[Senate Hearing 118-259]
[From the U.S. Government Publishing Office]
S. Hrg. 118-259
MEDICARE AND MEDICARE ADVANTAGE:
CHALLENGES AND OPPORTUNITIES
WITH ENROLLMENT
=======================================================================
HEARING
BEFORE THE
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
OMAHA, NEBRASKA
__________
FEBRUARY 23, 2024
__________
Serial No. 118-15
Printed for the use of the Special Committee on Aging
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
_______
U.S. GOVERNMENT PUBLISHING OFFICE
55-341 PDF WASHINGTON : 2024
SPECIAL COMMITTEE ON AGING
ROBERT P. CASEY, JR., Pennsylvania, Chairman
KIRSTEN E. GILLIBRAND, New York MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts MARCO RUBIO, Florida
MARK KELLY, Arizona RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania PETE RICKETTS, Nebraska
----------
Elizabeth Letter, Majority Staff Director
Matthew Sommer, Minority Staff Director
C O N T E N T S
----------
Page
Opening Statement of Senator Pete Ricketts....................... 1
PANEL OF WITNESSES
David Lange, Medicare Applicant, Plattsmouth, NE................. 2
Jina Ragland, Associate State Director of Advocacy and Outreach,
AARP Nebraska, Lincoln, NE..................................... 4
Kierstin Reed, Chief Executive Officer, LeadingAge Nebraska,
Lincoln, NE.................................................... 6
John Trapp, M.D., System Vice President of Medical Affairs and
Chief Medical Officer at Bryan Health, Lincoln, NE............. 8
Jana Danielson, Vice President, Revenue Cycle at Nebraska
Medicine, Omaha, NE............................................ 11
APPENDIX
Prepared Witness Statements
David Lange, Medicare Applicant, Plattsmouth, NE................. 33
Jina Ragland, Associate State Director of Advocacy and Outreach,
AARP Nebraska, Lincoln, NE..................................... 35
Kierstin Reed, Chief Executive Officer, LeadingAge Nebraska,
Lincoln, NE.................................................... 39
John Trapp, M.D., System Vice President of Medical Affairs and
Chief Medical Officer at Bryan Health, Lincoln, NE............. 41
Jana Danielson, Vice President, Revenue Cycle at Nebraska
Medicine, Omaha, NE............................................ 44
MEDICARE AND MEDICARE ADVANTAGE:
CHALLENGES AND OPPORTUNITIES
WITH ENROLLMENT
----------
Friday, February 23, 2024
U.S. Senate
Special Committee on Aging
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m. CT, at
the Douglas County Health Center, Omaha, Nebraska, Hon. Pete
Ricketts, presiding.
Present: Senator Ricketts
OPENING STATEMENT OF SENATOR PETE RICKETTS
Senator Ricketts. This hearing is called to order. Isn't
that cool? I actually get a gavel. This is pretty cool.
This is the first time I have been in charge of a hearing,
so I am very excited to have all of our guests here today and I
welcome everybody as a part of this. Thank you very much for
taking time out of your schedules to be here. Again, this is
the first time I have done this. Please give me a little grace
in case we make mistakes or something happens here.
I really appreciate everybody coming here to discuss
Medicare Advantage enrollment program and application process
and how confusing and cumbersome it can be for older Americans
and their loved ones. I want to start by thanking my lovely
wife, Susanne. Susanne, where are you? Back there, thank you,
Susanne. One of the inspirations for this hearing was the
difficulty we had with Susanne's parents as we were going
through this transition of Medicare and Medicare Advantage and
so forth, and it raised a lot of questions.
One of the things, then, really what I hope for this
hearing is that we are going to be able to maybe clear up some
of the questions or maybe surface some issues, educate people
about what they should be thinking about with regard to
Medicare and Medicare Advantage. We have got a great group here
of people to be able to help us.
I would also like to recognize LeadingAge Nebraska and the
Douglas County Health Center for graciously hosting this event
today.
As the population in the United States ages it is vital
that we take a closer look at the institutions and programs
that we trust to take care of our older folks. In addition, we
must ensure programs like Medicare have accurate and easily
understandable information that is accessible to those who rely
upon it.
From 2008 to 2018, the population over 65 years of age grew
from 39 million to 52 million. By 2060, that population will be
95 million people. According to the last census, 16.4 percent
of Nebraska's population was over the age of 65. Every family
has a loved one, a mother, a father, a grandparent, who is
enrolled in Medicare or Medicare Advantage. One day, if we are
all fortunate enough, we will also have to make these decisions
for ourselves. That makes today's hearing topic an enormous
concern for every American.
Our job is to protect America's most vulnerable citizens
and ensure that they are equipped with the tools to make the
best decisions for their own care.
I am going to start today by introducing each of our
witnesses, so I will start over here on my right. Mr. Lange is
from Omaha, Nebraska, and is a recently retired maintenance
supervisor with Omaha Steaks. Mr. Lange turned 65 this month--
so you have been going through this very recently, and is here
to share his personal experience with the Medicare application
process.
Next we have Jana Danielson. Ms. Danielson serves as the
Vice President of Revenue Cycle for Nebraska Medicine. Oh, I am
sorry. That is over here. Sorry, Jana. Sorry. That is Jina over
there. Like what is going on over there? All right, sorry. They
didn't put these in order. You guys all sat--okay, so here is
an example, first time the host of this stuff. Rookie mistake.
All right. Well, next on my list actually, we are going to
go this way as well, Jina Ragland. Ms. Ragland is the Associate
State Director of Advocacy and Outreach of AARP Nebraska. Thank
you, Jina, for joining us.
Kierstin Reed. Ms. Reed is the Chief Executive Officer of
LeadingAge Nebraska, so thank you very much, Kierstin, for
being here.
All right. Now we are going to go over here. We already
covered Jana, so sorry, Jana, for getting out of order there.
Then, finally, Dr. John Trapp. Dr. Trapp is the System Vice
President of Medical Affairs and Chief Medical Officer at Bryan
Health. Thank you very much for joining us.
In a moment we will be hearing from all of them, so I think
we are going to start with the witness testimony now. We will
just kind of go in the order and swing this way and do the
witness testimony. David, we will go ahead and start with you,
and then we will go to Jina and kind of work our way around, so
let's start with you.
STATEMENT OF DAVID LANGE, MEDICARE APPLICANT, PLATTSMOUTH, NE
Mr. Lange. Thank you. Good morning. I appreciate the
opportunity to be here. It is also my first time for anything
like this so don't feel alone.
Dave Lange, 65 years old. I just had my birthday. I just
turned 65 on the 16th of February. When I was 18 years old, I
went into the United States Navy after finishing high school
with a GED. I tested high on a mechanical scale, so they turned
me into a boiler technician, a rate that no longer exists as
far as I know. A little while after my tour of duty I wound up
applying to the Maintenance Department at the Swanson Building
in downtown Omaha, owned by Campbell Soup. I was there 20
years. I met and married my wife of 25 years while working
there. We lived in Plattsmouth and raised my daughter, her two
sons, and her other daughter. Instant full household.
The kids are grown and moved away now. Both my wife Joyce
and I have continued to work in various food production
facilities throughout the metro area, companies such as
Conagra, Tyson, Armor Swift. She is presently still the QA
manager at Mammas' Tortillas in downtown Omaha. I just left
Omaha Steaks. Unfortunately, I wasn't a supervisor there, but
thank you. I have had that experience, but I was just turning a
wrench there. There were two things I wanted for my birthday.
One of my birthday presents was retirement at 65.
Sometime in late 2023, I received information in the mail
that indicated enrollment in Medicare was required prior to my
65th birthday. I was also getting bombarded with phone calls,
messages, emails, about Medicare plans, and what I needed to do
about it all. After doing some research, asking a lot of
questions from current retirees, recent retirees, et cetera, I
was even more confused than when I started. Some of their
information going back to older retirees had changed, so I
expected some of that. I came to realize many of these were and
are, in my opinion, ``sales'' opportunists. I contacted some of
them only to find out whatever they offered, whether it be a
``plan'' or ``service,'' it would come at a cost. Maybe I
didn't make the right phone calls to the right people, but like
I said, I tried to figure it out.
With good faith in mind, I set out to visit the website and
see how far I could get. I have been fortunate in my life where
I have had to learn and develop good computer skills in order
to hold the management positions I have had. No prodigy but can
hold my own. Unfortunately, me and passwords don't get along,
so we went round and round a little bit.
Eventually this became a little more user friendly. I
reviewed the ``items/info required'' list. Sorry, but this was
pretty helpful. I don't mean sorry. It was very helpful, by the
way. I gathered up everything and started the application. Once
started it was very quick and went pretty smooth. It took
probably 20 minutes because we were reading carefully. I am
pretty sure I saw a box on the app that asked if I was
presently covered by a health plan. I answered yes.
At the end of January 2024, I received a bill for $524.10
for Part B coverage for the time of 02/01/2024 to 04/30/2024. I
received this prior to the first of February, so I hadn't even
started it yet. This was a shocker. I reached out and was able
to locate a reputable Medicare counselor. She was able to coach
me and well as assist with the correct form to ``un-enroll''
from Part B. I am covered under my wife's employer-provided
group health insurance plan, hopefully for the next five years.
I have got a little parachute there. That is what I had to do
in order to get out from underneath that bill, not that that
was my only driving. I just didn't need it right now. I was a
little confused with why I was being told I had to do that
prior to 65.
I think I got an explanation, but it was very confusing.
The counselor tried to help me think my way through it, but
once the problem was resolved we just moved on.
I have since gone back onto the website to check my status
and have seen the correction has been made. In early February,
I applied for Social Security benefits.
I am sorry. That was my Medicare application experience.
I have since gone back onto the website to check, and that
has been corrected. In early February, I applied for Social
Security benefits. This process was similar to signing up for
Medicare, minus the previously endured ``log in/password''
issues. I am still awaiting news of acceptance. Overall, I
would say the system works, needs a little getting used to, but
hopefully will be fine. Oh, what was the second thing I wanted
for my birthday? An ice-cold margarita.
Through it all, it was daunting, it is a big decision to
make, and the more I dug the more it enveloped. It kind of
mushroomed on me, and sorry, it kind of irritated me a little
bit because I couldn't really nail down what I was looking for,
and then when I thought I did, there would be a dollar sign at
the end of the road. The Part B, the supplementals, the extras
that you can buy when you retire strike me as a threat to what
I am getting out of the basics. Already we are deducting from
the basic that I will desperately need. I suspect someday she
is going to retire, in five years hopefully. I am a little
older than her. We don't have nest eggs, but I am hoping for
the best. It is a big decision.
The website is a little bit better than I initially thought
it was going to be, so good job on that one.
Senator Ricketts. Good. Thanks, David. We will do some more
questions in a little bit, too. We will let everybody kind of
get a chance to do their testimony.
Mr. Lange. Thank you for me being here today.
Senator Ricketts. Thank you very much, David. I appreciate
you sharing your experience with us. I have got some questions
for you as well.
Jina.
STATEMENT OF JINA RAGLAND, ASSOCIATE STATE
DIRECTOR OF ADVOCACY AND OUTREACH, AARP
NEBRASKA, LINCOLN, NE
Ms. Ragland. Thank you for inviting AARP to participate in
today's hearing. My name is Jina Ragland, and I am the
Associate State Director of Advocacy and Outreach for AARP
Nebraska.
AARP, which advocates for the more than 100 million
Americans aged 50 and older appreciates the Senate Aging
Committee's effort to examine the Medicare enrollment process
and ways to improve it for older Americans. We would like to
thank Senator Ricketts for leading the Improving Measurements
of Loneliness and Isolation Act and for co-sponsoring the
Alleviating Barriers for Caregivers Act.
There are currently over 66 million Americans with Medicare
and roughly four million people join Medicare for the first
time each year. In Nebraska alone there are over 370,000
Medicare beneficiaries, which is roughly 19 percent of our
population.
For many, Medicare enrollment is a confusing and time-
consuming process, often requiring the help of loved ones and
trusted individuals to guide them through it. Congress and
community partners like AARP can all play a role in making the
enrollment process as stress-free as possible. I would like to
take a few minutes to mention some positive steps that can be
taken to improve the process for everyone.
First is beneficiary eligibility notification. One of most
common complaints about initial Medicare enrollment is lack of
awareness about eligibility timelines and enrollment
requirements. Failure to timely enroll in Medicare can result
in costly penalties that can be added to your premiums for as
long as you have Medicare. The Social Security Administration
should notify potential Medicare beneficiaries well before they
reach Medicare eligibility at age 65. They should inform them
about the steps that they will take to enroll and about the
circumstances under which premium penalties may be assessed.
Bipartisan legislation in the Senate, the Beneficiary
Enrollment Notification and Eligibility Simplification Act
would help people approaching age 65 punctually and properly
enroll in Medicare, thereby preventing delays in coverage and
costly penalties.
