Medicare Advantage Insurance Denial
When Americans sign up for Medicare, they can opt for original Medicare or Medicare Advantage. Medicare Advantage (MA) is offered from a private health insurance company. This coverage typically includes Medicare Part A, Part B, and often Part D as well as other benefits. In 2023, Medicare Advantage plans accounted for 51% of eligible Medicare recipients. And Medicare Advantage participation is projected to reach 62% by 2033. This page reviews Medicare Advantage plans, the largest private health insurers offering MA plans, how to select a MA plan, and recent issues with these plans. We discuss what to do if you receive a Medicare Advantage health insurance denial. If you receive a Medicare Advantage insurance denial, contact the Law offices of Scott Glovsky. We’ve been helping Medicare Advantage policyholders get the care they need for over 20 years.
What is Medicare?
Medicare is the federal health insurance plan for Americans 65+. Medicare also covers some younger disabled individuals as well as those with End-Stage Renal Disease. In 2022, over 58 million people are Medicare recipients. When you become eligible, you have choices. You can sign up for original Medicare that includes Part A (hospital insurance) and Part B (medical insurance). Original Medicare is sometimes called, “fee for service.” In addition, you may sign up for Medicare Part D (drug insurance) and Medigap (Medicare supplemental insurance). Medigap is a private health insurance company that supplements Medicare and covers costs that Medicare doesn’t cover. Instead of selecting original Medicare, however, you can also enroll in a Medicare Advantage plan. You have the same protections and rights in original Medicare and Medicare Advantage plans.
Is Medicare the Same as Medicaid?
Medicare is different than Medicaid. Individuals 65+ and some younger individuals with disabilities are eligible for healthcare through Medicare. Medicaid (known as Medi-Cal in California), on the other hand, is primarily for low-income people. Medicaid and the Children’s Health Insurance Program (CHIP) give free or low-cost health coverage to certain low-income individuals, families and kids, pregnant women, the elderly, and people with disabilities. Medicare is a federal program while Medicaid is a federal and state program, financed by both. The federal government sets standards for Medicaid, but states oversee Medicaid and determine who is covered, what is covered, how much doctors and facilities are paid, and so on. Over 70% of Medicaid recipients are enrolled in managed care plans. Managed care plans are often offered by commercial health insurance companies such as Anthem Blue Cross, Centene, and UnitedHealthcare. These plans operate in a similar way to Medicare Advantage plans.
One complaint about Medicaid is that recipients don’t always receive timely, high-quality access to care. In July 2023, Health and Human Services’ Office of Inspector General found that one in eight requests for prior authorization of health services to Medicaid Managed Care in 2019 was denied. That’s a 12.5% denial rate. Looking at specific insurance company denial rates, Molina was 17.7%, UnitedHealthcare was 13.6%, Anthem was 12.9%, and Aetna was 12.1%. Medicaid managed care has fewer appeal levels than Medicare Advantage. In fact, many states don’t even have an external appeal process. And because CMS doesn’t require states to monitor denials, there isn’t appropriate state oversight.
What is Medicare Advantage and Why Would There Be a Medicare Advantage Health Insurance Denial?
Medicare Advantage plans are also known as Medicare Part C or MA plans. These plans offer Medicare-approved private company health insurance. These private health insurers include companies like Blue Shield, Anthem Blue Cross, UnitedHealthcare, Cigna, and others). Medicare Advantage private insurance companies must comply with Medicare rules. MA plans include Medicare Part A, Part B, and Part D. Medicare Advantage plans get a certain amount from Medicare for each participant every month. Like other private company health insurance plans, MA members must adhere to the insurer’s policies. For example, you utilize the insurer’s network approved healthcare providers and adhere to its out-of-pocket expense rules. Sometimes you need prior authorization prior to coverage of treatments or medications. Some plans have lower out-of-pocket expenses than original Medicare and some offer coverage not included in Medicare. As an example, some MA plans offer dental, hearing and vision services.
Keep in mind that if you select a MA plan, you still have Medicare. However, you’ll receive most of your Part A and Part B coverage from your MA plan instead of from original Medicare.
Why Do Health Insurance Companies Offer Medicare Advantage Plans?
