Dennis Scanlon, PhD, professor of health policy and administration at the Pennsylvania State University, discusses how expanded benefits in a Medicare Advantage plan can sometimes come with more limited provider networks, and how the Office of the Inspector General is identifying problems in these plans.
As MA programs grow, beneficiaries should be aware that some MA plans include expanded benefits but with sometimes limited provider networks, says Dennis Scanlon, PhD, professor of health policy and administration, Pennsylvania State University.
In April 2022, the Office of the Inspector General released a report that some MA plans deny necessary care that should be covered. With more seniors picking MA plans, what might be done to address concerns over denials of services and payment?
Denial of services is always a hot button issue in any insurance plan. Whether it comes under the form of utilization management, or care management review, or pharmacy and therapeutics committees making decisions, ultimately, I think any high-quality insurance plan is going to cover the services that beneficiaries need and cover services that are part of a covered benefit under a contract.
The OIG’s [Office of the Inspector General] report that says that in some circumstances there are Medicare Advantage plans that are either not covering services or delaying coverage of services, which puts Medicare beneficiaries in a bad spot—that they have to worry that they may have delays in care, whatever the case may be—is clearly a concern.
I guess what I would say is this: Under any program, the quality of the insurance product from the perspective of the enrollee—or even if you are a self-insured employer choosing which plans or which third-party administrator to provide to your employees—is going to be a function of how well they administer the benefits.
You don't want complaints. You don't want delays in care, access to care. I think the fact that we do have the Office of the Inspector General looking at these things and identifying problems is important. Presumably those organizations that may choose to push the envelope, like either delay coverage or not cover things that should be, will not only be subject to penalties around their participation in the Medicare Advantage program, but also word will get out on the street that you may not want to enroll in this plan because you may face this as a consumer.
I think, to some degree, it's great the OIG is looking at this. I think, to some degree, the market itself should be able to discipline this kind of behavior. But I'll also put it in the context of what Medicare Advantage plans are relative to the traditional fee-for-service plans: When a beneficiary decides to enroll on a Medicare Advantage plan, it's choosing not only covered benefits, and in some cases, greater covered benefits—because there are expanded benefits, with many Medicare Advantage plans: vision, dental, fitness memberships, things of that nature—but they're doing that in conjunction with potentially more limited provider networks. Not always, but in some cases, particularly in HMO [health maintenance organizations]-type Medicare Advantage plans, but also how they administer the insurance benefit, the customer service, and those types of things.
All of this matters to beneficiaries, and as we see more and more growth, the question will become, how much of this occurs? How much do these plans differentiate themselves on any of these dimensions? And how does the word get out on the street, both in terms of positioning in the market, but also from a regulatory discipline perspective?