50 Wishes for
Medicare’s Future

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Enhance Education and Choice

Allow open enrollment in Medigap for all people with Medicare

Beneficiaries are entitled to select a Medicare Advantage plan every year during the annual enrollment period, but most are only guaranteed the right to enroll in a Medigap plan during very limited times. Additionally, in most states, Medigap insurers are permitted to charge more or deny coverage outright to some populations, including people with disabilities and people with End Stage Renal Disease. Congress should expand Medigap enrollment rights to ensure that all beneficiaries have access to Medigap plans and to allow all Medicare beneficiaries to make a choice about the coverage best suited to their needs each year.

Consolidate and standardize Medicare Advantage and Part D plans

Selecting an MA or Part D plan is a daunting task for most people with Medicare. There are simply too many plan choices and too many variables to compare. Alarmingly, only 13 percent of Medicare beneficiaries opt to reevaluate their coverage options year to year—despite annual changes to premiums, plan coverage rules, and cost-sharing. Congress should enact legislation to consolidate MA and Part D plan choices and standardize options in order to facilitate informed decision-making by Medicare plan enrollees.

Provide a federal notice for everyone approaching Medicare eligibility

No federal agency provides notification about Medicare eligibility to individuals not yet collecting Social Security benefits—meaning those not automatically enrolled in Medicare are not informed about enrollment rules and policies. Honest enrollment mistakes can result in lifetime premium penalties, gaps in health coverage, and higher health care costs. The federal government should provide a notice to all people approaching Medicare eligibility about how and when to enroll.

Put beneficiary needs at the center of delivery system and payment reforms

Recent legislation is fundamentally changing the way that Original Medicare pays doctors and other health care providers to deliver care. Over time, the federal government will increasingly pay for high-value care as opposed to high-volume care. As these payment reforms are implemented, the federal government must actively engage, involve, and educate Medicare beneficiaries and consumer advocates. Strong oversight and transparency is also important to protect against discriminatory practices and diminished access to care.

Align all enrollment periods for Original Medicare, Medicare Advantage, and Part D

The fall open enrollment period for Medicare Advantage (MA) and Part D plans runs from October to December of each year, followed by an MA disenrollment period from January through February. In contrast, the General Enrollment Period (GEP) for delayed Part B enrollment runs from January to March of each year. Congress should align these disparate enrollment periods to create a Medicare enrollment season, allowing the federal government, community-based organizations, and others to more effectively educate beneficiaries about their Medicare enrollment options.

Require Part D plans to give the reason for a medication denial at the pharmacy counter

Knowing why a prescription drug is refused at the pharmacy counter is critical to helping beneficiaries determine their next steps—whether it is working with their physician to secure an alternative or appealing for coverage from their Part D plan. The federal government should require Part D plans to provide an individually tailored notice at the pharmacy counter when a medication is refused. The notice should explain why the prescription cannot be filled, for instance because it is off-formulary or because prior authorization is needed.

End passive enrollment for Medicare-Medicaid managed care plans

Ongoing demonstration programs to test new models of care for dually eligible Medicare and Medicaid beneficiaries are allowing private health plans to passively enroll beneficiaries. This means low-income, vulnerable individuals are not actively choosing their coverage or determining if the selected plan is the best option for their needs. Congress should prohibit the use of passive enrollment, a practice that fundamentally undermines beneficiary choice and informed decision-making.

Create a publicly-administered Part D benefit

The Medicare prescription drug program is operated solely by private health plans. Adding a public drug benefit to the Part D program would diminish confusion among beneficiaries who now must navigate a complicated maze of private health plans and year-to-year formulary changes. In addition to enhancing beneficiary choice, a Medicare-administered plan also has the potential to create federal savings through simplified administrative processes. Congress should create a publicly-administered Part D benefit.

Prohibit Medicare Advantage plans from dropping doctors mid-year without cause

Beneficiaries enrolled in MA plans should be able to count on stability in their plan networks and the knowledge that their doctors will be there when they need them. Congress should pass legislation to prohibit MA plans from dropping doctors without cause in the middle of the plan year and strengthen beneficiary notice on provider network changes.

Incorporate Medicare Advantage (MA) provider network information in the Plan Finder tool

Information about which health care providers are in network and out of network is vital for helping beneficiaries make smart decisions about their coverage. Yet this critical information is absent from Medicare’s primary online decision-making tool—Plan Finder. The federal government should incorporate accurate and timely MA provider network information in Plan Finder.

Create an individually tailored Annual Notice of Change for Medicare Advantage (MA) and Part D plans

Annual changes to MA and Part D plan coverage rules, cost-sharing amounts, and provider networks are commonplace. At the same time, comparing and contrasting plan options during the Medicare open enrollment period is a dizzying task for many. To help beneficiaries make informed decisions, the federal government should require that Medicare private health plans provide a tailored notice to beneficiaries, based on claims data, describing how a plan will change in the coming year.

Enhance audit capacity and increase transparency on Medicare Advantage (MA) and Part D sanctions

The federal government is currently only able to audit 10 percent (about 30 of 300) of Medicare private health plan sponsors each year. Recent audits uncovered noncompliance among most plan sponsors on multiple measures related to beneficiary grievances and appeals. These audits are critical to judging plan performance, assessing customer service, and ensuring beneficiary access to needed care. Both Congress and the federal government should prioritize avenues to mandate more regular and consistent auditing of MA and Part D plan sponsors.

Improve beneficiary education on low-to-no cost preventive services and screenings

Prior to the Affordable Care Act, many preventive screenings were not covered by Medicare. Now, not only are certain preventive services covered, most of the time they are covered without cost sharing. Unfortunately, too many Medicare beneficiaries remain unaware of the preventive services now available to them. At the same time, many are uninformed about when cost sharing might apply, such as when a screening test automatically leads to a diagnostic procedure. The federal government should work with physicians and consumer advocates to ensure people with Medicare have the right information about preventive coverage and benefits.

Improve Medicare Advantage (MA) and Part D denial notices

The most common call to the Medicare Rights national helpline comes from a beneficiary denied access to a health care service or prescription medication, and most of these calls are from people enrolled in an MA or Part D plan. All too often, beneficiaries struggle to interpret denial notices and remain unclear about their appeal rights. The federal government should require that MA and Part D plan denial notices include the right information (including clinical content), are available in languages other than English, and include content accessible to diverse health literacy levels.

Enhance beneficiary education on quality and star ratings scores across all parts of Medicare

The star ratings programs are becoming an important tool to help Medicare beneficiaries identify high quality (and low quality) Medicare private health plans, nursing homes, hospitals, and more. Yet available evidence suggests that beneficiaries rarely reference these quality scores when making health care decisions. Congress should support a wide-reaching education campaign to help beneficiaries better understand what the star ratings scores mean and how to use them.

Increase federal funding for State Health Insurance Assistance Programs (SHIPs)

SHIPs provide in-depth, one-on-one counseling to seniors and disabilities about how to navigate Medicare. SHIPs play a critical role in ensuring that beneficiaries make informed decisions about their coverage, including selecting among Medicare Advantage and Part D prescription drug plans as well as supplemental Medigap insurance. SHIPs are also integral to helping beneficiaries and their families find their way in an evolving and increasingly complex benefit, with many ongoing pilot initiatives changing how care is delivered, both in Original Medicare and private health plans. For too many years, SHIPs have been flat funded, meaning that federal resources have not kept […]