Medicare Advantage is a lucrative market for health insurance companies. A study published in Feb 2023 showed that MA gross margins per enrollee were double or more that of other types of health insurance plans in 2021 (the most recent year data was available). Specifically, gross margins per enrollee were $1,730 for the Medicare Advantage market, $745 for the individual non-employer market, $689 for the group employer market, and $768 for the Medicaid managed care market.
The government gives incentives to Medicare Advantage insurance companies based on bonus points from the Quality Bonus Program. The ACA created this program based on a 5-star rating system (see below) to encourage insurers to provide high quality care to enrollees. Government spending on bonus payments has increased every year since 2015 and reached $15 billion in 2023. And in 2023, 85% of MA participants were enrolled in plans that receive bonus payments. Although payments per member vary by specific MA insurer, some are substantial. For example, Kaiser was expected to receive $523 for a member, UnitedHealthcare was expected to get $439 for an enrollee, and Cigna was expected to receive $432 for a member in 2023.
What Types of Medicare Advantage Plans Can I Choose From?
Like commercial health insurance plans, you have options. You can select a Health Maintenance Organization (HMO) plan or a Preferred Provider Organization (PPO) plan. Options also include a Private Fee-For-Service (PFFS) plan or a Special Needs Plan (SNP). A few other less common plans include a HMO Point of Service (HMOPOS) plan and a Medicare Medical Savings Account (MSA) plan. You can learn more about some of these types of plans here.
Who Can Sign Up for a Medicare Advantage Plan?
You are eligible if you have original Medicare. Of course you must be a U.S. citizen, aged 65 or older, and so on as explained above. And you must have Medicare Part A and Part B. However, to join a MA plan, you must live in an area covered by the specific plan you select.
Is Medicare Advantage More Expensive than Medicare?
Costs are different and vary depending on the specific Medicare Advantage plan selected. Original Medicare stipulates that after you meet your deductible for Medicare Part B (medical), you typically pay 20% of the approved Medicare amount. You also pay a monthly premium for Part B and a different premium for Part D (prescriptions). Plus, there is not an annual limit on out-of-pocket expenses except if you have Medigap. For Medicare Advantage plans, however, out-of-pocket costs vary by the specific plan and the service provided. Like original Medicare, you pay a monthly Part B premium that usually includes your Part D coverage. You might also have to pay a monthly plan premium. MA plans do have out-of-pocket limits for both Part A and Part B. And you don’t need to purchase Medigap. For additional differences, go here.
To calculate your out-of-pocket costs with a MA plan, evaluate your premium, deductible, copayments, and coinsurance. Also review what kind of healthcare treatments you need and the frequency that you need them. Review if your provider accepts the Medicare-approved amount for payment. And go here to see other things to evaluate.
Why Might Someone Select Medicare Plus Medigap Instead of Medicare Advantage?
The cost of Medicare and Medigap is often more expensive than Medicare Advantage for individuals with long-term health issues. However, Medigap expands a person’s network because Medicare Advantage plans require participants to select providers and facilities within their networks. (Note that Medicare Advantage participants cannot purchase Medigap.) Also, regardless of the insurer, federal regulations standardize Medigap coverage for copays and deductibles. And since each Medigap insurance company can offer ten different plans with unique benefits, Medicare plus Medigap provides flexibility.
Note that if you want to enroll in Medigap, it is best to do so when you are first eligible for Medicare. At this time, you have a six-month open enrollment period in which Medigap health insurance companies cannot deny your application. Also, your Medigap insurer must renew your policy so long as you adhere to its guidelines (i.e., pay your premiums, be truthful in your application, don’t enroll in a Medicare Advantage policy, etc.). But after this period, there are set enrollment windows, you might not be able to sign up, and you may be charged more. For example, when you enroll later, Medigap insurance companies can deny you if you have a preexisting condition like heart disease or diabetes. That said, on February 16, 2024, SB 1236 was introduced in California’s legislature. If passed, starting January 1, 2025, Medigap insurance companies couldn’t deny or price discriminate coverage based on health conditions and other things during a 90-day open enrollment period starting January 1st each year. (As of August 2023, New York, Connecticut and Vermont offer year-round Medigap enrollment.)
Why are Medicare Advantage Programs Growing Vs. Original Medicare?
