medicare administrators to move more quickly on Medicare Advantage plan audits to get back overpayments: “That is money that should be recovered.”

As Medicare Advantage plans face growing criticism from government watchdogs and in Congress, the industry has tried to rally seniors to its side while disputing audit findings and research that asserts the program costs taxpayers more than it should.

The insurance industry trade group AHIP criticized KHN’s reporting on the newly released audits as “misleading,” and the pro-industry group Better Medicare Alliance said the audits were “in some cases, more than a decade old.”

Jeff De Los Reyes, a senior vice president for the GHG Advisors health care consulting group, said he thinks the health plans have improved their documentation in recent years. But, he said, “coding is never 100{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} perfect, and there will be errors despite the best of intentions.”

U.S. Rep. Katie Porter, D-California: But U.S. Rep. Katie Porter, D-California.

U.S. Rep. Katie Porter, D-California: But U.S. Rep. Katie Porter, D-California: “When big insurance bills taxpayers for care it never intends to deliver, it is stealing our tax dollars.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues.

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Medicare Advantage boosterism & a health insurance firewall

Medicare Advantage boosterism & a health insurance firewall

You are looking at the website version of Overall health Treatment Inc., STAT’s weekly publication next the flow of funds via the health and fitness care program. Sign up here to get it in your inbox.

The most up-to-date in the Medicare Gain Discourse™

We are at the point in the Medicare Gain Discourse in which overall health insurers have certain them selves, and are continuing to check out to encourage the general public, that MA saves taxpayers oodles of revenue. The verdict from professionals on this extremely in-the-weeds challenge: Do not obtain it.

The most current show arrives from America’s Health Coverage Strategies, which introduced a report past 7 days that was done by actuaries at Wakely Consulting Team. AHIP claims the report proves Medicare Gain — the controversial substitute to authentic Medicare that has turn into a funds cow for insurers — is “saving People in america billions of pounds just about every 12 months.” The actuaries, having said that, by no means use that language in the report.

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STAT spoke with various impartial Medicare coverage specialists, all of whom claimed AHIP’s report was incomplete at greatest and refuted by other experiments that analyzed the same data. Analysts also stressed the federal govt unquestionably is not reaping any financial savings from Medicare Edge.

Study the tale to listen to the specifics and rebuttals about the report’s two central products: MA’s out-of-pocket cap, and evaluating the expending of MA enrollees only with standard Medicare enrollees who are suitable for Medicare Benefit.

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Everything’s much more litigious in Texas

All roads, evidently, lead again to Texas in the never ever-ending litigation against the federal surprise billing law.

The Texas Healthcare Affiliation has submitted a model new lawsuit in a district court in jap Texas, arguing the Biden administration’s last shock billing rule from August nonetheless places a “thumb on the scale” for well being insurers. Three dominant company lobbying teams — the American Healthcare facility Affiliation, American Professional medical Association, and Affiliation of Air Healthcare Solutions — also instructed a judge previous week they were being dismissing their claims against the No Surprises Act in their D.C. district court docket and as an alternative have been heading to cheer on their Texan comrades’ new lawsuit.

To recap: These company teams even now detest the component of the legislation that settles out-of-community disputes involving companies and insurers, even although the last rule built it a very little a lot easier for them to perhaps get higher payments from arbiters. Now, they are placing all their eggs into the basket of Decide Jeremy Kernodle, a Trump appointee who was officially assigned the case on Friday.

Why go operating to Kernodle? Nicely, it absolutely sure seems to be like helpful territory: He has already dominated favorably for both of those the Texas Health care Association and LifeNet, an air ambulance business. Kernodle also made use of to work at a legislation firm, Haynes and Boone, that not only signifies vendors but also represented a shadowy team termed Action for Wellbeing that filed a temporary in support of the Texas Health care Association’s original surprise billing lawsuit. The AHA and AMA did not react to queries about Kernodle.

