US health officials are looking for new restrictions on private Medicaid plans

Federal health officials are proposing a comprehensive set of stricter measures Rules Administers private medical benefit health plans in response to widespread complaints that many patients’ medical claims are wrongly denied and the plans’ marketing is deceptive.

Medicare Advantage is a private-sector alternative to the federal program that covers people over age 65 and those with disabilities. By next year, More than half Medicare recipients are expected to be enrolled in private plans. These policies are less expensive than traditional health insurance and sometimes offer attractive, additional benefits such as dental care.

Despite their popularity, the programs have recently come under considerable scrutiny and criticism. A recent Report The inspector general of the US Department of Health and Human Services found that many programs may be inappropriate. Denies care For patients. Every major insurance company in the program, including UnitedHealth Group, Eleventh Health, Kaiser Permanente and Cigna. Sued by the Judiciary for fraudulently overcharging the Govt.

This year’s deadline for admission, which was set to December 7, has fueled widespread criticism. Cheating tricks Some brokers and insurers lured people to switch plans. In November, Senate Democrats issued a strong condemnation Report It describes some of the worst practices, including advertisements representing federal agencies and ubiquitous television commercials featuring celebrities.

Federal Medicare officials have said they will review TV ads before they air, and the new rule targets some of the practices identified in the Senate report that confused some consumers with the companies’ government Medicare program. The proposed regulation would prohibit the use of the Medicare logo and require that the agency behind the ad be identified.

“It’s certainly a shot in the arm for brokers and insurers with the growing number of complaints about improper marketing practices,” said Tricia Newman, executive director of the Center for Medicare Policy at the Kaiser Family Foundation. Ms. Newman and her team regularly review television commercials from the programs.

The plan also allows users to opt out of marketing calls for programs and limits how many companies can contact a user after filling out a form asking for information. The Senate report detailed patients who received dozens of unsolicited invasive marketing calls.

David Lipschutz, co-director of the Center for Medicare Advocacy, said that while the federal proposed rules don’t include everything on his wish list, the goals are broad and significant.

“It’s actually a meaningful response,” he said. “Where we’re sitting, we can’t say that very often.”

Changes will ultimately be determined by how effectively and aggressively Medicare implements the standards, Mr. Lipschutz said. Much of the deceptive marketing is now conducted by brokers, agents and other third-party marketing firms, who are paid commissions when they enroll people, not by insurers. The proposed rule would hold insurers liable for the actions of the companies they employ.

“These proposals are an important step in protecting seniors on Medicare from fraudsters and unscrupulous insurance companies and brokers,” Senator Ron Wyden, Democrat of Oregon, who chairs the Senate Finance Committee, said in a statement.

Rules address the use of technologies by health plans. Patients and their doctors have complained to Medicare that private plans abuse pre-authorization processes to deny needed care. The Inspector General’s report estimated that tens of thousands of individuals were denied medical assistance they needed.

The new proposal would require plans to disclose the medical basis for refusal and would rely more on experts familiar with the patient’s care to be involved in decision-making. Medicare has also established tighter time limits for responses to authorizations; Patients now wait up to 14 days. The new rules will require authorization to cover the entire length of treatment, so patients don’t have to continually request the same authorizations.

Dr. Meena Seshamani, director of the Centers for Medicare and Medicaid Services and deputy administrator of the Centers for Medicare and Medicaid Services, said the changes were influenced by thousands of public comments solicited by the agency and lawmakers.

“We believe the proposals in this rule will meaningfully improve people’s timely access to Medicare for the care they need,” he said.

The insurance industry has said it generally supports regulators’ efforts to protect Medicare enrollees from deceptive marketing, and the Better Medicare Alliance, a group that advocates for Medicare Advantage, “agreed with officials that there is no place in the system for people who deceive seniors,” according to a statement from the group’s chief executive, Mary Beth Donahue.

Ms. Donahue added that her team is continuing to review the agency’s proposals for how patients should be pre-authorized for treatment. He said the agency hopes to work with Medicare officials to improve the process.

Hospitals, which have been pushing for changes that address their concerns that insurers are abusing prior authorization, applauded the proposals. But they urged the Biden administration’s health officials to commit to implementing stricter oversight.

“Agencies really need to keep their eye on the ball,” said Molly Smith, group vice president for public policy at the trade organization American Hospital Association.

The proposed regulations are yet to be finalised. Health officials can ask for feedback from the public and make changes.

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