[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 
        
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                 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
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               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director   
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                
                         C  O  N  T  E  N  T  S

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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.]

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                                APPENDIX

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                      Prepared Witness Statements

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                 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
    
    
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