[Pitbull voice] 🎵There’s a firewall 🎵

A federal decide previous week cleared the way for UnitedHealth Team to get Alter Healthcare, developing a dominant entity that audits and adjudicates health and fitness insurance plan promises. My colleague Tara Bannow study via the redacted impression and was most intrigued in why the choose decided to enable the deal move forward.

The decide was fully swayed by testimony from UnitedHealth executives who stated there is a demanding firewall between the conglomerate’s health coverage company (UnitedHealthcare) and its statements processing business enterprise (Optum), Tara writes. Optum homes sensitive info on 220 other competing insurers — really considerably each and every important insurance company in the region — and federal antitrust lawyers argued UnitedHealth could quickly use that knowledge versus its competitors to poach employer insurance coverage clients.

But UnitedHealth CEO Andrew Witty said at the demo that breaching that firewell, and the belief of insurers, would be “hugely destructive” to the company’s name and economical interests. The decide went along with these vibes, indicating the federal government “failed to present that United’s put up-merger incentives will lead it to choose these serious steps.” It is almost certainly well worth checking no matter whether UnitedHealth starts off capturing additional employer wellbeing prepare company from opponents.

A single other notice: UnitedHealth is advertising a main component of Adjust, a subsidiary termed ClaimsXten that immediately processes insurance plan claims, to personal fairness agency TPG. That sale “will preserve competition in the market” instead of giving UnitedHealth 90{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} market share, the opinion reads. But that sale could possibly not have occurred until the federal government intervened, mainly because UnitedHealth did not genuinely glimpse to sell ClaimsXten right until January 2022.

So a great deal for that broker brawl

In August, we explained to you about a lawsuit unfolding in between two significant insurance coverage consulting houses, Gallagher and Alliant, in which allegations of staff poaching and spying had been bandied about. Well, it turns out neither side needs to air its dirty laundry.

Gallagher and Alliant attained a tentative and unspecified settlement previously this month, according to a new court docket filing. They are halting all discovery of paperwork and are asking the court docket for a month to finalize the settlement. We, of system, would enjoy to see those paperwork, and I’m certain companies would, also.

Marketplace odds and ends

  • ICYMI: Imagine Health care, just one of the poster children for shock billing, now has bottom-tier, junk-degree personal debt. Moody’s Investors Support thinks the medical professional staffing organization likely will go bankrupt and run out of funds by the end of 2023.
  • Optum is generating it more tough and high-priced for tutorial researchers to use its big vault of health and fitness information, my colleague Casey Ross reviews. Have you encountered troubles with Optum’s info licensing agreements? Enable us know.
  • Humana and CVS Health are eyeing an acquisition of Cano Overall health, the chain of main care clinics that cares for more mature adults, the Wall Road Journal experiences. We pointed out very last 7 days that Humana continues to have a right of initial refusal to buy Cano.
  • CommonSpirit Health’s fiscal 2022 fiscal statements came out Friday: -3.8{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} working margin, -5.4{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} internet margin.
  • The “high income margins, predictable profits, and the eventual fatalities of tens of hundreds of thousands of baby boomers” are attracting personal equity corporations to funeral households, Markian Hawryluk of Kaiser Overall health News reports.
  • Health insurers that run point out Medicaid packages are meant to convey to point out officers how considerably funds they are expending on treatment for Medicaid enrollees, but pretty much 50 percent of all studies reviewed by HHS’ Business of Inspector Standard have been missing “essential” details which is employed to compute all those figures correctly.
  • Getting rid of a little one is an unimaginably heartbreaking and tragic scenario that lots of mothers and fathers have experienced to endure. The health care program, in an specifically cruel way, can make individuals intervals infinitely more hurtful when healthcare charges commence flowing in — forcing parents to relive their grief by way of unlimited cellular phone phone calls with suppliers and insurers. Read through this total tale, detailing parents’ tales, from Lauren Weber of Kaiser Wellbeing News.