From 2007 to 2023, Medicare Advantage enrollees increased from 19% to 51% of eligible Medicare enrollees. Enrollment in MA plans was 30.8 million in 2023. In 2023, MA overtook traditional Medicare with 51% of all eligible beneficiaries. And this percent is projected to grow to 62% by 2033.
Some people prefer MA plans because they work just like the health insurance plans they had prior to turning 65. They offer integrated and coordinated care. And they enable you to get coverage for many different healthcare services in the same plan. Other individuals prefer MA plans because they have an out-of-pocket limit. As mentioned above, original Medicare only provides this limit if a person also purchases Medigap. Depending on the type of MA plan you select, many of these plans also have smaller monthly premiums. In fact, a 2022 Better Medicine Alliance study found that MA enrollees pay almost $2,000 less in out-of-pocket expenses and premiums than original Medicare participants.
Another study observed that some of the most vulnerable enrollees had better outcomes with MA plans. The most vulnerable includes those most at risk with multiple health conditions, greater disabilities, and other issues. These outcomes included utilization of care, quality of care, lower costs for care, fewer hospitalizations and readmissions, and more. A whitepaper published in November 2023 found similar results. The whitepaper showed that MA recipients had fewer preventable hospitalizations, less hospital readmissions, and reduced rates of high-risk prescription medications than traditional Medicare recipients.
Of course, some MA plans offer additional benefits such as dental, hearing, and vision. In fact, some plans even offer gym discounts or memberships as well as assistance getting to doctor appointments.
Another potential reason for MA growth is broker commissions. In 2024, CMS will pay brokers $611 to $762 (based on the particular state) for a recipient’s initial year enrollment in a MA plan, and then 50% of that amount for renewals each year. On the other hand, CMS only pays $100 in commissions for a participant’s first year of Medicare enrollment and $50 for annual renewals.
MA plan downsides include less flexibility in your healthcare providers. You need prior authorization for some medical services and medications. In fact, as of August 2023, 99% of MA enrollees are in plans that require prior authorization for expensive services such as Part B drugs (99%), skilled nursing home stays (99%), and inpatient hospital stays (98% for acute and 93% for psychiatric). Also, you might pay more with out-of-pocket costs than people who have both original Medicare and Medigap.
Criticism of Medicare Advantage Plans and Why There Is Medicare Advantage Health Insurance Denial
Medicare Advantage plans are managed by health insurance companies, not by Medicare. With original Medicare, Medicare pays hospitals and doctors according to a fee-for-service model. As such, doctors dictate patient care. With Medicare Advantage plans, Medicare pays MA insurance companies a fixed per-patient dollar amount and pays extra for some patient health concerns. These health concerns like heart disease and diabetes qualify for extra “risk adjustment” dollars. MA insurance companies, not Medicare, dictate patient care. And given the fixed fee, there is an incentive for MA plans to deny care to retain more profits. There is also an incentive to make patients appear sicker than they are (known as excess billing or excess coding) to receive risk adjustment dollars. In fact, a January 2024 status report from the Medicare Payment Advisory Commission (MedPac) projected that the government will spend $88 billion more for MA plans than for traditional Medicare plans in 2024.
Lawsuits against MA insurers for excess billing are common. A few whistleblowers alleged this against UnitedHealthcare in 2017. The DOJ alleged something similar and filed a lawsuit against Cigna in 2020. (Cigna agreed to pay $172 million in September 2023 to settle a similar 2022 DOJ lawsuit.) As of September 2022, the DOJ 2020 lawsuit against Anthem alleging potentially tens of millions of dollars in fraudulent claims was set to go to trial. In fact, of the 10 largest MA health insurers, 5 have been accused of fraud by whistleblowers, 5 have been accused of fraud by the government, 8 have been accused of overbilling by the Inspector General, and 3 overbilled and have been accused by both whistleblowers and the government. The government watchdog Medicare Payment Advisory Commission (MedPac) estimates MA plan excess billing in 2023 at $27 billion, while a USC study thinks overpayments to MA could exceed $75 billion in 2023.
In March 2022, the Medicare advisory commission presented Congress and HHS with recommendations to help repair the “deeply flawed” MA payment rules. The suggestions include creating more suitable benchmarks to define plan payments, changing the quality bonus program, and fixing the excess coding issue that drives incentives for additional diagnoses and thus risk adjustment payments.
