Medicare Advantage

Medicare Advantage (MA), or Medicare Part C, is a health coverage option provided by private health insurance companies as an alternative comprehensive plan to traditional Medicare. These plans aim to expand beneficiary choice, offer additional benefits, and improve care coordination. As of 2024, more than half of all Medicare eligible individuals are enrolled in private MA plans.

However, within the healthcare industry and in Congress, there is growing frustration by some with MA plans’ marketing practices, provider networks, prior authorization process, reimbursement timeframes, and clinical documentation requirements. HLC is committed to supporting this public-private sector option while meeting beneficiary needs and maintaining fiscal sustainability.

Key challenges and opportunities include:

• Balancing growth in MA amid concerns about Medicare Trust Funds’ sustainability.
• Diagnostic coding practices and the appropriate role of oversight and review for improved oversight.
• Additional health-related needs and opportunities to provide health-related assistance to low-income, minority, and rural populations.
• Improving transparency on supplemental benefits, prior authorization, and out-of-pocket costs.
• Streamlining administrative processes to reduce provider burdens and prevent delays in care.
• Aligning incentives to drive efficiency, reduce costs, and improve health outcomes.

Collaborative efforts between the private sector, Congress, and the Administration can refine and improve the public-private partnership program while meeting beneficiaries’ needs and maintaining financial sustainability.

Solutions

HLC advocates for patient-centered policies to promote competition, advance value-based care, and better align incentives to reward quality, access, and choice in Medicare Advantage.

Key policy solutions include:

• Ensure appropriate and sufficient payment for providers and plans to sustain the program’s effectiveness while demonstrating responsible stewardship and financial accountability.
• Address individual and community-specific challenges that cause complex, varied healthcare barriers to improve health and ensure access to care.
• Structure supplemental benefits to address gaps in care, improve quality and outcomes, and mitigate disparate variation in health while also enhancing accountability and personal engagement.
• Support efforts to collect and analyze data on supplemental benefits utilization and prior authorization processes to inform future policy decisions.
• Identify opportunities to simplify and expedite prior authorization processes to reduce administrative burdens while ensuring appropriate utilization of services.
• Advocate for policies that enhance care coordination, particularly for dual-eligible beneficiaries and those with chronic conditions.