The Meme Ward

 

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Medicare Advantage in 2022: Enrollment Update and Key Trends

Medicare Advantage in 2022: Enrollment Update and Key Trends

Since 2006, the role of Medicare Advantage, the private plan alternative to traditional Medicare, has steadily grown. In 2022, more than 28 million people are enrolled in a Medicare Advantage plan, accounting for nearly half or 48 percent of the eligible Medicare population, and $427 billion (or 55{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) of total federal Medicare spending (net of premiums). The average Medicare beneficiary in 2022 has access to 39 Medicare Advantage plans, the largest number of options available in more than a decade.

To better understand trends in the growth of the program, this brief provides current information about Medicare Advantage enrollment, including the types of plans in which Medicare beneficiaries are enrolled, and how enrollment varies across geographic areas. A second, companion analysis describes Medicare Advantage premiums, out-of-pocket limits, cost sharing, extra benefits offered, prior authorization requirements, and star ratings in 2022.

The share of eligible Medicare beneficiaries enrolled in Medicare Advantage has more than doubled since 2007

In 2022, nearly half of (48{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) eligible Medicare beneficiaries – 28.4 million people out of 58.6 million Medicare beneficiaries overall – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has more than doubled from 2007 to 2022 (19{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} to 48{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}). KFF now calculates the share of eligible Medicare beneficiaries enrolled in Medicare Advantage, meaning they must have both Part A and B coverage. This affects both 2022 data as well as trends over time. The share would be somewhat smaller if based on the total Medicare population that includes 5.7 million beneficiaries with Part A only or Part B only who are not generally eligible to enroll in a Medicare Advantage plan. See methods for more details.

Between 2021 and 2022, total Medicare Advantage enrollment grew by about 2.2 million beneficiaries, or 8 percent – a slightly slower growth rate than the prior year (10{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}). The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to 61 percent by 2032 (Figure 2).

In 2022, two-thirds of Medicare Advantage enrollees are in individual plans that are open for general enrollment

Two-thirds (66{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) of Medicare Advantage enrollees, or 18.7 million people, are in plans generally available to all beneficiaries for individual enrollment. That is an increase of 1.3 million enrollees compared to 2021. Individual plans have accounted for approximately the same share of total Medicare Advantage enrollment since 2018.

Nearly one in five Medicare Advantage enrollees (18{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) are in group plans offered to retirees by employers and unions in 2022

Nearly 5.1 million Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union. While this is roughly the same share of enrollment since 2010 (18{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), the actual number has increased from 1.8 million in 2010 to 5.1 million in 2022 (Figure 4). With a group plan, an employer or union contracts with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. For example, some states, such as Illinois and Pennsylvania, provide health insurance benefits to their Medicare-eligible retirees exclusively through Medicare Advantage plans. As with other Medicare Advantage plans, employer and union group plans often provide additional benefits and/or lower cost sharing than traditional Medicare and are eligible for bonus payments. The employer or union (and sometimes the retiree) may also pay an additional premium for these supplemental benefits. Group enrollees comprise a disproportionately large share of Medicare Advantage enrollees in six states: Alaska (99{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), Michigan (42{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), Maryland (36{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), West Virginia (35{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), New Jersey (35{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), and Illinois (30{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}).

More than 4.6 million Medicare beneficiaries are enrolled in Special Needs Plans in 2022

More than 4.6 million Medicare beneficiaries are enrolled in Special Needs Plans (SNPs). SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. The majority of SNP enrollees (89{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) are in plans for beneficiaries dually enrolled in both Medicare and Medicaid (D-SNPs). Another 9 percent of SNP enrollees are in plans for people with severe chronic or disabling conditions (C-SNPs) and 2 percent are in plans for beneficiaries requiring a nursing home or institutional level of care (I-SNPs).

While D-SNPs are designed specifically for dually-eligible beneficiaries, 1.9 million Medicare beneficiaries with Medicaid were enrolled in non-SNP Medicare Advantage plans in 2020 (the most recent year for which this data is available).