An article in October 2022 pointed out that Medicare Advantage plans were sending patients home from skilled nursing and rehabilitation facilities before they were sufficiently healthy. And in March 2023, a Stat investigation revealed that MA health insurers were using unregulated artificial intelligence predictive algorithms to determine when to send patients home and were doing so too early. Advocates for patients said these algorithms, implemented at the beginning of the care process, don’t adjust for individual patient circumstances and can be different than what Medicare routinely covers. (In fact, a class action lawsuit was filed against UnitedHealthcare in November 2023 due to an AI predictive tool.) As mentioned previously, original Medicare and MA plans cover the same minimum benefits. These benefits include up to 100 days in these facilities. Healthcare providers, patient advocates and nursing home representatives claim that MA plans are increasingly not abiding by these rules.
Another criticism is denying medically necessary care. We review Medicare Advantage Health Insurance Denials below.
Changes to Medicare Advantage Programs to Increase Access to Medically Necessary Care and to Reduce Fraud
In January 2023, CMS announced plans to take back billions of dollars of overpayments to Medicare Advantage health insurers going back to 2018. Regulators will apply an error rate extrapolated from audits conducted to the remainder of the insurer’s MA plans. CMS decided not to take back overpayments from 2011 to 2017, saving insurers billions of dollars.
In March 2023, CMS proposed new rules for Medicare Advantage programs that could help reduce fraudulent claims. The new rules include removing 2,000 diagnosis codes from the payment calculation and simplifying some diagnostic codes. After insurance industry pressure, CMS decided to roll out the changes over the next 3 years instead of all at once.
In April 2023, CMS announced a new rule that Medicare Advantage insurance plans must comply with traditional Medicare coverage rules. The new utilization management policies aim to eliminate obstacles for Medicare Advantage recipients to access medically necessary care. Another aspect of this new rule is that insurance companies cannot rely solely on predictive technology to make coverage decisions. Instead, insurers must factor in an individual’s specific circumstances and have a qualified healthcare professional with expertise in the area review the request prior to denying coverage based on lack of medical necessity. The announcement also included rules to help eliminate Medicare Advantage deceptive and fraudulent marketing practices.
CMS Change To Medicare Advantage Plans to Reduce Prior Authorization Delays for Medically Necessary Care
On January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) released a new Interoperability and Prior Authorization Rule for health insurers that participate in Medicare Advantage, Medicaid, Medicaid Managed Care Plans, Children’s Health Insurance Program (CHIP) fee for service programs, CHIP managed care entities, Affordable Care Act exchange (healthcare.gov) plans, and a few others. Starting on January 1, 2026, these insurers must respond to a standard (non-urgent) prior authorization (PA) request in 7 calendar days and to an expedited prior authorization request within 72 hours. In addition, they must give a specific reason for denying a PA request (to aid resubmissions or appeals) and publicly report PA metrics. They must also implement and maintain a specific application program interface (API) to streamline the process and to enhance the electronic exchange of healthcare data.
This new CMS Prior Authorization Rule will be very helpful. Unfortunately, it doesn’t go far enough because it doesn’t include prescription medications and it does not cover individuals insured by employers – about 158 million Americans.
What Private Insurance Companies Offer Medicare Advantage Plans?
In 2023, the average Medicare recipient could select from 9 different Medicare Advantage insurance companies and from 43 different plans. In 2016, the number of accessible MA plans was only 19. And across all types of MA plans in 2023, there were 3,998 specific plans available. Plan types split by HMOs (58%), PPOs (40%), and others (2%).
In terms of specific health insurers offering MA plans, Humana and UnitedHealthcare offered plans in 32% of counties. There were 30.8 million Medicare Advantage enrollees in 2023. Enrollment in 2023 by health insurer was as follows: UnitedHealthcare (29%), Humana (18%), and Blue Cross Blue Shield (14%). CVS Health had 11% of enrollees, Kaiser had 6%, Centene (Health Net) had 4%, and Cigna had 2%. All other health insurers comprised the remaining 16% of enrollees.
Based on the numbers above, the top two health insurers UnitedHealthcare and Humans represented 47% of all MA enrollees. In fact, 95% of Medicare enrollees had access to at lease one UnitedHealthcare plan and 92% of Medicare recipients could access at least one Humana plan.