We must work to improve Medicare education. Even if a
person knows they can sign up for Medicare they may not know
how. The decision-making process can be overwhelming for many
individuals, and AARP endeavors to be a trusted friend for
older Americans to turn to, but oftentimes there are more
complicated questions that come to play, so the State Health
Insurance Assistance Programs, or the SHIPs, become a valuable
resource. SHIPs provide local, in-depth, and objective
insurance counseling and assistance to Medicare-eligible
individuals, their families, and caregivers. Each state has a
SHIP, and it is managed through the Nebraska Department of
Insurance with Federal funding support. An important step the
Federal Government can take to help people through the Medicare
enrollment process is to increase funding for SHIPs, Area
Agencies on Aging, and the Disability Resource Centers. We urge
Congress to fully restore the $50 million in mandatory funding
in the next spending deal to enable SHIPs and other entities to
help make Medicare more affordable for low-income
beneficiaries.
Next we should include family caregivers more. While it can
be confusing or overwhelming for Medicare beneficiaries or
those enrolling in Medicare to navigate the program, it can
also be challenging for family caregivers who are assisting or
advocating on behalf of a loved one. AARP supports two
bipartisan bills that help make providing care easier and save
family caregivers time and frustration when trying to navigate
or get care for their loved ones in Medicare. First, the
Alleviating Barriers for Caregivers Act would help reduce red
tape by requiring CMS and Social Security to review their
eligibility determination and application processes. We
appreciate Senator Ricketts co-sponsoring this important
legislation. Second, the Connecting Caregivers to Medicare Act
would help inform people about the voluntary option for
Medicare beneficiaries to allow family caregivers to access
their health information through 1-800-MEDICARE. Supporting
family caregivers helping their loved ones navigate Medicare is
essential.
Fourth, we can better educate employers. Most people
enrolling in Medicare for the first time are transitioning from
employer-sponsored health coverage. The employer is well-
positioned to help individuals make the transition to Medicare
and avoid enrollment mistakes and costly penalties. Yet they
are often ill-equipped to provide guidance or answer questions
for their employers. Better employer education can help reduce
information errors and provide another reliable source of
information for consumers.
Last, we need clearer Medicare Advantage information. The
explosion of Medicare Advantage plan availability with the
average beneficiary having access to 43 different plan options
in 2024 alone can make enrollment in the right plan a daunting
process for even the most knowledgeable consumers. Plan
marketing directly affects consumers' experience and ability to
make informed choices. In many cases, deceptive marketing
practices have led individuals to enroll in a plan that does
not meet their needs. There are concerns about Medicare
marketing abuses about MA plans, and there is a need for
greater oversight, enforcement, and regulation of marketing
materials and marketing standards for MA plans.
Improved transparency about agent, broker, and third-party
organizations' compensation and financial incentives could
better help inform consumer decision-making. It is also
critical to equip consumers with a clear pathway to lodge a
complaint about problematic marketing practices. Increasing
access to unbiased sources of information, such as through
SHIPs, is essential to helping consumers discern Medicare
marketing information.
In conclusion, thank you for the opportunity to provide
AARP's perspective on improving Medicare's enrollment process.
I would be more than happy to answer questions, and we look
forward to working with you to address this important issue and
ensure continued access to affordable health benefits for
Americans.
Senator Ricketts. Thank you, Jina.
Kierstin.
STATEMENT OF KIERSTIN REED, CHIEF EXECUTIVE OFFICER,
LEADINGAGE NEBRASKA, LINCOLN, NE
Ms. Reed. Well, good morning, Senator Ricketts, fellow
witnesses, and members of the public. Thank you for being here
today. My name is Kierstin Reed, and I serve as the President
and CEO of LeadingAge Nebraska.
We appreciate Senator Ricketts bringing this hearing to
Nebraska. LeadingAge Nebraska is a membership association that
provides advocacy and education for providers of long-term care
services in our State. We represent 80 providers across the
State and work with our national partner, LeadingAge, to
provide support to over 5,000 long-term care providers across
the U.S.
Since the inception of the Medicare system in 1965, there
have been numerous development and changes with the system that
now covers over 63 million beneficiaries across the U.S., with
over 300,000 of them being in Nebraska. The most recent change
to that system is the addition of Medicare Advantage, also
known as Part C or private insurance option, that is meant to
replace traditional A and B benefits.
The process for choosing to receive Medicare benefits is a
daunting task, for beneficiaries and supporters, because the
number of options has increased. The amount of information they
need to wade through to try to understand the benefits that are
available to them and the differences between traditional
Medicare and Medicare Advantage plans can be very overwhelming.
The number of services claiming to help seniors select an
Advantage plan seems to be a never-ending list and that
continues to provide difficultly to find a reputable, trusted
source to provide their decision-making process.
LeadingAge Nebraska works with many nursing homes and home
health providers across the State, providing support to older
adults. When older adults find themselves in need of nursing
care, either short term or long term, and they have generally
already enrolled in a Medicare plan, it is often at this point
in time that a professional is explaining the fine print of the
plan that they chose and what services are available to them.
When you find yourself or a loved one in a long-term care
service it is already a difficult process to understand.
We find that beneficiaries and their family members may not
fully understand what is covered in their Medicare plans. Many
beneficiaries are under the belief that because they have
Medicare, long-term care services are going to be completely
covered without any out-of-pocket expense, and they will last
until they no longer need them. Beneficiaries are often
surprised by the limitations on the services that they receive
and the overall cost of the care that they need. For those in
skilled medical services, Medicare will pay a portion of their
stay, if they are approved, for a period of time. If they no
longer meet the skilled stay or they have used their maximum
benefit, Medicare no longer covers these services. The average
cost of nursing home care in Nebraska is $7,500 a month, for
custodial care, which is not covered by Medicare.
As people are living longer and have more complex health
conditions, we find that beneficiaries are often outliving
their personal resources for care, even with their Medicare
benefits. Currently, 60 percent of nursing home residents in
Nebraska rely on the Medicaid system as their payer source
because they no longer have funds to pay for service.
The expansion of Medicare Advantage programs has increased
this confusion for beneficiaries when they are selecting a
plan. There are numerous Advantage plans that muddy the waters
of an already complicated system. Currently, more than 50
percent of beneficiaries nationally are enrolled in a Medicare
Advantage option. For Nebraska, this average is closer to 30
percent, but the average continues to rise. These plans entice
beneficiaries with many benefits that are not available through
traditional Medicare model. However, beneficiaries find that
these plans may not be widely accepted by every provider or
that they are limited in their options for care. Beneficiaries
may also find that Medicare services that they expect to
receive are not the same through Advantage plans as compared to
traditional Medicare, due to Advantage plans' authorizations,
denials, and limitations of service. The intent of these plans
was to provide equitable coverage that matches Parts A and B,
in addition to providing the extra benefits such as vision and
dental, that are not included in the base plan.
Today there is evidence that Medicare Advantage plans are
denying coverage for services and terminating before the
beneficiary is ready to go home. We need to assure that
beneficiaries are receiving equitable coverage regardless of
how they choose to receive their benefits.
In order for our health system to work efficiently and
effectively, there needs to be a focus on provider payment
equity for services that are covered by Medicare. Traditional
programs like Medicare and Medicaid have paid lower
reimbursements than private insurance. The introduction of
Medicare Advantage moved this to a deeper level. Some Advantage
contracts to providers are equal to the State Medicare level,
which experts agree does not begin to cover the cost of
custodial care, let alone more intense skilled care that are
provided through a beneficiary with significant health needs.
If the concerns of Medicare, particularly with the
Advantage plans, continue, it will cause an erosion in our
health care system. Providers of long-term care services are
already closing at an alarming rate due to the rising costs of
care, staffing shortages, and inadequate reimbursement system.
Patients are waiting for weeks to months in our Nebraska
hospitals for placement in long-term care. Nebraska has lost 17
percent of our nursing homes since 2017, and we are at risk for
losing more in the coming years, particularly if the proposed
Federal minimum staffing rule on the horizon that would require
nursing homes to add more positions that cannot be filled under
our current workforce or reimbursement constraints.
In closing, LeadingAge Nebraska wants to assure that older
adults receive fair and equitable access to Medicare services.
We want to assure that they understand the benefits that they
are receiving and that they have made a clear choice in
choosing between traditional Medicare and Medicare Advantage,
and the long-term impacts of those choices are known to them.
We also want to ensure that the services are available to them
when they need them. There are improvements that can be made to
address the access to these benefits and meet the needs of
beneficiaries.
Thank you for the opportunity to testify today.
Senator Ricketts. Thank you, Kierstin.
Dr. Trapp.
STATEMENT OF JOHN TRAPP, M.D., SYSTEM VICE
PRESIDENT OF MEDICAL AFFAIRS AND CHIEF MEDICAL
OFFICER AT BRYAN HEALTH, LINCOLN, NE
Dr. Trapp. Thank you. Good morning. My name is John Trapp.
I currently serve as the Vice President for Medical Affairs and
Chief Medical Officer for Bryan Health. Bryan Health is a six-
hospital, locally owned, locally governed Nebraska health
system.
For those of you who don't know me, my background is in
pulmonary medicine, critical care, and sleep disorders
medicine. I also currently serve as the President of the
Nebraska Medical Association for the current year, and we
represent over 3,000 physicians, residents, and students in
Nebraska.
We want to thank Senator Ricketts for his bringing
attention to this important issue and providing a venue for
which we may share our concerns about Medicare Advantage. Today
I hope to outline a number of our concerns, namely that there
are inappropriate practices by insurers offering Medicare
Advantage that put vulnerable patients at risk and negatively
impact hospital capacity, all while reducing payments to those
who are actually providing the medical care to our patients.
In a recent Modern Healthcare article, published in
February of this year, the author, Caroline Hudson, summarized
many of the Medicare Advantage plans well - ``Medicare
Advantage plans generate billions of dollars for payers as they
woo members with zero-dollar premiums and supplementary
benefits.''
Now, at its inception, Medicare Advantage's intention was
to allow for highly coordinated, proactive, population-based
care that would actually reduce health care costs over time,
something that I believe we can all agree on. In reality, the
financially driven interests of these insurance companies have
resulted in Medicare Advantage programs becoming the most
profitable arm of many of the major insurance companies, at the
expense of the patient, the taxpayer, and the Medicare trust
fund.
The Medicare Payment Advisory Commission, MedPAC, projects
that the Federal Government will pay Medicare Advantage plans
$88 billion more this year than if those same beneficiaries
would have been covered under traditional Medicare. Yet these
additional funds are not going to providers. Just the opposite.
Most physicians will receive less in 2024 as their Medicare
Advantage fees are tied directly to the Medicare provider fee
schedule, which has been cut as of January of this year by 3.4
percent, and this culminates in roughly a 10 percent reduction
in payments over the last four years.
At Bryan Medical Center, traditional Medicare reimburses us
approximately 80 percent of our actual costs, meaning that we
lose approximately $90 million per year on the Medicare
patients we care for, which includes Medicare Advantage. Our
contracts with Medicare Advantage plans call for reimbursement
rates that are at least 100 percent of Medicare.
However, due to what we believe is inappropriate denials as
well as delays in preauthorization and payments, we receive
less than what traditional Medicare would have reimbursed. For
one of the most prominent Medicare Advantage insurance programs
in the country we receive approximately 88 percent of
traditional Medicare reimbursement, despite fighting Medicare
Advantage tactics along the way, expending numerous resources
to fight through unfair tactics, where the advantage typically
lies with the insurer.
More important than the impact on reimbursement, prior
authorization and denial practices have, at times, overwhelmed
hospital systems and created logjams that impact vulnerable
patients and hospital capacity. Bryan Medical Center, located
in Lincoln, Nebraska, has around 664 licensed beds, and we are
often full. We consistently serve patients from all of
Nebraska's 93 counties and surrounding states.
As an example, on a recent Friday morning earlier this
month we had over 40 patients in our emergency department
awaiting inpatient beds. Several of these beds could have been
made available except that a number of patients were
effectively stuck at Bryan, awaiting preauthorization by
Medicare Advantage plans to be discharged to the post-acute
facility such as a skilled nursing or long-term care.
I would like to spotlight another reason why we are here
today. This involves patients and delivery of high-quality
care. I am going to provide you a couple of stories of two
real-life patients from the last several weeks at Bryan Medical
Center.
Example A, a patient has been accepted to a long-term care
facility. Their Medicare Advantage plan requires authorization
for them to move to the next most appropriate level of care.
They no longer require acute care hospitalization. The
authorization was submitted to their health insurance plan on
January 26, 2024. We follow-up on February 1st. Just a few days
later, our care transition talks to the insurer, asking for an
update. Their reply, ``We have 10 more days to make a
decision,'' 10 more days of delay to receive the rehabilitation
care that those patients require, 10 days of being unable to
leave the hospital and move on with a rehabilitation course, 10
days for the hospital of unreimbursed care, 10 days of
frustration for all.