Enrollment in SNPs increased from 3.8 million beneficiaries in 2021 to 4.6 million beneficiaries in 2022 (20{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} increase), and accounts for about 16{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of total Medicare Advantage enrollment in 2022, up from 11{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in 2011, with some variation across states. In the District of Columbia and Puerto Rico, SNPs comprise about half of all Medicare Advantage enrollees (47{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in DC and 48{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in PR). In 11 states, SNP enrollment accounts for about one-fifth of Medicare Advantage enrollment (29{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in MS, 27{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in NY and in LA, 24{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in AR and in FL, 23{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in GA, 22{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in SC, 21{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in CT, and 20{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in TN, in AZ, and in HI). More than 95{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of C-SNP enrollees (about 380,000 people) are in plans for people with diabetes or cardiovascular conditions in 2022. Enrollment in I-SNPs has been increasing slightly, but is still fewer than 100,000.

The share of Medicare beneficiaries in Medicare Advantage plans, by state, ranges from 1{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} to 59{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}

The share of Medicare beneficiaries in Medicare Advantage plans varies across the country, but in 25 states, at least half of all Medicare beneficiaries are enrolled in Medicare Advantage plans. In contrast, Medicare Advantage enrollment is relatively low (less than 20 percent) in four mostly rural states (SD, ND, WY, and AK). Overall, Puerto Rico has the highest Medicare Advantage penetration, with 93 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan. This may be due in part to the high share of beneficiaries in Puerto Rico with low incomes who are dually enrolled in Medicare and Medicaid, as noted above.

The share of Medicare beneficiaries in Medicare Advantage plans varies widely across counties

The share of Medicare beneficiaries enrolled in Medicare Advantage varies widely across counties. For example, in Florida, 56{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of all Medicare beneficiaries in the state are enrolled in Medicare Advantage, ranging from 19{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in Monroe County (Key West) to 78{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in Miami-Dade County. In Ohio, 52{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of all Medicare beneficiaries are enrolled in Medicare Advantage, with the share ranging from 30{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in Mercer County (Celina) to 64{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} in Stark County (Canton).

In 2022, one in five (21{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (321 counties). That is substantially more than in 2010 when just 3 percent of the Medicare population lived in a county where 60 percent or more of Medicare beneficiaries were enrolled in a Medicare Advantage plan (83 counties). Many counties with high Medicare Advantage penetration are centered around relatively large, urban areas, such as Monroe County, NY (78{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), which includes Rochester, and Allegheny County, PA (72{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), which includes Pittsburgh. However, some urban areas, such as Baltimore City, MD (33{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), Charleston, SC (33{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), and Cook County, IL (Chicago, 39{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) have lower Medicare Advantage enrollment.

UnitedHealthcare and Humana account for nearly half of all Medicare Advantage enrollees nationwide in 2022

Medicare Advantage enrollment is highly concentrated among a small number of firms. UnitedHealthcare and Humana together account for 46 percent of all Medicare Advantage enrollees nationwide. In nearly a third of counties (29{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}; or 945 counties), these two firms account for at least 75{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of Medicare Advantage enrollment. (BCBS affiliates (including Anthem BCBS plans) account for 14 percent of enrollment, and four firms (CVS Health, Kaiser Permanente, Centene, and Cigna) account for another 24 percent of enrollment in 2022.

UnitedHealthcare and Humana have consistently accounted for a relatively large share of Medicare Advantage enrollment

UnitedHealthcare has had the largest share of Medicare Advantage enrollment and largest growth in enrollment since 2010, increasing from 20 percent of all Medicare Advantage enrollment in 2010 to 28 percent in 2022. Humana has also had a high share of Medicare Advantage enrollment, though its share of enrollment has grown more slowly, from 16 percent in 2010 to 18 percent in 2022. BCBS plans share of enrollment has been more constant over time, but has declined moderately since 2014. CVS Health, which purchased Aetna in 2018, has seen its share of enrollment nearly double from 6 percent in 2010 to 11 percent in 2022. Kaiser Permanente now accounts for 6{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of total enrollment, a moderate decline as a share of total since 2010 (9{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}), mainly due to the growth of enrollment in plans offered by other insurers and only a modest increase in enrollment growth for Kaiser Permanente over that time. However, for those insurers that have seen declines in their overall share of enrollment, the actual number of enrollees for each insurer is larger than it was in 2010.