Note that on January 30, 2024, Cigna announced an agreement to sell its Medicare Advantage plans to Health Care Service Corporation. This deal is not expected to close until Q1 2025. And, once it closes, Cigna’s pharmacy benefit manager Express Scripts will continue to service its former Medicare businesses for four years.
How Do I Select a Medicare Advantage Plan?
With so many MA plans available, choosing the ideal one can be complex and confusing. Medicare publishes a five-star rating system based on over 40 metrics and publishes it on the Medicare Plan Finder website. The score includes a lot of things such as responsiveness to appeals and participant ratings. Other criteria include access to services and medications as well as customer service. The website asks a series of questions and then gives you plan options with the plan’s composite score. The number of five-star MA with Plan D contracts moved form 74 in 2022 to 57 in 2023 to 31 in 2024. (Note that the 2024 5-star numbers also reflect a new CMS method to decrease the impact of statistical outliers on ratings.) When reviewing ratings, compare the average star rating to plans you review. Also evaluate the specific metrics that are most important to you.
But the ratings don’t tell the entire story for participants who experienced Medicare Advantage health insurance denials. Concerns include the fact that MA health insurers can combine quality scores of plans in different states for different types of enrollees. The ratings mostly highlight treatments as opposed to treatment outcomes. There are too many measures and some of them are based off of small sample sizes. The ratings aren’t compared to traditional Medicare options in specific local markets. And the Medicare Plan Finder website is difficult to navigate due to the number of decisions required. Decisions include plan type, premium amount, copayments and other parameters.
Find free resources here for selecting Medicare Advantage (and Medicare) plans.
Should I Select a Medicare Advantage Plan Based on Its Cost?
Today, enrollees look to premium cost twice as strongly as quality ratings. In fact, a November 2023 report found that 83% of MA beneficiaries chose $0 premium plans. But an August 2022 RAND study found that more expensive Medicare Advantage plans don’t equate to better care. The study looked at $0 monthly premium plans as well as plans with $60-$120+ monthly premiums. Researchers found insignificant differences in patients’ experience scores based on monthly premiums. The study suggests that enrollees should evaluate other factors including star ratings.
Oftentimes, people associate higher monthly premiums with lower out-of-pocket costs. But this association is different with MA plans due to the Quality Bonus Program (QBP). In this program, the past highest performing plans receive 5% bonuses to either lower enrollee monthly premiums or to provide more enrollee benefits. And QBP bonuses are substantial – 2023 bonuses were $15 billion. In fact, they are so substantial that some financial analysts projected that specific MA health insurers such as Centene and CVS Health’s Aetna that were set to lose bonuses in 2023 might see as much as a 10% drop in their earnings outlook. In fact, on December 29, 2023, Elevance Health, Inc. sued Health and Human Services (HHS) over its lower 2024 plan star ratings claiming HHS’ calculation changes were illegal. In 2023, 64 percent of Elevance plans had four or five stars. But in 2024, only 34 percent of its plans had four or five stars. According to Elevance, these ratings drops could lower its bonus payments by approximately $500 million.
75% of MA participants are enrolled in plans that receive bonus money. Bonuses that lower premiums change the relationship between pricing and quality.
Another Reason Not To Select a Medicare Advantage Plan Based on Cost
Another report from the Brookings Institution suggested that the five largest MA health insurers – UnitedHealthcare, Humana, Elevance (Anthem), Aetna and Kaiser – may disguise profits as costs. How? By doing so with their related businesses that aren’t regulated by Medical Loss Ratios (MLR). These insurers all own related businesses including Pharmacy Benefit Managers, physician practices, hospitals and post-acute healthcare providers. And spending on the related businesses may reach 70%. The ACA sets the minimum MLR at 80%. (MLR rates vary by plan type.) So, 80% of all premium revenue must be spent on medical care and quality improvements vs. marketing, profits and operations. Prices charged from related businesses to MA insurance plans substantially impact costs and profits. As such, health insurers may move profits to where they are not regulated by MLR. The report focused on the ability to do so, not on insurer current practices.
Are There High Medicare Advantage Insurance Denials?