This is what happens when patients select Medicare
Advantage plans, thinking that they will have access to timely
care and to expanded benefits. Rather, many are at the mercy of
their health insurance plan, not necessarily what their doctor
thinks is best for them. The hospital is not getting paid care
for this patient because the patient no longer requires acute
care medicine. The insurance company is getting days and weeks
of free nursing care for their patient while they sit in a
hospital at the expense of the patient's well-being, their
family, and the hospital, all at the same time while the
insurer is making record profits.
A second example. Patient B has been waiting for
authorization since February 12th. For the subsequent three
days our capacity management director has emailed the Medicare
Advantage insurance company and called multiple times, trying
to get an answer. They do not respond. The nursing facility has
already accepted the patient, but it cannot take them over the
weekend. If we don't get authorization by Friday, February
16th, the patient will not be able to be discharged for
additional days, until the following Monday at the earliest.
Again, this resulted in even more delays that the patient is in
the hospital, really for no reason, thus allowing another
patient with acute medical needs from accessing this inpatient
care.
Now the insurance companies will tell us, and will tell
you, that they will pay for these delayed days, simply not
true. The patients they will pay for are very limited, and
these patients that they will pay require an additional
preauthorization to get those days to stay in the hospital, so
therefore, the hospital is further burdened in trying to recoup
costs because the Medicare Advantage plan wasn't efficient in
the first time processing their authorization.
Why do Bryan and other hospitals continue to accept
Medicare Advantage? Primarily because we take care of those who
need us in our State. However, the current tactics of large
national insurers, who hold essentially all of the power, we
feel must be addressed for the sake of the vulnerable patients
and for those who take care of them. The current model is not
sustainable, as the insurers claim record taxpayer-funded
margins and the hospitals and the health care providers subsist
in the aim to fulfill our mission of care. Medicare Advantage
plans are selling patients a bill of goods that they cannot and
choose not to fulfill.
Thank you for the opportunity to share a small picture of
the ways that we feel Medicare Advantage is impacting
Nebraskans. Our State story is not unique. These behaviors are
impacting Americans nationwide. As you hear from myself and
others today I ask that we move to take action, and I would
welcome any questions when the time is appropriate.
Senator Ricketts. Great. Thank you, Dr. Trapp.
Ms. Danielson.
STATEMENT OF JANA DANIELSON, VICE PRESIDENT,
REVENUE CYCLE AT NEBRASKA MEDICINE, OMAHA, NE
Ms. Danielson. Good morning. I am Jana Danielson, and I am
the Vice President for Revenue for Nebraska Medicine. First, I
wanted to say thank you for the opportunity to speak regarding
the challenges associated with Medicare and Medicare Advantage.
My testimony today will focus on challenges faced by health
care providers, quite similar to Dr. Trapp, who are committed
to caring for our Medicare and Medicare Advantage population.
Nebraska Medicine provides health care services to a
significant number of patients who are covered by Medicare and
Medicare Advantage. These patients represent 43.5 percent of
health care services provided by Nebraska Medicine in Fiscal
Year 2023. The Medicare-eligible population has been trending
upward over the last several years, and we anticipate that
trend will continue as our state's population ages. Of total
Medicare-eligible patients, Medicare Advantage enrollees make
up approximately 35 percent of the total Medicare-eligible
population, and this proportion of patients enrolled in MA
plans versus traditional Medicare for Nebraska Medicine
continues to grow.
Medicare Advantage plans, offered as an alternative to
traditional Medicare, are intended to provide the same
benefits, as traditional Medicare is a minimum standard.
Unfortunately, health care providers routinely face challenges
securing medically necessary services when Medicare Advantage
coverage has been chosen by the Medicare beneficiary. The
greatest challenges include prior authorization requirements,
reimbursement challenges, and inconsistent Medicare Advantage
plan interpretation of Medicare rules.
The most recent CMS Interoperability and Prior
Authorization Final Rule is a good start to address concerns
related to denied or delayed care for Medicare Advantage
beneficiaries, resulting from prior authorization requirements.
However, opportunities remain to ensure timely access to
appropriate care for Medicare Advantage beneficiaries while
reducing administrative burden for providers.
APIs, or application programming interfaces, and timeframes
for payer responses included in the rule do not address or
standardize payer reasons for denial, which can vary across MA
plans and are often out of sync with Medicare coverage
guidelines. The contract year 2024 Medicare Advantage final
rule continues to allow Medicare Advantage plans to apply their
own coverage criteria when Medicare coverage criteria is not
fully established. This results in variability among various MA
plans and a requirement for providers to navigate multiple
payer policies, creating additional burden.
As an example, Nebraska Medicine routinely experiences
authorization denials for medically necessary care, with
requirements from the Medicare Advantage plan to complete a
peer-to-peer discussion or a letter of medical necessity, even
though the care plan is considered the best course of treatment
by our providers. The care would meet standard of care
guidelines and potentially Medicare coverage policy does not
exist.
To further complicate matters, the appeal process for every
Medicare Advantage plan is different. Some allow a peer-to-
peer, some require a letter of medical necessity, while others
may require a letter of medical necessity followed by a peer-
to-peer discussion. Providers must navigate numerous different
payer policies, as one Medicare Advantage plan is simply one
Medicare Advantage plan.
Imagine a patient recently diagnosed with cancer, waiting
for approval to begin cancer treatment, and having a payer
question the treatment plan of a highly respected provider with
excellent outcomes that the patient trusts. The patient wants
to act quickly, they want their payer and provider to act
quickly, yet delays occur due to prior authorization
requirements that are simply administrative in nature. In most
cases, final approval is received with no change to the
original treatment plan, making all of the administrative work
ultimately unnecessary.
Imagine the provider who is caring for the same patient,
and many other, who is focused on quick, appropriate, medically
necessary care for all patients. They see their patient face-
to-face, talk to them, examine them, they are aware of the most
up-to-date research and best courses of treatment, yet they are
required to spend countless hours talking to payers, during the
payers' business hours, or writing letters to substantiate
their treatment plan. This additional burden placed on
providers takes time away from caring for patients, which is
their top priority.
Now consider the same patient may require hospital care
followed by post-acute care needs. Hospital stays with Medicare
Advantage plans present another set of challenges. In an acute
hospital there is a difference in reimbursement for stays
classified as observation and those classified as inpatient.
Inpatient stays require a higher, more resource-intense level
of care, and thus are reimbursed at a higher rate.
To simplify the classification, Medicare implemented a Two-
Midnight Rule in 2013, which means that the inpatient services
are considered appropriate if the physician expects the patient
to require medically necessary care spanning two midnights. The
contract year 2024 Medicare Advantage final rule clarified that
the Medicare Advantage plans must comply with general coverage
and benefit conditions included in traditional Medicare
regulations, yet Nebraska Medicine is experiencing medical
necessity denials for inpatient stays on cases with lengths of
stay four midnights, or twice the requirement by the
traditional Medicare plan. Medicare Advantage plans continue to
deny medically necessary care for patients that would have been
approved for inpatient status based on the traditional Medicare
Two-Midnight Rule.
Not only does the classification of care's observation or
inpatient affect hospital reimbursement but it can also impact
patient out-of-pocket costs. Those may increase due to the
difference in deductible, co-insurance, and coverage guidelines
associated with observation versus inpatient stays.
The denials are often received within the first 24 to 36
hours of care, and place additional administrative burden on
the hospital to work with the payer to overturn the denial
while the patient is being treated. The administrative burden
in this case includes both nurse and physician time. The
hospital is then forced to contract with outside physicians to
simply battle the payer's physician to allow inpatient status.
Holding the MA plans accountable to traditional Medicare Two-
Midnight Rule would protect our patients and reduce
administrative burden and cost for the provider and the payer.
Imagine this same patient is now ready for discharge and
the care team agrees an acute rehab facility is necessary.
Nebraska Medicine contacts the Medicare Advantage plan, who
denies acute rehab authorization. A peer-to-peer is completed
by the attending physician, and the MA plans confirms the acute
rehab denial, but approves the patient for discharge to a
skilled nursing facility. The family and care team identify a
skilled nursing facility for discharge purposes. After a week
of waiting for approval, the Medicare Advantage plan denies the
SNF level of care.
At the same time that many MA plans are denying ongoing
hospital care for lack of medical necessity, their process for
approval of post-acute care creates barriers to accessing a
lower level of care for these patients, which leads to longer
lengths of stay in the hospital. When this occurs, the cost and
burden of care falls to the hospital to supply services that go
uncompensated while awaiting approval and acceptance to a
skilled nursing facility, an acute rehab, or a long-term care
hospital, and the patient waits.
After discharge, the same patient may require readmission
back to the acute setting. The Medicare Advantage plans do not
follow CMS readmission guidelines. Readmission denials have
been escalating, and the only path to appeal is a written
letter. At this time, some MA plans deny all readmissions
without consideration for diagnosis or expected readmission
rates.
In conclusion, administrative costs to comply with rules,
monitor for denials, appeal for proper patient care, and
pursuit of proper and fair reimbursement continues to escalate
in cost and time, and is unsustainable.
Thank you for the opportunity to share my perspective.
Senator Ricketts. Great. Thank you very much.
In 2023, CMS reported, and I think this was, Jana, what you
were citing--364,469 Nebraskans enrolled in Medicare,
representing about 18.5 percent of the statewide population. As
of July 2023, 372,967 individuals were eligible for enrollment
in Medicare Advantage, with 107,829, or about 29 percent,
actively enrolled in that program, and I think, Ms. Danielson,
you kind of referenced that your experience is about 35
percent, so 29, 35 percent, kind of ballpark in the same area.
Medicare open enrollment periods run from October 15th
through December 7th of each year, and during this time seniors
may change their Medicare Advantage plan or switch to
traditional Medicare. Seniors that regularly review their plans
and opt to switch can save money and get better coverage for
things they need. Unfortunately, studies have shown, however,
that only about 10 percent of beneficiaries with Medicare
Advantage or standalone prescription drug coverage are
switching their plans during this period.
According to a recent report, one of the biggest challenges
with Medicare Advantage plans is poor patient education. Some
applicants opt to selecting a Medigap plan. A Medicare
beneficiary may be enrolled in both Part A and Part B but not
enrolled in a Medicare Advantage plan to be eligible for
Medigap coverage. Medigap plans have Parts A through N, which
can be confusing for older Americans when choosing the right
plan for themselves. Furthermore, it is stated that nearly one-
third, or about 32.5 percent of Nebraska hospitals, do not
accept Medicare Advantage. I think that was a point, Dr. Trapp,
you do accept to take care of people. Therefore, it is vital
that beneficiaries living in rural areas know what plan is best
for them.
Despite the difficulties that many seniors and caregivers
face, there are a number of available resources that can help
Nebraskans, and we hope to cover that here in the hearing
today.
Maybe what I will start with is just a question for some of
our testifiers here today to talk about that aspect that this
is insurance, and that it can be reviewed on an annual basis,
right. From that open enrollment period starting October 15th
to December 7th, seniors can go back and review those, and like
any insurance plan would you say they ought to be doing that?
Ms. Ragland, I will start with you. Is that something that
seniors ought to be doing?
Ms. Ragland. I think that opens Pandora's Box because
Medicare plans with a supplemental plan, Senator Ricketts, once
you are locked into that plan if you try to get out of it, you
have a 12-month period where you can get into a Medicare
Advantage plan and try it out for the first year and then get
back out and get a Medicare supplement, but I think the problem
we are finding is people don't understand that open enrollment
period, when you are enrolling into Medicare, you have three
months before your birthday month, your birthday month, and
three months after. That is a period where there can be no
preexisting conditions that are slapped on you by an insurance
plan.
If you are doing that period of time and you go with a
Medicare supplement you can purchase any of those products
because they can't ask you any existing questions of your
health. Medicare Advantage, again, you can try that out for the
first year. They can't ask you any of those questions also, but
the problem we are finding--and a lot of this is where I was
talking about the transparency with the marketing and the
targeting--a lot of times people on limited incomes are being
targeted that maybe there is a better product that you pay
less, but not understanding what the benefits, those out-of-
pocket costs and that sort of thing. They get stuck and maybe
go beyond that year and want to get out and go to a Medicare
supplement and they cannot do that.
Senator Ricketts. They can't do that because they may have
a preexisting----
Ms. Ragland. Correct.
Senator Ricketts [continuing]. condition, and that may be
the thing that prevents them? The plan providers can deny them
for that.
Ms. Ragland. Correct. They cannot deny them as long as they
are in that open enrollment period or if it is that year and
then they want to try it out for the first time, but anything
beyond that, you can't go in and out of Medicare supplemental
plans. You can Medicare Advantage, but Medicare supplement, if
you have any preexisting conditions, you are pretty much locked
out.
Senator Ricketts. Locked out of getting into the----
Ms. Ragland. Back into the Medicare supplemental plans.
Senator Ricketts. Okay. What would your advice--maybe I
should take a step back. Is this one of those things where when
seniors are looking to apply for this, do they have to do it
online?
Ms. Ragland. No, and that is one of the things, with
Medicare supplement you can't apply for those things online.