For the sixth year in a row, enrollment in UnitedHealthcare’s plans grew more than any other firm, increasing by more than 749,000 beneficiaries between March 2021 and March 2022. Centene had the second largest growth in plan year enrollment, which was a little less than half of UnitedHealthcare’s with an increase of about 306,000 beneficiaries between March 2021 and March 2022. BCBS plans had the third highest growth in plan year enrollment of 293,000 beneficiaries between March 2021 and March 2022. CVS Health had the fourth largest growth in plan enrollment with an increase of about 282,000, followed by Humana, increasing by about 250,000 beneficiaries between March 2021 and March 2022. However, Cigna actually lost enrollees, declining by about 12,000 between March 2021 and March 2022.

Discussion

Medicare Advantage enrollment has increased steadily since 2006, with nearly half (48{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f}) of all eligible Medicare beneficiaries enrolled in Medicare Advantage plans in 2022. The share of Medicare Advantage enrollees varies across the country: in 25 states and Puerto Rico, at least 50 percent of Medicare beneficiaries are enrolled in Medicare Advantage plans in 2022. In a growing number of counties, 60 percent or more of all Medicare beneficiaries are in a Medicare Advantage plan, in lieu of traditional Medicare. Enrollment continues to be highly concentrated among a handful of firms, both nationally and in local markets, with UnitedHealthcare and Humana together accounting for 46 percent of enrollment in 2022.

As Medicare Advantage takes on an even larger presence in the Medicare program, and with current payments to plans higher for Medicare Advantage than for traditional Medicare for similar beneficiaries, it will be increasingly important to assess how well Medicare’s current payment methodology for Medicare Advantage is working to enhance efficiency and hold down beneficiary costs and Medicare spending. It will also be important to monitor how well beneficiaries are being served in both Medicare Advantage and traditional Medicare, in terms of costs, benefits, quality of care, patient outcomes, and access to providers, with particular attention to those with the greatest needs.

Meredith Freed, Jeannie Fuglesten Biniek, Tricia Neuman are with KFF.

Anthony Damico is an independent consultant.

This analysis uses data from the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Enrollment, Benefit and Landscape files for the respective year. KFF uses the Medicare Enrollment Dashboard for enrollment data, from March of each year.

In previous years, KFF had calculated the share of Medicare beneficiaries enrolled in Medicare Advantage by including Medicare beneficiaries with either Part A and/or B coverage. We have modified our approach this year to estimate the share enrolled among beneficiaries eligible for Medicare Advantage who have both Medicare Part A and Medicare B. In the past, the number of beneficiaries enrolled in Medicare Advantage was smaller and therefore the difference between the share enrolled with Part A and/or B vs Part A and B was also smaller. For example, in 2010, 24{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of all Medicare enrollees were in enrolled in Medicare Advantage versus 25{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} with just Parts A and B. However, these shares have diverged over time: in 2022, 44{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} of all Medicare enrollees were in enrolled in Medicare Advantage versus 48{08cd930984ace14b54ef017cfb82c397b10f0f7d5e03e6413ad93bb8e636217f} with just Parts A and B. These changes are reflected in both the 2022 data and in data displayed trending back to 2010.

Additionally, in previous years, KFF had used the term Medicare Advantage to refer to Medicare Advantage plans as well as other types of private plans, including cost plans, PACE plans, and HCPPs. However, cost plans, PACE plans, HCPPs are now excluded from this analysis in addition to MMPs. In this analysis, KFF excludes these other plans as some may have different enrollment requirements than Medicare Advantage plans (e.g., may be available to beneficiaries with only Part B coverage) and in some cases, may be paid differently than Medicare Advantage plans. These exclusions are reflected in both the 2022 data and in data displayed trending back to 2010.

Enrollment counts in publications by firms operating in the Medicare Advantage market, such as company financial statements, might differ from KFF estimates due to inclusion or exclusion of certain plan types, such as SNPs or employer group health plans.