Like other health insurance plans, Medicare Advantage Health insurance denials are not uncommon. And sometimes they are mistakes. A report from HHS’ Office of Inspector General showed that MA and Medicare Part D enrollees encounter a considerable number of incorrect denials. These denials may prevent or delay medically necessary care. Specifically, among MA prior authorization denials, 13% met Original Medicare coverage rules. Why were these requests denied? MA plans used criteria outside of Medicare’s criteria. MA plans requested unnecessary documentation. And MA plans made system and manual review errors. Denial examples included MRIs, injections, and enrollee stays in facilities such as rehabilitation facilities. The OIG also showed that among payment denials, 18% met Medicare coverage rules and MA billing rules. Most occurred due to human errors in manual claims processing reviews and due to system processing errors.
Unfortunately, only 1% of MA participants appeal these denials even though up to 75% of appealed denials are overturned. The percent of people who appeal is likely small because the appeals process is complex, time consuming, and hard to understand.
What Should I Do if I Receive a Medicare Advantage Insurance Denial?
As with private commercial insurance plans, you can appeal. Regardless of the type of MA plan you have, we recommend that you speak with a qualified health insurance attorney prior to filing your appeal. Why? Because this attorney can help optimize your chances of overturning the Medicare Advantage Health Insurance Denial.
You must always go through the Medicare appeals process. Even prior to appealing, however, the initial step is to request an “Organization Determination.” You, your representative, or your doctor can request the OD. This determination is essentially a request for the plan to cover or pay for your medical care. Your Medicare Advantage plan provides you information on how to make this request. If your MA plan denies your request, it will explain why in writing. The communication also tells you how to appeal.
Five Levels of Medicare Advantage Appeals: Levels 1 – 2
The appeals process for Medicare Advantage Health Insurance Denials has five levels. Each level’s decision tells you how to appeal in the next level. Learn more about what to include in your appeal here.
Appeal Level 1: You request a Reconsideration of the Organization Determination from your insurance plan. You have 60 days from the OD denial date to request a reconsideration. Then your MA plan has 72 hours to respond to an expedited care request and 30 days for a standard request. The plan can take 60 days to respond to a payment request.
Appeal Level 2: If MA denies your Reconsideration appeal, your case is automatically sent to the second level, an Independent Review Entity (IRE). (Some IREs refer to themselves as “Part C Qualified Independent Contractors” or QICs.) Then you have ten days to send the IRE information about your situation. And just like the Reconsideration first level, the IRE has the same timeframe to respond to your appeal. If the IRE denies your appeal, you must request your case be sent to the next level within 60 days. The Medicare Reconsideration Notice from the QIC provides instructions on how to do so. The next level is a decision from the Office of Medicare Hearings and Appeals (OMHA).
Five Levels of Medicare Advantage Appeals: Levels 3 – 5
Appeal Level 3: In the OMHA level, you request a decision based on a hearing with an Administrative Law Judge (ALJ) or an attorney adjudicator. Your case must have a value of $180 or more in 2022 to get a hearing. This judge reviews your case and your testimony prior to deciding. The hearing may be over the phone, via video-teleconference or in person. And a hearing isn’t necessary if the ALJ or adjudicator decides to overturn the prior denial. However, if OMHA overturns the denial, your MA health plan may appeal its decision. It appeals by requesting a Medicare Appeals Council (Appeals Council) review. Also, if OHMA doesn’t provide you a decision in the allowed timeframe, you can request OHMA to send your case to the next appeal level. If OHMA doesn’t overturn the denial, you have 60 days to ask for a Medical Appeals Council review.
Appeal Level 4: You can request that the Medicare Appeals Council review your case following instructions from the ALJ’s hearing decision. If the Appeals Council doesn’t provide a determination in the allotted timeframe, you can request that your case be moved to Level 5. You have 60 days to request a judicial review by a federal district court if the Appeals Council doesn’t overturn your denial.
Appeal Level 5: In 2022, your case must be valued at no less than $1,760 to receive a federal district court judicial review.
Contact Law Offices of Scott Glovsky if You Receive a Medicare Advantage Health Insurance Denial
The California-based Law Offices of Scott Glovsky has been helping health insurance policyholders for more than twenty years. Scott Glovsky is recognized as one of the most experienced, well-respected, and compassionate insurance lawyers in the nation. We understand a Medicare Advantage Health Insurance Denial and have helped many patients get the care they need. Results of our cases have impacted millions of California insurance policyholders by forcing insurance companies to change their behavior.