You can with Medicare Advantage. That is part of my testimony
too, that I have given to you in my written form, but I think
the Medicare Plan Finder, it is a great online tool, but I
think it is a little bit misleading to consumers, because when
you are going on there, there is no ability to enroll in
specific Medicare supplement. It guides people to look at the
Medicare Advantage plans, and you can enroll online on a
Medicare Advantage plan along with your drug plan, but
supplemental plans, you have to call the plan directly and work
with them individually.
The SHIP program, which I have talked about also, cannot
enroll people in the supplemental plans. They can guide them to
the plan, but the Medicare Advantage plans, you can do those
all online, so there is a difference in the two products.
Senator Ricketts. Okay.
Ms. Ragland. The other piece of it--and then I will stop--
Medicare supplement plans are regulated at the state level.
They have the oversight of the Department of Insurance.
Medicare Advantage plans are not. They are regulated through
the Federal, so CMS regulates all of them, and we see a lot of
those. There are some differences in----
Senator Ricketts. In how they are being regulated?
Ms. Ragland. Yes, when there are complaints or problems
with supplement you can go to the Insurance Department, but
when there is Medicare Advantage we have to go back through
Medicare and work that process at the federal level, so that
would be one of the points, too, is the streamlining process of
oversight at the state level, from our concerns.
Senator Ricketts. Again, you talked about some of the
difficulty if you have a preexisting condition, about being
able to switch plans. If you don't have preexisting conditions
are there still other difficulties in trying to switch plans,
even if you are within the enrollment period?
Ms. Ragland. If you are within the enrollment period, I
mean, you can call any plan and ask. If you don't have
preexisting, some plans will probably entertain that. Other
plans will be if you are outside of your open enrollment we
don't have to, and therefore we won't do that. It just depends
on the plans.
Senator Ricketts. The open enrollment, is that an annual
thing, though, from October to December, that anybody, like
once you have a plan you can go in that period and try and
change it?, but you have to do it within that period?
Ms. Ragland. Correct. Again, the caution is with Medicare
supplement if you have already been in your open enrollment
period, if you have already----
Senator Ricketts. The first time.
Ms. Ragland. Correct, you have to be very careful because
if you get out of that and go to Medicare Advantage you have 12
months to get back out that first year, but anything beyond
that you do not have that ability. You can switch Medicare
Advantage plans in between there.
Senator Ricketts. You can't go back to the Medicare
supplement plans.
Ms. Ragland. Most likely not.
Senator Ricketts. Most likely not. Okay. It is, again,
confusing, especially as you just said, you can do the Medicare
Advantage online but then if you are doing the Medicare
supplement you have to call to talk to somebody, so there are
different processes even to do it.
Kierstin, can you just share kind of your perspective on
that as well, like when you have got the open enrollment period
for seniors, what ought they be doing the first time around,
thereafter? I mean, what kind of difficulties do you see people
having?
Ms. Reed. Yes. Most folks that we see are coming into
services into long-term care, and it is at that point that they
realize that, boy, I maybe picked the wrong plan, and sometimes
there is not a lot that they can do about that. In addition to
the Medicare Advantage plans we also have special needs plans,
so, I mean, just to muddy the waters even more.
I think, overall, seniors really want to make sure that
they have the care that they need, when they need it, and that
it is taking care of them, and right now I think we have got so
much that is muddying the waters that it is really difficult to
be able to guarantee that. They want to make sure that they are
getting those services, so yes.
Senator Ricketts. Okay. David, tell me about your
experience. You know, what was the single biggest barrier when
you were going through the process with regard to applying and
trying to figure out what plan was right for you, and that sort
of thing?
Mr. Lange. I could honestly tell, as I sit here today, and
I hear all of these fine folks talking about these issues, that
is the nail on the head, and you made a very good point there
too. Now, this all comes crashing in at you and you have got to
make a decision.
Trying to sort through the data to make that good decision
I thought would be very difficult for myself to make, but my
wife and I sat down and we looked at certain things. You have
been very educational to me today in understanding some of the
differences between the plans that I couldn't understand
before.
Unfortunately, I hear a lot of you talking about the
shortcomings of some of these plans and what you have to do to
stay on the right path. I am the kind of guy that if I am going
to sign up for this stuff, you know, I want to sit down, I want
to pick what I need, sign up for it, and then, you know what,
then I retire.
I didn't know about you could change things during the open
enrollment period, so that was helpful. There again, we are
old. We don't want to be messing around with that every year.
We want to get our stuff and know, like you said, we want to
know that it is the right decision at the time, and we don't
have anything to worry about. Unfortunately, all the
supplementals, all the additional plans, there again, I am
looking at monthly payment from SSI, and I don't want to be
disrespectful or anything like that, but everybody will
question, can I live on that? Okay, so all these other plans,
all these other extras are a takeaway from being able to do
that.
It is very scary. I have to be blunt, but that is kind of
where I am at right now, and will make this decision in five
years when she goes to retire and we no longer have that
employer group health plan to see us through this, so it is
kind of scary.
Senator Ricketts. Yes. Well, the good news is you have got
five years to research it. It may take that much time.
Mr. Lange. Yes, sir.
Senator Ricketts. What was your knowledge of Medicare and
Medicare Advantage before you had to go through this process?
What did you know about it, leading up to your retirement?
Mr. Lange. I had none. I wasn't smart, Senator. I didn't
save a nest egg. Through all my entire retirement experience, I
can say that is my biggest mistake, so I am kind of winging it.
I have a little bit of money, but not much, and we are worried
about the unplanned things coming up.
Senator Ricketts. Would you say that your level of
knowledge was actually pretty typical, though, for people in
your situation?
Mr. Lange. Oh, no. I think people are a lot smarter than
me.
Senator Ricketts. Do they know about Medicare and Medicare
Advantage, though, leading up to retirement?
Mr. Lange. No, sir, I did not. I assumed a lot of things,
like you sign up for Social Security you are going to get this
much a month money, so you sign up for Medicare you are going
to assume, hey, I have got health coverage.
Senator Ricketts. Do you think that is what most people
think?
Mr. Lange. Well, that is what I thought. I can answer for
myself. That is kind of what I thought, and shame on me for not
doing the homework and finding out, so I take 50 percent of
that.
Senator Ricketts. What kind of things do you think would be
helpful as far as education or helping you do the research?
Like what ways to reach you? You know, if we were going to try
and make sure that folks who are approaching retirement age
have a good background or knowledge and education about what
they should be thinking about as they decide what they want to
enroll for with Medicare and Medicare Advantage, what ways
would be helpful to be able to do that? What things would you
have liked to have seen?
Mr. Lange. There is too much. Streamline it. There are too
many choices, with too many directions. I believe the lady down
here was talking about different charges for this plan, handle
this plan this way. I can only imagine what a hospital has to
go through in order to keep all that straight.
Here as a patient or a benefactor or whatever, you know,
you see that going on, and--okay, I am a mechanic from way
back. Engineering-wise, you should keep it simple, you know.
You know the rest of that, the K-I-S-S. Keep it simple, I
think, would be very helpful. I know it would have been to me
because it just added confusion because it was coming from so
many different ways, so many different companies.
Senator Ricketts. Would it have been helpful to start
having that dialog earlier? I mean, if, say, the Federal
Government had reached out sooner to you and said, hey, this is
coming to you in two years, or something like that, would that
have been helpful?
Mr. Lange. Well, that is a good question. Possibly, if the
person has the right frame of mind. I didn't when it came to
initial investments 40 years ago when I started my maintenance
career, but as I got closer I thought about stuff like that, so
I was probably more open-minded, I think. Two years might have
helped me. I can't say that for everybody.
Senator Ricketts. Jana and Kierstin, you obviously deal
with a lot of folks. I mean, do you have an opinion on what we
could be doing better as far as trying to help people who are
approaching that decision, what we could do and how we could
reach them?
Ms. Ragland. I agree that earlier the better, and the
repetition. My problem, though, is that we allow Medicare
supplement, Medicare Advantage, all the plans themselves are
out--I don't know if you get piles in your mail.
Mr. Lange. It has been overwhelming.
Ms. Ragland. There are postcards that are coming all of the
time, like pick my product, pick my product. I mean, they can
buy those lists so they know who to go and find when they know
they are turning 65, so that part is extremely overwhelming,
first of all, and then you see the ads on TV. You know, it is
buyer beware in the sense of know what you are buying and know
what the product is.
I think, again, it is just that overwhelming fact of you
have got all of these options, and if you don't know where to
go. I do think that there is some responsibility that lies with
CMS, and I do think earlier notifications and repeated
notifications that are simplified. Also, again, using our SHIP
programs if you need help or hear some assets of how you can go
with that planning process. Again, maybe someone is not in that
state of mind, but if you see it five times you are probably
going to be more receptive than if you----
Senator Ricketts. Repetition.
Ms. Ragland. Yes.
Senator Ricketts. I think there is a common thing in
marketing that you have to get a message out seven times before
people start remembering it. Kierstin?
Ms. Reed. You know, I think the other thing is there are so
many people in the marketplace that are trying to talk to these
beneficiaries, or potential beneficiaries, that it is so
overwhelming who those trusted resources are and how you can
get to them. My parents, as an example, they have a trusted
person that they have been using for this for years, but at one
point their phone rang, and the person on the phone talked them
into setting up an appointment, and luckily my mom reached out
to me and said, ``What do you think? Should we do this?'' and I
said, ``No. You have everything you need. We are not talking to
them.'' You know, they initially contacted my dad, who has
dementia, and he would have gladly met with them.
Who is watching out for people and who is making sure that
they are not falling prey to these deceptive advertising
practices? Ultimately, it is going to hurt them in the long
run. These plans are what we face in long-term care and in our
hospital settings that are not providing adequate payment or
they are denying care, and ultimately, the beneficiary is going
to be on the hook for those expenses when their claim gets
denied, and it is going to cost them.
Senator Ricketts. What would be the best way to reach out
to folks who are approaching retirement age? Is it through the
mail?
Ms. Reed. I think Dave talked about that, you know, having
them come to your employer and getting that involvement early,
before you retire. I think that is a great idea.
I do think that we need to have more official information
coming from CMS. It needs to be directly from the government
that is explaining to them, transparently, what is expected and
what is going to happen.
Senator Ricketts. Very good. Well, I don't want to ignore
our hospital systems over here, so maybe you could talk a
little bit about, one of the things you both mentioned was the
difficulty with the insurance plans, but some hospitals don't
take insurance plans. Obviously, Nebraska is an agricultural
state, and we have a lot of folks in our rural areas. Can you
maybe talk a little bit about, you know, if you are in a rural
area what are some of the things that, as you are thinking
about these plans, should be the questions that maybe are
different from if you are in Omaha or Lincoln, and asking those
kinds of questions?
Dr. Trapp, do you want to start with that one?
Dr. Trapp. Yes. David, you are not alone in not
understanding Medicare Advantage plans. I mean, I am a
physician. I look at this stuff. We can't figure it out, and
most of my colleagues can't figure it out. We hire an army of
people at our hospital to sort through this stuff, and we pay
physicians to take our place to advocate for those plans, so
you are not alone in that challenge of that.
What I will say is that health care is a real odyssey. You
don't know what is going to happen next. When we leave places
like this, if you were involved in a car accident you don't
know what your health care needs would be at that time, so even
if you signed up for a plan, you don't know what you might need
down the road. Your next colonoscopy, they could find a polyp
or a cancer. Your next chest x-ray you could find a new
diagnosis, and you are left with saying, ``What do I need to
do?'' If I was diagnosed with a cancer, a new diagnosis, I
didn't know what the Medicare Advantage plan covered and what
it did not. Now you are seeking a new medication. Some of these
medications are tremendously expensive, and now you are trying
to figure out, does my plan cover that or not? It is a real
challenge with trying to figure out what I might need next year
and the year after.
As far as hospitals, how we select plans, I mean, there is
a process that hospitals go through to really try to look at
these plans. The challenge with it is the print looks good. The
Medicare plans tell you, we will pay for this, we will pay for
this, we will pay for this, and you say, okay, let's sign up,
and then, all of a sudden, when you submit that bill, oh, you
didn't submit that correctly, or we don't pay for that. You are
like, but it says here that you do. Well, it is denied or there
is a preauthorization process and there are delays.
The challenge is we sign up for a plan that we think we are
going to receive adequate reimbursement from--again, supposed
to be equal to Medicare--and then what we find is that they
deny their way to pay less than that, closer to Medicaid rates.
The challenge is, it isn't what is printed on the paper about
what they promise to pay. It is actually can you collect that
amount.
I don't know that I have an answer on how do we ferret that
out. Experience tells us what we do, and as we find out that
plans don't reimburse as promised, we re-evaluate those on a
regular basis and decide, do we renew that plan or not, or we
negotiate or eliminate that plan, realizing that puts everybody
who signed up for that Medicare Advantage plan at risk that now
they have to find a new hospital system, new doctors, and that
is a real challenge, and then the patients still want to come
to us. They don't understand that, and they may end up in our
emergency room still seeking care, now of which they are out of
network, and that presents its own problems.
