Viewpoint: CMS must stop harmful care denials in Medicare Advantage

As Medicare Advantage insurance companies continue to grow in popularity, it’s important for our nation’s health policy leaders to ensure that MA enrollees have access to the same level of medically-necessary coverage as traditional Medicare. Fortunately, CMS has proposed a rule to address this problem, and public comments are due Feb. 13.

Last year, the HHS Office of Inspector General found that MA plans frequently deny requests for needed care that meet traditional Medicare coverage rules. The OIG warned that these inappropriate denials “delay or prevent patient access to needed care, cause patients to pay out of pocket for services, and create an administrative burden for patients and providers.”

To illustrate this problem, the Louisiana Hospital Association recently posted two video testimonials about Mrs. Frances Moore, a cancer survivor who is the widow of New Orleans Saints' legend Derland Moore. After Mrs. Moore received strong chemotherapy treatments, she fell three times, and her doctors determined that she met the traditional Medicare coverage rules to qualify for inpatient rehab services. Mrs. Moore’s insurance company denied her this needed level of care, arguing that a lower level of care could be provided "safely" in other settings. "This put her life and health at risk," said her son Chip. "She fell two more times with two return visits to a hospital."

Arbitrary care denials based on secret MA coverage rules can increase costs and reduce quality. CMS' proposed rule (CMS-4201-P) would require MA plans to disclose their secret coverage rules and more closely align these coverage decisions with traditional Medicare. In Mrs. Moore's case, her MA plan would not be able to deny coverage for medically-necessary post-acute care or redirect her to a lower level of care unless she explicitly did not meet Medicare coverage criteria for the recommended level of care.

Healthcare providers and MA beneficiaries urge federal leaders to finalize the rule and to strengthen its enforcement with aggressive audits of inappropriate MA denials.

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