Senator Ricketts. Can you talk a little bit, though, about
the challenges, urban versus rural? Do folks that are
approaching, you know, signing up for this need to think
differently if they are in a rural area versus an urban area?
Are there different challenges?
Dr. Trapp. Maybe I will let Jana answer that one.
Ms. Danielson. I think individuals in a rural area, you
really need to think about who is in your immediate network and
then take into consideration what may you require beyond that,
and so in Nebraska Medicine, Bryan, we receive patients across
the State of Nebraska. We receive patients from other states as
well, and so along with Bryan we are in network with Medicare
Advantage plans to make sure we can take care of folks.
I think that as you get out into maybe like private
practice groups or some of those areas in the rural communities
there is going to be a possibility that someone that you want
to maintain established care with may not be in network, and so
it is making sure they understand that, and then also
understanding that that can change. You know, folks can be in
network today and maybe out of network tomorrow.
Senator Ricketts. Is that a question, as somebody who is
looking to do this, maybe they are going through the open
enrollment period for the first time, is that a question they
should look at----
Ms. Danielson. Absolutely.
Senator Ricketts [continuing]. and say, ``Hey, I want to go
to Nebraska Medicine because I have gotten great care there
through my previous employer and the health plan I had there.''
Should they contact Nebraska Medicine and say, ``What Medicare
Advantage plans do you accept?''
Ms. Danielson. Yes, and most of us, as providers, also list
the plans that we are in network with, and the individual
trying to sell their plan should be able to answer those
questions for a patient.
Senator Ricketts. A good question to ask if somebody is
calling you.
Ms. Danielson. It is a question to ask. I have had personal
experience. I think, for some of us we are that resident expert
for our family members and others when they are approaching
Medicare age, and it is quite complicated even for those of us
who are in the industry sometimes to answer the questions. I
can only imagine David going through that process. It is not
easy.
Senator Ricketts. Do you list that, for example, on your
website?
Ms. Danielson. yes.
Senator Ricketts. Dr. Trapp, Bryan healthcare system as
well?
Ms. Danielson. Yes.
Senator Ricketts. You said it was about 35 percent Medicare
Advantage.
Ms. Danielson. Of our Medicare population, about 35 percent
is Advantage.
Senator Ricketts. Is that similar?
Dr. Trapp. I would say similar, but growing rapidly. The
acceleration phase is expected to really rise over the next few
years.
Senator Ricketts. Why do you think that is growing so
rapidly?
Dr. Trapp. Well, those plans are enticing. They sound
really good.
Senator Ricketts. It is marketing.
Dr. Trapp. You have the face of celebrities selling these
plans. Hey, zero dollars this. They sound really good. You sign
up for the plan thinking you are doing the right thing because
they promise a lot, and then the challenge is the delivery of
that, and oftentimes the patient receives the care. It is the
provider who doesn't get reimbursed for that and then struggles
to determine should we do that.
We don't oftentimes try to pit the patient and say--we
don't walk in the room when you are still there 10 days later
and say, ``You shouldn't be here,'' and make them feel bad
about it. We provide the care each and every day, make sure we
take care of that. We value the quality and safety of that
patient, but we struggle with, hey, we are waiting to hear
back, or we are waiting for the nursing home to be able to
accept you. It is not going to be today. It is going to be
tomorrow. It is going to be Monday, and we just communicate
that each and every day.
Patients oftentimes don't--this may be their first
experience with a complex medical issue. They really don't
know, okay, if it takes me eight days to get there, is that
normal or not? It is hard to understand that unless you are a
person who is really enmeshed with chronic health problems
where you are struggling with this, but for many people health
care is complex, it needs navigation, and we try to do that,
but for the first-time person who is experiencing a complex
health issue, they really don't know what to expect, so we try
to walk them along, but waiting six, seven, eight days, going
through preauthorization, oftentimes they are not aware that
that should not have to be that way.
Senator Ricketts. Yes. Jana, you mentioned that sometimes
you are the resident expert for friends and family, or
something like that. How often--and I am going to ask Dr. Trapp
the same thing for you as well, which is how often do you find
somebody has a caregiver that can help them through this, and
maybe talk a little bit about the challenge of the people who
don't have that caregiver, and maybe also talk about difference
in outcomes with regard to the kind of care they receive, if
they have a caregiver versus not having a caregiver, or family
expert, or whatever it is.
Ms. Danielson. Yes. In my circle, how small it is, I would
say that the majority of individuals do not have somebody who
is a caregiver or somebody who is in their circle that they can
reach out to. I know that there are wonderful resources
available for patients to access and to ask questions. Even
from a hospital perspective, we will have patients ask
questions to our financial counselors. They may call customer
service and say what resources are available to get my
questions answered.
I also don't feel like everybody understands what those
resources are necessarily to reach out and ask the questions,
to get them set up appropriately and in the best plan for them
for the long term. To David's point, you don't want to have to
change all the time or re-evaluate annually, and you get in the
plan and you are good, you know.
Mr. Lange. That is right. It is one more opportunity to
make another mistake.
Senator Ricketts. Dr. Trapp, what is your experience at
Bryan?
Dr. Trapp. The scenario I see is actually what Kierstin
described. A family gets called. They are trying to follow the
right things, being very Nebraska nice, if you will, willing to
meet with those people, and unless they had a daughter like
Kierstin that said, ``No, wait. Time out. You have got all
that. You don't need to meet,'' it doesn't happen for most of
our patients. They wander the complex pathway of health care,
and it just gets too complex, and you don't know what you don't
know.
Senator Ricketts. I know that there are even people you can
hire to help you, right. There are consultants you can hire to
help you navigate this process, but what about like low-income
people that can't afford to hire somebody, don't necessarily
maybe even have somebody that can help walk them through it.
Would you say that the complexity of the system is
disadvantaging people on lower incomes because maybe they don't
have somebody to help them, they can't afford to hire somebody,
they don't necessarily maybe know the right questions to ask
because maybe they didn't have health care before they were
going into this? I mean, can you talk a little bit about that?
Dr. Trapp. Go ahead.
Ms. Danielson. My opinion would be, without having any data
to support it, is that our low-income individuals are
disadvantaged. If you think about even access to resources, to
seek out somebody to assist, if you think about the ability to
either search for information online and all of those types of
things, they certainly don't have the opportunity to pay
somebody to help them through the process, and I know that
exists. I have actually been asked why I don't do that, but I
would prefer to do it for free, you know, just to help the
individuals who ask.
I think there is a possibility that in some cases if low-
income individuals are already potentially in Medicaid or if
they have some of those things that are already in place, that
they may have more input from someone to help guide them
through the process, but I always feel like that we do have
some individuals who are just lost in totality, and they just
don't know what they don't know and where to go, and so somehow
it would be great if we could figure that out and make sure
everybody has the same opportunities to have a conversation and
get enrolled appropriately.
Dr. Trapp. I agree with that completely. I mean, your
resources and who you know certainly is going to impact those
with less education, less sources of revenue, less connection
with the health care system.
Senator Ricketts. Actually, Jina and Kierstin, I will throw
the same question to you as well. If you are lower income and
don't have the same sort of resources is that definitely a
disadvantage with such a complex system?
Ms. Reed. I think it is absolutely a disadvantage. There
are public programs, like the SHIP program, that are out there
for people, but again, sometimes people don't even know where
to find those resources or what to do about it.
You know, CMS has really let this Medicare Advantage
program expand to a point that I don't think anyone ever
anticipated. I don't think it was the goal that we were going
to have 50 percent of people on these plans, so they didn't put
up enough guardrails. The rules for this were developed when
three percent--we were actually trying to entice people to use
these plans because enrollment was so low.
We are at a point now where we need to reevaluate the rules
on this program, one of those being that there is a rule in
place that CMS can't step in and set a floor for the base
payment rate or the lowest payment rate for reimbursement, so
they are kind of at liberty to do whatever they want at this
point, and that is a really bad place for our consumers to be.
That is a bad place for beneficiaries, so we need to make sure
that we are stepping in, for all income levels, to look after
folks and make sure that their best interests are being taken
care of.
Senator Ricketts. Jina?
Ms. Ragland. Yes, I echo all of the comments again. Yes,
how could there not be a disadvantage, especially because they
don't have access to the resources? Even our broadband, it is
getting better, but to go online we have a lot of people who
still don't have----
Senator Ricketts. That is a great point.
Ms. Ragland [continuing]. appropriate broadband access that
works, let alone do they have the skills to get on and be
digitally literate to do that. You can make phone calls to
Medicaid, you can make phone calls to SHIP, but I think, you
know, again, sometimes it is very overwhelming and it is very
confusing, so I would definitely agree with that.
One other point, I wanted to go back, when we were talking
about rural versus urban. One issue we see very frequently with
people that call our office who might have been in Medicare
Advantage, ``I did all the checking. I know I am in network
with my hospital,'' but there may be a specialist that is
coming out to visit that is not, and that falls through the
crack and then guess what, here comes your bill.
Senator Ricketts. How could you even anticipate that?
Ms. Ragland. Correct. Well, I mean, again, it is empowering
consumers, but those phone calls sometimes to figure out, you
know, even to go onto the providers' networks or the payer's
network, as it has been said, that network can change on a
daily basis, so it is being due diligent on the part of the
consumer, but how would you know that, especially if you have
this looming medical procedure or surgery that has got to take
place. It may be the last thing you think about, or because you
are having it in that surgical procedure hospital, you think
that that surgeon is covered, and it may not be.
Senator Ricketts. You said with Medicare Advantage that is
a problem. Is that with traditional Medicare? Is that less of a
problem?
Ms. Ragland. It is less of a problem just because generally
most providers in Nebraska accept Medicare assignment, yes.
Senator Ricketts. Yes. Great. I also want to get back to
something that both of you talked about with regard to the
Medicare Advantage plans and this delay. You said they needed
to be held accountable. What mechanisms are in place to hold
the Medicare Advantage plans accountable for the Two-Midnight
Rule, for example? I think you both said that they don't
necessarily always do that. If somebody is not doing that, how
do you hold them accountable?
Dr. Trapp. Well, at a minimum, they should follow the same
rules that Medicare sets up there. The challenge is if there is
any gray area they take advantage of that, with regard to that.
As far as getting timely returns on denials and
preauthorization, oftentimes we get 24 or 48 hours. That can be
done in a relatively short period of time. To take two weeks to
come back and let us know whether or not that patient can go to
the next level of care, it is just way too long.
Senator Ricketts. Is that written in the rules, though,
that two-week timeframe? Is that part of what is established by
CMS, that they have that much time?
Dr. Trapp. No. Medicare Advantage establishes its own.
Senator Ricketts. It is a state-level thing, right? Is that
established at the state level? What does that timeframe get
set? you mentioned, I think----
Dr. Trapp. By the Medicare Advantage plan.
Senator Ricketts. Yes. Somebody said back to you, ``We have
10 days to make that decision.'' Where do they get that 10
days?
Dr. Trapp. They develop their own guidelines on when they
will get back with that.
Senator Ricketts. Okay, so that is not necessarily
regulated at the state level that they have a specific thing.
Could that be something that is regulated at the state level?
Could the state say, hey, every Medicare Advantage plan in
Nebraska has two days to get back, or five days?
Dr. Trapp. Medicare Advantage is a Federal program, so it
is going to require more of a Federal solution. State plans,
things like that, can be done at the state level, but Medicare
Advantage is a Federal plan.
Senator Ricketts. That would have to be done at the Federal
level, and CMS would have that.
Dr. Trapp. Correct.
Senator Ricketts. Okay. We are going to go back over here
for a second. Go ahead.
Ms. Danielson. I agree with what Dr. Trapp says. You know,
part of the problem is, too, that even with the new rules that
are coming out to attempt to address the authorizations issues
and other things, there still remains that gray area, and you
know, we can file a complaint with CMS regarding an MA plan,
but generally speaking we are held to all of the different
plans' payer payment policies, which is really difficult to
navigate, even as a provider, because one MA plan is one MA
plan.
Senator Ricketts. If you have seen one MA plan, you have
seen one. Is that essentially it?
Ms. Danielson. Yes, and they are all different, but it is
extremely difficult to navigate.
Senator Ricketts. When you file a complaint letter with
CMS, what does that do?
Ms. Danielson. Sometimes nothing. You know, you may get an
answer back. I mean, there are times that it could come with a
good result. There are also guidelines around when you can. You
know, what can you complain about, or what can you file with
CMS related to an MA plan, and it really has to be something
that they can provide some oversight to. It can't be this gray
area. You know, if CMS policy says an MA plan can still apply
medical necessity criteria if Medicare does not have something
specifically called out related to that condition, that is not
something that you can file a complaint, because in reality
that plan can still have those guidelines, and so, I mean, that
alone is also difficult to navigate as far as which path can
you take, if you are trying to hold the MA plan accountable,
because they generally have the upper hand. Do you agree?
Dr. Trapp. Oh, they definitely have the upper hand, and
even when we try to pass guidelines that implement change to
improve that, oftentimes the MA plans say, ``We need time to
change that. That is a massive change,'' so the changes may not
take effect until 2026 or later, and it is just challenging to
say, what do we do until then? We still are challenged by that
revenue loss and just getting consistency.
Senator Ricketts. Jina, did you have anything to add to
that, or Kierstin?
Ms. Reed. I just wanted to comment on that, so on the
skilled nursing side and long-term care we call that the Three-
Day Stay Rule--Two-Midnight, same thing, so we have addressed
that issue at LeadingAge with CMS, and what they tell us is
this is a regulatory issue, so there is a law on the books that
needs to be repealed in order to make that fair ground for
everyone and get rid of that three-day stay. There is a bill in
the House that would do that. We need a Senate companion bill
to be able to address that issue.
I think that is a very important one because now that 50
percent of people are on Medicare Advantage, we have two
different systems at play. We have folks that aren't required
to meet that three-day stay and then we have folks that do need
that, but the big problem is the reason that they aren't
holding themselves to it is because they don't want to
authorize inpatient services, so they keep people on an
outpatient basis, and to that patient that is receiving care it
doesn't look any different. It looks just the same. You are in
the same hospital room. You are receiving the same services.
Nothing about your stay looks different to you, but for those
that are on Medicare, if they come out and they go into skilled
nursing care and they didn't have that three-day stay, Medicare
is not going to pick up any of their first 20 days or up to 100
days. They are not going to pay for that.
We need to make sure that we have got clear and consistent
rules, and right now with the number of programs that are
really able to make this up, we don't have it.
Senator Ricketts. Yes. Of the roughly 300,000 Nebraskans
that are eligible for Medicare, how many of them require that
long-term care?
Ms. Reed. Well, that is a good question. You know, I think
all of them require long-term care from time to time. Long-term
care could be for a rehab stay, where they are coming in and
getting rehab after a surgery. It could be that they have a
significant illness and they need some time in a skilled
nursing facility to take care of that.
I think one of the big misconceptions about long-term care
in Medicare is that their stay there is going to be paid at 100
percent, and that is simply not true. Unless they have a
medical reason for being in that level of care that is when it
is going to be paid, and it is still only time limited, so the
only get so many days and they have to qualify through their
plan.
We face the same types of denials and delays and
preauthorization's. Sometimes someone will come into a skilled
nursing facility and they may be authorized for 48 hours. They
can't even get a plan together to be able to support that
person, to do their rehab to recover within 48 hours, and then
they are denying them and sending them home.
Senator Ricketts. You are saying, with a lot of the folks
that are coming to those skilled nursing facilities or
whatever, that, kind of like David said, hey, I just want to
get set up with the insurance and retire, and they are coming
in and they are realizing, oh, this is actually not going to
pay for everything for me, that I am going to come here, and I
may not even able to get authorization for it.
Ms. Reed. There are still co-pays.
Senator Ricketts. There are still co-pays, even if I do.
Ms. Reed. Sometimes upward of $1,000 plus a day.
Senator Ricketts. A thousand dollars a day.
Ms. Reed. Yes.
Senator Ricketts. Oh, my gosh. David, could you afford to
pay $1,000 a day if that is what was happening there? I mean,
you don't have to answer that, but that seems like a lot of
money for somebody who didn't realize that could be happening
to him.
I think you also mentioned something about if they have to
go back to the hospital after they have been in long-term care,
that that is difficult as well.
Ms. Reed. That Three-Day Stay Rule still applies, so if
they are on traditional Medicare, and Advantage plans, again,
don't have to necessarily do that, but we have got that
inconsistency there. so yes, there are things that the skilled
nursing facility or the nursing home can't take care of, and
they do have to go back to the hospital. Obviously they try to
avoid that at all costs, but if they do go back then they have
to have that stay again before they can come back to get their
skilled nursing facility services paid for.
Senator Ricketts. That all requires preauthorization, so
there could be delays with regard to that?
Ms. Reed. Oh yes.
Senator Ricketts. Okay. Very good. Well, I do want to be
respectful to everybody's time. What I would like to do now is
just with all of our witnesses give you a last chance to wrap
up and say if there is anything that you didn't think about,
didn't cover, would like to just comment on. David, we will go
ahead and start with you.
Mr. Lange. I would like to thank you again for letting me
be here today. I don't know what I brought to the panel, but
you have given me tremendous information today. I really
appreciate that. That is going to help my educational side. I
think you have struck on a couple of really good points. It is
kind of a mess, guys. I am sorry. That is my first impression,
but thank you again for letting me be here today.
Senator Ricketts. Thank you, David. I appreciate it.
Ms. Ragland. I don't have any additional comments or
thoughts, Senator, but I do appreciate us being able to be at
the table and provide our comments, and we do look forward to
working with you on this issue.
Senator Ricketts. Okay. Great. Kierstin?
Ms. Reed. Same. I think there are definitely improvements
that CMS can make, but I think there are some issues where
their hands are tied as well, and so that is where we need to
have the House and Senate to be able to step in to address some
of these problems. Thanks.
Senator Ricketts. Okay.
Dr. Trapp. Thank you for the opportunity to be a part of
this and to have the community involved with this. You know, in
the beginning Medicare Advantage plans were really designed to
allow for highly coordinated, proactive, population-based
health care that would actually reduce costs. It has grown
tremendously. It is not meeting the needs. We need to re-
evaluate.
Senator Ricketts. I do have something to add. The whole
point of Medicare Advantage plans was to be proactive and
preventative, right, and you said that in your opening remarks.
We all agree that if we can be preventative that is actually
going to reduce costs long term.
Dr. Trapp. Absolutely.
Senator Ricketts. Would you say then your evaluation of
this, your assessment is we actually have not met that goal,
that we are not being as preventative and we are not actually
saving costs in this program?
Dr. Trapp. Yes. They pay for some preventative care. There
is no question, but I don't think that they have met the need
of reducing costs overall of the patients' care.
Senator Ricketts. Okay. Thanks.
Ms. Danielson. Thank you for the opportunity. I do want to
say happy belated birthday to David, because I did hear you
mention that that was quite recent. If it was later in the day
I might take you for one, and then I do also want to agree with
Kierstin on the SNF Three-Day Rule. I did have that in my
original testimony and cut it for time.
Senator Ricketts. Please go ahead. I am over here if you
want to talk about that once more.
Ms. Danielson. Really, my comment was just that it does
need to be re-evaluated and essentially repealed. It came into
play when Medicare originally came into play, and it is
problematic, and it is a discrepancy between traditional
Medicare and the Advantage plans, and it can cause significant
issues with getting a patient to an appropriate level of care.
You know, even if you are in a facility that is
unnecessary, there are other risks to that as well, and then
getting the patient to the right place, to have the appropriate
rehab or other items is really, really important. Other than
that thank you so much, and have a margarita later, David.
Senator Ricketts. Well, again I would like to thank all of
our witnesses for taking time this morning to be able to help
talk about Medicare and Medicare Advantage and some of the
opportunities we have to be able to improve the system. It
sounds like the biggest thing is trying to reduce some of the
complexity we have got going on here with regard to it, and
that we have got lots of opportunities to be able to make those
improvements, but I appreciate everybody sharing their time and
expertise with regard to this, so thank you very much for being
here.
I hope all of you who were here in the audience enjoyed
learning more about this. I think that we certainly--I don't
know that we have got things we specifically can say we have to
take action on, but it does leave us a lot of opportunities to
be able to work together to be able to find those improvements
and work through the House and the Senate to be able to make
those changes.
Again, folks, thank you very much. I appreciate it. Happy
belated birthday then, David, and with that we will go ahead
and close the hearing. Thank you.
[Whereupon, at 11:24 a.m., the hearing was adjourned.]
?
=======================================================================
APPENDIX
=======================================================================
?
=======================================================================
Prepared Witness Statements
=======================================================================
?
U.S. Senate Special Committee on Aging
"Medicare and Medicare Advantage:
Challenges and Opportunities with Enrollment"
February 23, 2024
David Lange Prepared Witness Statement
Dave Lange, 65yrs. I just had my birthday. The 16th of
February. When I was 18yrs. old, I went into the United States
Navy after finishing high school via a G.E.D. I tested high on
a mechanical scale so they turned me into a Boiler technician.
A rate that no longer exists as far as I know. A little while
after my tour of duty I wound up applying to the maintenance
department at the Swanson building downtown Omaha. Owned by
Campbell Soup, I was there 20 years. I met and married my wife
of 25 years while working there. We lived in Plattsmouth and
raised my daughter, her two sons, and one daughter.
The kids are grown and moved away. Both my wife Joyce and I
have continued to work in various food production facilities
throughout the metro area. Companies such as Conagra, Tyson,
Armor Swift. She is presently still Quality Assurance manager
at Mammas' Tortillas. My most recent employer was Omaha Steaks.
There were two things I wanted for my birthday. One of my
birthday presents was retirement at 65.
Sometime in late 2023 I received information in the mail
that indicated enrollment in Medicare was required prior to my
65th birthday. I was also getting bombarded with phone calls,
messages, e-mails, about Medicare plans, and what I needed to
do about it all. After doing some research, asking a lot of
questions from current retirees, recent retirees, etc. I was
more confused than when I started. I came to realize many of
these were/are in my opinion "sales" opportunists. I contacted
some of them only to find out what ever they offered, whether
it be a "plan" or "service" it would come at a cost.
With good faith in mind, I set out to visit the web site
and see how far I could get. I have been fortunate in life
where I have had to learn and develop good computer skills in
order to hold the management positions I have had. No prodigy,
but can hold my own. Unfortunately, me and passwords don't get
along, so we went round and round a little bit. Eventually this
became a little more user friendly. I reviewed the "items/info
required" list. Very helpful by the way. Gathered up everything
and started the application. Once started it was very quick and
went pretty smooth. Took probably 20 minutes because we were
reading carefully. I'm pretty sure I saw a box on the app that
asked if I was presently covered by a health plan? I answered
yes. At the end of January 2024, I received a bill for $524.10
for part B coverage 02/01/202404/30/2024. This was a shocker. I
reached out and was able to locate a reputable Medicare
counselor. She was able to coach me and well as assist with the
correct form to "un-enroll" from part B. I am covered under my
wife's employer provided group health insurance plan.
I have since gone back onto the website to check my status
and have seen the correction has been made. In early February I
applied for Social Security benefits. The process was similar
to signing up for Medicare. Minus the previously endured "log
in/password" issues. I am still awaiting news of acceptance.
Overall, I would say the system works, needs a little getting
used to, but hopefully will be fine. Oh, what was the second
thing I wanted for my birthday?.......an ice-cold margarita!
U.S. Senate Special Committee on Aging
"Medicare and Medicare Advantage:
Challenges and Opportunities with Enrollment"
February 23, 2024
Jina Ragland Prepared Witness Statement
Thank you for inviting AARP to participate in today's
hearing. My name is Jina Ragland and I am the Associate State
Director of Advocacy and Outreach for AARP Nebraska. AARP,
which advocates for the more than 100 million Americans age 50
and older, appreciates the Senate Aging Committee's effort to
examine the Medicare enrollment process and ways to improve it
for older Americans. In particular, we would like to thank
Senator Ricketts for leading the Improving Measurements for
Loneliness and Isolation Act and for cosponsoring the
Alleviating Barriers for Caregivers Act. These bills will help
Americans thrive as they age.
There are currently over 66 million Americans with
Medicare, and roughly four million people join Medicare for the
first time each year. In Nebraska, there are over 370,000
Medicare beneficiaries - roughly 19% of the population. For
many, Medicare enrollment is a confusing and time-consuming
process, often requiring the help of loved ones and trusted
individuals to guide them through it. Congress and community
partners, like AARP, can all play a role in making the
enrollment process as stress-free as possible. The actions
discussed below are just a few of the positive steps that can
be taken to improve the process for everyone.
BENEFICIARY ELIGIBILITY NOTIFICATION
One of the most common complaints about initial Medicare
enrollment is lack of awareness about eligibility timelines and
enrollment requirements. Failure to timely enroll in Medicare
can result in costly penalties that can be added to your
premiums for as long as you have Medicare. AARP has long
recommended that the Social Security Administration should
notify potential Medicare beneficiaries, well before they reach
Medicare eligibility at age 65, about the steps to take if they
want to enroll and about the circumstances under which premium
penalties may be assessed. Directing the Social Security
Administration to work with the Department of Health and Human
Services to inform potential Medicare beneficiaries of their
eligibility annually for five years prior to turning age 65
will help ensure that older Americans have adequate time to
plan for their transition to Medicare. Bipartisan legislation
in the Senate, the Beneficiary Enrollment Notification and
Eligibility Simplification (BENES) 2.0 Act (S. 1687), would
help people approaching age 65 punctually and properly enroll
in Medicare, thereby preventing delays in coverage and costly
penalties.
IMPROVED CONSUMER EDUCATION
Even if a person knows they can sign up for Medicare, they
may not know how. The decision-making process can be
overwhelming for many individuals. AARP endeavors to be a
trusted friend for older Americans to turn to. The AARP
Magazine and AARP Bulletin, delivered to all our members,
regularly publishes tips and information on Medicare
enrollment. In addition, we have developed a web page of
resources at aarp.org/medicare, as well as our online Medicare
Enrollment Guide which offers a step-by-step tool for first
time enrollees. We also try to meet people where they are
through webinars, on-demand tutorials, and local seminars.
AARP is limited, though, when individuals require more
hands-on or personalized assistance. That is why State Health
Insurance Assistance Programs (SHIPs) are such a valuable
resource. SHIPs provide local, in-depth, and objective
insurance counseling and assistance to Medicare-eligible
individuals, their families, and caregivers. Each state has a
SHIP program administered by professional staff and volunteers
who can help you navigate the Medicare program. Nebraska SHIP
is managed through the Nebraska Department of Insurance with
Federal funding support. An important step the Federal
government can take to help people through the Medicare
enrollment process is to increase funding for SHIPs, Area
Agencies on Aging, Aging and Disability Resource Centers, the
National Center on Benefits Outreach and Enrollment, and other
programs administered by the Administration for Community
Living which engage with people locally in our community.
Additional resources could help to increase awareness of the
SHIPs and increase the number of people the SHIPs can assist.
Unfortunately, one part of SHIP's funding has been stalled
thus far this fiscal year. Mandatory funding for outreach and
assistance to low-income Medicare beneficiaries was not
included in the recent series of Continuing Resolutions which
are currently funding the Federal Government. The modest
funding has been regularly passed as a "health extender" in the
annual appropriations process. We urge Congress to fully
restore the $50 million in mandatory funding in the next
spending deal to enable SHIPs and other entities to help make
Medicare more affordable for low-income beneficiaries.
FAMILY CAREGIVER INCLUSION
While it can be confusing or overwhelming for Medicare
beneficiaries or those enrolling in Medicare to navigate the
program, it can also be challenging for family caregivers who
are assisting or advocating on behalf of a loved one. There are
more than 48 million family caregivers in the U.S. They assist
their older parents, spouses, siblings, grandparents, adult
children, and other loved ones so they can live independently
in their homes - where they want to be. Caregivers provide an
estimated $600 billion in unpaid labor each year, saving
taxpayers billions of dollars. Without them, America's health
and long-term care systems would collapse.
Caregivers help with everything including meals, bathing,
dressing, medications and medical care, coordinating and
providing care, chores, finances, grocery shopping,
transportation, and much more, including assistance with
Medicare enrollment, coverage options, appeals, and beneficiary
advocacy. Caregivers provide, on average, about 24 hours of
care each week. Over half (56 percent) of family caregivers
advocate with care providers, community services, or government
agencies on behalf of their loved one. One in four want help
figuring out forms, paperwork, and eligibility for services.
Among those coordinating care, 31 percent find it difficult to
do so.
AARP supports two bipartisan bills to help make providing
care easier and save family caregivers time and frustration
when trying to navigate or get care for their loved ones in
Medicare. First, the Alleviating Barriers for Caregivers Act
(ABC Act, S. 3109) would help reduce red tape by requiring the
Centers for Medicare & Medicaid Services and the Social
Security Administration to review their eligibility
determination and application processes, procedures, forms, and
communications for Medicare, Medicaid, Children's Health
Insurance Program, and the Social Security programs to reduce
administrative challenges for caregivers. They must report to
Congress within a year on issues identified and findings,
actions they are taking, an estimated timeframe for completion,
any recommended changes in Federal law to address identified
issues, and more. We appreciate that Senator Ricketts has
cosponsored this important legislation. Second, the Connecting
Caregivers to Medicare Act (S. 3766/H.R. 7274) would help
inform people about the voluntary option for Medicare
beneficiaries to allow family caregivers to access their health
information through 1-800-MEDICARE. This can make it easier for
caregivers to communicate with Medicare to help their loved one
or to advocate on their behalf. The sign-up form and other
educational materials would be made available in non-English
languages. The bill would also help ensure 1-800-MEDICARE
operators provide appropriate resources and information for
family caregivers. These two bills are bipartisan commonsense
solutions that we urge Congress to enact into law. Supporting
family caregivers helping their loved ones navigate Medicare is
essential.
IMPROVED EMPLOYER EDUCATION
AARP understands that most people enrolling in Medicare for
the first time are transitioning from employer-sponsored health
coverage. The employer or, when available, the health benefits
administrator is well positioned to help individuals make the
transition to Medicare and avoid enrollment mistakes and costly
penalties, yet they are often ill-equipped to provide guidance
or answer questions from their employees. AARP is working to
address this issue by developing educational programs and
training resources designed specifically for employers. More
than merely creating pamphlets and brochures, AARP is
proactively reaching out to employers. In only the first couple
years of this effort, already 1,700 employers have participated
in our Medicare 101: For You, Your Employees, and Your Business
program and 30,000 Medicare educational resources have been
distributed to employers. Better employereducation can help
reduce information errors and provide another reliable source
of information for consumers.
MEDICARE ADVANTAGE INFORMATION
AARP supports enabling all Medicare beneficiaries to make
their own health care coverage choices based on their specific
health care needs, preferences, and history. The explosion of
Medicare Advantage (MA) plan availability - with the average
beneficiary having access to 43 different plan options in 2024
alone - can make enrollment in the right plan a daunting
process for even the most knowledgeable consumers. With
enrollment in MA plans eclipsing that in traditional Medicare,
it is increasingly important for Congress to ensure that
beneficiaries are adequately served in both MA and traditional
Medicare in terms of costs, benefits, quality of care, and
patient outcomes. AARP has long supported efforts to improve
the quality and affordability of all Medicare coverage options
while working to ensure that consumers maintain a robust choice
of both MA and traditional Medicare options.Plan marketing
directly affects consumers' experience and ability to make
informed enrollment choices. In many cases, deceptive marketing
practices have led individuals to enroll in a plan that does
not meet their needs. AARP has repeatedly raised concerns about
marketing abuses around MA plans and advocated for greater
oversight, enforcement, and regulation of marketing materials
and marketing standards for MA plans. Despite the progress made
by new consumer protections, additional policy improvements
continue to be needed. For example, improved transparency about
agent, broker, and third-party organizations' compensation and
financial incentives could help better inform consumer decision
making. It is also critical to equip consumers with a clear
pathway to lodge a complaint about problematic marketing
practices.
In addition, increasing access to unbiased sources of
information, such as through SHIPs, is essential to helping
consumers discern Medicare marketing information. Medicare.gov,
in particular, is often the first stop when choosing a coverage
option regardless of whether a person is enrolling in Medicare
for the first time or thinking of making a change during Open
Enrollment. The website's Plan Finder tool is useful for
researching MA plans and Part D prescription drug plans.
However, there are still improvements that can be made to the
website that would help in a person's decision making. For
instance, the tool does not readily present traditional
Medicare as an alternative choice to Medicare Advantage for
health coverage. While the tool provides some introductory
information about the difference between traditional Medicare
and Medicare Advantage, Plan Finder inadvertently steers
beneficiaries towards MA by not presenting traditional Medicare
as a meaningful choice while they are comparing plans.
Additionally, it is often difficult to make apples-to-apples
comparisons between plans on Plan Finder because it receives
incomplete information on plan provider directories and
coinsurance costs from insurers. At best, Plan Finder links to
the insurer's own provider directory, which is often inaccurate
or out of date. Greater transparency and reporting requirements
are needed so that consumers have a full look at pertinent
information.
In conclusion, thank you for the opportunity to provide
AARP's perspective on improving Medicare's enrollment process.
I would be happy to answer any questions. We look forward to
working with you to address this important issue and ensure
continued access to affordable health benefits for older
Americans.
U.S. Senate Special Committee on Aging
"Medicare and Medicare Advantage:
Challenges and Opportunities with Enrollment"
February 23, 2024
Kierstin Reed Prepared Witness Statement
Good Afternoon, Senator Ricketts, fellow testifiers, and
members of the public. My name is Kierstin Reed and I serve as
the President & CEO for LeadingAge Nebraska. Thank you for
allowing me to testify today. We appreciate Senator Ricketts
bringing this hearing to Nebraska. LeadingAge Nebraska is a
statewide membership association that provides advocacy and
education for providers of long-term care services in our
State. We represent 80 providers across the State and work with
our national partner LeadingAge, to provide support to over
5,000 long term care providers across the US.
Since the inception of the Medicare system in 1965, there
have been numerous developments and changes to the system that
now covers over 63 million beneficiaries across the US, with
300,000 of them being in Nebraska. The most recent change to
the system is the addition of Medicare Advantage, also known as
Part C as a private plan option, replacing the traditional Part
A and B benefits. The Medicare selection process can be a
daunting task for beneficiaries and supporters because the
number of options has increased. The amount of information they
need to wade through to try to understand the benefits
available to them can be overwhelming. The number of services
claiming to help seniors select a Medicare plan seems to be
never ending and it is difficult for seniors to find a
reputable, trusted source to support them in the decision
making process.
LeadingAge Nebraska works with many nursing homes and home
health providers across the State supporting older adults. When
older adults find themselves in need of nursing care, either
short term or long term, they have generally already been
enrolled in a Medicare plan. It is often at this point in time
that a professional is explaining the fine print of the plan
they have selected to them and what services are available to
them.
When you find yourself or a loved one in need of long-term
care services, it can be difficult for anyone to understand the
entire process. We find that beneficiaries and their family
members may not fully understand what is covered under their
Medicare plan. Many beneficiaries are under the belief that
because they have Medicare, their long-term care services will
be completely covered without out-of-pocket expenses and will
last until they no longer need the services.
Beneficiaries are often surprised by the limitations on the
services they receive and the overall cost of the services they
need. For those needing skilled medical services, Medicare will
pay for a portion of their stay if they are approved for this
level of care for a period of time. If they no longer meet the
criteria for skilled care, or have used their maximum benefit,
Medicare no longer covers their need for these services. The
average cost of nursing home services in Nebraska is $7,500 per
month for custodial care, which is not covered by Medicare. As
people are living longer and have more complex health
conditions, we find that beneficiaries are often outliving
their personal resources for care, even with their Medicare
benefits. Currently, 60% of nursing home residents in Nebraska
rely on Medicaid as their payor source because they have no
longer have funds to pay for services.The expansion of the
Medicare Advantage program has increased the confusion for
beneficiaries when they are selecting a plan. There are
numerous Advantage plans available, which can muddy an already
complicated system. There are now 46%% of beneficiaries
nationally enrolled in a Medicare Advantage option. For
Nebraska, this is closer to 30%, however this number continues
to rise. These plans entice beneficiaries with many benefits
that are not available in the traditional Medicare model,
however beneficiaries may find that these plans are not widely
accepted at every medical provider, limiting their options for
care. Beneficiaries may also find that the services they would
expect from Medicare are not the same that they anticipated
compared to traditional Medicare due to authorization denials
and limitations of services.
The intent of these plans is to provide equitable coverage
in Part A and B, in addition to providing other benefits, such
as vision and dental. Today, there is evidence that Medicare
Advantage plans are denying coverage for Medicare services and
in other cases, terminating care before the beneficiary is
ready to go home. We need to assure that beneficiaries are
receiving equitable care, regardless of the plan the choose.
In order for our health care system to work efficiently and
effectively, there needs to be a focus on provider payment
adequacy for services covered by Medicare. Traditionally,
programs like Medicaid and Medicare have paid at a lower
reimbursement than private insurance. The introduction of
Medicare Advantage continued this trend at a deeper level. Some
advantage contract to providers is equal to the state Medicaid
rates, which experts agreed don't begin to cover the cost of
custodial care, let alone the more intense skilled care
provided when a beneficiary has significant health care needs.
If the concerns with Medicare, particularly with Advantage
plans continues, it will cause erosion in the health care
system. Providers of long-term care services are already
closing at an alarming rate due to the rising cost of care,
staffing shortages, and an inadequate reimbursement system.
Patients are waiting for weeks to months on average in Nebraska
hospitals for a placement in long term care. Nebraska has lost
17% of our nursing homes since 2017 and we are at risk for
losing more in the coming years.
In closing, LeadingAge Nebraska wants to assure that older
adults receive fair and equitable Medicare services. We want to
assure they understand the benefits they are receiving and that
they have a clear understanding of the choices they make when
selecting a plan and the long-term impact those choices may
have for their health care coverage. We also want to assure
that the services they need are available to them when they
need them. There are improvements that need to be made to
address the access to benefits that meet the needs of
beneficiaries.
Thank you for providing me the opportunity to testify
today.
U.S. Senate Special Committee on Aging
"Medicare and Medicare Advantage:
Challenges and Opportunities with Enrollment"
February 23, 2024
Dr. John Trapp, M.D., Prepared Witness Statement
Good morning, my name is Dr. John Trapp. I am the Vice
President of Medical Affairs and Chief Medical Officer for
Bryan Health, a six hospital locally owned and governed
Nebraska health system, and a pulmonary, critical care
physician. I have been in clinical practice in Nebraska for 25
years. I will begin by thanking Senator Ricketts for his
attention to this issue and providing a venue by which we may
share our concerns about Medicare Advantage and their practices
with all of you. Today I will outline a couple of our concerns,
namely that abusive practices by insurers offering Medicare
Advantage programs put vulnerable patients at risk and
negatively impact hospital capacity, all while reducing
payments to those who are actually providing the care.
In a Modern Healthcare article published February 16th, the
author Caroline Hudson summarized many of the MA plans well,
"Medicare Advantage plans generate billions of dollars for
payers as they woo members with $0 premiums and supplementary
benefits." At its inception MA's intention was to allow for
highly coordinated, proactive, population-based care that would
reduce health care costs over time - something we can all agree
on. In reality, the financially driven interests of the
insurance companies have resulted in MA programs becoming the
most profitable arm of many of the major insurance companies at
the expense of the patient, taxpayers and the Medicare trust
fund.
The Medicare Payment Advisory Commission (MEDPAC) projects
that the Federal Government will pay MA plans $88 billion more
this year than if those same beneficiaries would have been
covered under the traditional Medicare program. Yet these
additional funds are not going to providers. Just the opposite.
Most physicians will receive less in 2024 as their Medicare
Advantage fees are tied directly to the Medicare provider fee
schedule, which will be cut 3.4% this year, culminating in a
roughly 10% cut over the last four years.
At Bryan Medical Center, traditional Medicare reimburses us
approximately 80% of our actual costs, meaning that we lose
more than $90 million dollars per year on the Medicare patients
we care for (including MA). Our contracts with MA plans call
for reimbursement rates that are at least 100% of Medicare.
However, due to inappropriate denials as well as delays in
preauthorization and payment we receive less than what
traditional Medicare would have reimbursed. For one of the most
prominent MA insurers in the country, we receive only 88% of
traditional Medicare reimbursement despite fighting their
tactics every step of the way expending numerous resources to
fight through unfair tactics where the advantage always lies
with the insurer.
More important than the impact on reimbursement, prior
authorization and denial practices have at times overwhelmed
hospital systems and created a log jam that impacts vulnerable
patients and hospital capacity. Bryan Medical Center is located
in Lincoln, Nebraska, has 664 licensed beds, and is often full.
We consistently serve patients from all of Nebraska's 93
counties and surrounding states. On a Friday morning earlier
this month we had 40 patients boarding in the emergency
department, waiting for a bed upstairs. Several beds could have
been made available except that a number of patients were
effectively stuck at Bryan awaiting authorization by Medicare
Advantage plans to be discharged to post-acute facility such as
skilled nursing or long term care.
Finally, I'd like to spotlight the reason we are all here,
patients and the delivery of quality care. These are the
stories of two real life patients from the last several weeks
at Bryan Medical Center. Patient A has been accepted to a long
term care facility, their MA plan requires authorization for
them to move to the next, most appropriate level of care. They
no longer need to be in the hospital. The authorization was
submitted to their health insurance plan on January 26th, 2024.
On February 1st, our care transitions staff called the insurer
asking for an update - their reply "We have 10 more days to
make a decision". Ten days of delay to receive the
rehabilitative care they need, ten days of being unable to
leave the hospital, ten days of unreimbursed care, ten days of
frustration - this is what happens when patient's select MA
plans thinking they will have timely care and access to
expanded benefits. Rather, they are at the mercy of their
health insurance plan not what their doctor thinks is best for
them. The hospital is not getting paid to care for this patient
because the patient no longer requires acute care. The
insurance company is getting days and weeks of free nursing
care for their patient, at the expense to the patient's
wellbeing, their family, and the hospital while making record
profits.
Patient B has been waiting for authorization since February
12th, for the subsequent three days our capacity management
director has emailed the MA insurance company and called
multiple times trying to get an answer - they do not respond.
The nursing facility that has accepted the patient cannot take
them over the weekend, so if we don't get authorization by
Friday, February 16th, the patient won't be able to discharge
until Monday at the earliest. This results in even more days
the patient is in the hospital for no reason, disallowing
another patient with acute medical needs from accessing
care.Now the insurance companies will tell you that they will
pay for the delayed days, this is simply not true. The patients
they will pay for are one - a limited group and two - require
another authorization for the excess days. The hospital is
further burdened in recouping costs because the MA plan wasn't
efficient in processing the authorization the first time.
Why does Bryan continue to accept Medicare Advantage?
Because taking care of those who need us is our first priority,
but the current tactics of large national insurers, who hold
the power, must be reined in for the sake of both the
vulnerable and those of us who take care of them. The current
model is not sustainable as the insurers claim record taxpayer
funded margins, and the hospitals and healthcare providers
subsist in the aim to fulfil our mission of care. MA plans are
selling patients a bill of goods they cannot and choose not to
fulfill.
Thank you for the opportunity to share but a small picture
of the ways Medicare Advantage is impacting Nebraskans. Our
State's story is not unique, these behaviors are impacting
American's nationwide. As you hear from myself and others
today, I ask that you be moved to take action. I would welcome
any questions you may have for me at this time.
U.S. Senate Special Committee on Aging
"Medicare and Medicare Advantage:
Challenges and Opportunities with Enrollment"
February 23, 2024
Jana Danielson Prepared Witness Statement
Thank you for the opportunity to speak regarding the
challenges associated with Medicare and Medicare Advantage
(MA). My testimony today will focus on challenges faced by
healthcare providers who are committed to caring for our
Medicare and Medicare Advantage population.
Nebraska Medicine provides health care services to a
significant number of patients who are covered by Medicare and
Medicare Advantage. These patients represented 43.5% of health
care services provided in FY23. The Medicare-eligible
population has been trending upward over the last several
years, and we anticipate that trend will continue as our
state's population ages. Of total Medicare-eligible patients,
Medicare Advantage enrollees make up approximately 35% of the
total of Medicare-eligible population, and this proportion of
patients enrolled in MA plans versus traditional Medicare
continues to grow.
Medicare Advantage plans, offered as an alternative to
traditional Medicare, are intended to provide the same benefits
as traditional Medicare as a minimum standard. Unfortunately,
healthcare providers routinely face challenges securing
medically necessary care when Medicare Advantage coverage has
been chosen by a Medicare beneficiary. The greatest challenges
include prior authorization requirements, reimbursement
challenges and inconsistent Medicare Advantage plan
interpretations of Medicare rules.
The most recent "CMS Interoperability and Prior
Authorization Final Rule CMS-0057-F" is a good start to address
concerns related to delayed or denied care for Medicare
Advantage beneficiaries resulting from prior authorization
requirements. However, opportunities remain to ensure timely
access to appropriate care for Medicare Advantage beneficiaries
while reducing administrative burden for providers.
Application Programming Interfaces (APIs) and timeframes
for payer responses do not address or standardize payer reasons
for denial which can vary across MA plans and are often of sync
with Medicare coverage guidelines. The Contract Year (CY) 2024
Medicare Advantage Final Rule continues to allow MA plans to
apply their own coverage criteria when Medicare coverage
criteria is not fully established. This results in variability
among various MA plans and a requirement for providers to
navigate multiple payer policies creating additional burden.
As an example, Nebraska Medicine routinely experiences
authorization denials for medically necessary care with
requirements from the MA plan to complete a peer-to-peer
discussion or a letter of medical necessity - even though the
care plan is considered the best course of treatment by our
providers, it meets standard of care guidelines, and a Medicare
coverage policy (local or national coverage decision, LCD or
NCD) does not exist. To further complicate matters, the appeal
process for every MA plan is different. Some allow a peer-to-
peer; some require a letter of medical necessity, while others
may require a letter of medical necessity first with a peer-to-
peer as a next step. Providers must navigate numerous different
payer policies, as one MA plan is simply one MA plan.Imagine a
patient recently diagnosed with cancer waiting for approval to
begin cancer treatment and having a payer question the
treatment plan of a highly respected provider with excellent
outcomes that the patient trusts. The patient wants to act
quickly; they want their payer and provider to act quickly.
Yet, delays occur due to prior authorization requirements that
are simply administrative in nature. In most cases, final
approval is received with no change to the original treatment
plan, making all of the administrative work ultimately
unnecessary.
Imagine the provider who is caring for the same patient and
many others, who is focused on quick, appropriate, medically
necessary care for all patients. They see their patients face
to face, talk to them, examine them; they are aware of the most
up to date research and best courses of treatment; yet they are
required to spend countless hours talking to payers (during
payer business hours) or writing letters to substantiate their
treatment plan. This additional burden placed on providers
takes time away from caring for patients which is their top
priority.
Now consider this same patient may require hospital care
followed by post-acute care needs. Hospital stays with Medicare
Advantage plans present another set of challenges. In an acute
hospital, there is a difference in reimbursement for stays
classified as "observation" and those classified as
"inpatient." Inpatient stays require a higher, more resource-
intensive level of care, and thus, are reimbursed at a higher
rate. To simplify the classification, Medicare implemented a 2-
midnight rule in 2013, which means that inpatient services are
considered appropriate if the physician expects the patient to
require medically necessary hospital care spanning at least two
midnights. The Contract Year 2024 Medicare Advantage Final Rule
clarified that Medicare Advantage plans must comply with
general coverage and benefit conditions included in Traditional
Medicare regulations. Yet, Nebraska Medicine is experiencing
medical necessity denials for inpatient stays on cases with
length of stays four days and greater - double the Traditional
Medicare requirement. Medicare Advantage plans continue to deny
medical necessity for patients that would have been approved
for inpatient status based on the Traditional Medicare 2-
midnight rule.
Not only does the classification of care as observation or
inpatient affect hospital reimbursement, patient out-of-pocket
costs may increase due to the difference in deductible,
coinsurance and coverage guidelines associated with observation
versus inpatient stays. The denials are often received within
the first 24-36 hours of care and place additional
administrative burden on the hospital to work with the payer to
overturn the denial while the patient is being treated. The
administrative burden in this case includes both nurse and
physician time. The hospital has been forced to contract with
outside physicians to simply battle payer's physicians to allow
inpatient status. Holding the MA plans accountable to
traditional Medicare 2-midnight rules would protect our
patients and reduce administrative burden and cost for the
provider and the payer.
Imagine this same patient is now ready for discharge, and
the care team agrees that an Acute Rehab Facility is necessary,
for example. Nebraska Medicine contacts the Medicare Advantage
plan, who denies Acute Rehab authorization. A peer-to-peer is
completed by the attending physician, and the MA plan confirms
acute rehab denial but approves patient discharge to a Skilled
Nursing Facility (SNF). The family and care team identify a SNF
for discharge purposes. After a week of waiting for approval,
the MA plan denies the SNF level of care. At the same time that
many MA plans are denying ongoing hospital care for lack of
medical necessity, their process for approval of post-acute
care creates barriers to accessing a lower level of care for
these patients, which leads to longer lengths of stay in the
hospital. When this occurs, the cost and burden of care falls
to the hospital to supply services that go uncompensated while
awaiting approval and acceptance to a SNF, acute rehab unit
(ARU) or long-term acute care hospital (LTACH). And the patient
waits.
After discharge, this same patient may require readmission
back to the acute hospital setting. The MA plans do not follow
CMS readmission guidelines. Readmission denials have been
escalating, and the only path to appeal is a written letter. At
this time, some MA plans deny ALL readmissions without
consideration for diagnosis or expected readmission rates.
Related to Traditional Medicare I would like to address two
items: First, the three-day inpatient requirement for a SNF
stay. For traditional Medicare patients, the requirement for a
three-day inpatient stay prior to coverage for skilled nursing
services is often viewed as an antiquated measurement of
severity of illness and does not reflect recovery timeframes in
today's healthcare world. Nebraska Medicine would advocate for
dissolution of the 3-day SNF requirement. Second, proposed
Medicare HOPD Cuts or "site neutral" policies. The concept of
"site neutral" policies on the surface makes sense to address
the goal of eliminating cost disparities between hospital
outpatient departments and independent physician offices. Going
beyond the surface, hospitals bear costs that physician
practices or Ambulatory Surgery Centers do not, including 24
hours day availability, the ability to treat complex medical
conditions, requirements to provide emergency care and to
participate in emergency preparedness activities. Continued
cuts have the potential to impact hospital's ability to provide
essential care for the communities they serve.
In conclusion, administrative costs to comply with rules,
monitor for denials, appeal for proper patient care, and
pursuit of proper and fair reimbursement continues to escalate
in cost and time and is unsustainable. Thank you for the
opportunity to share my perspective.
/s/
Jana Danielson
Vice President, Revenue Cycle
Nebraska Medicine
[all]