Problems & Solutions

We can fix Medicare Advantage by tackling the worst problems with reasonable policy solutions that restore fairness, transparency, and accountability in the system. Here are some of the key problems with Medicare Advantage and policy solutions that will make a big difference.

Make Medicare Advantage Great Again Plan
Problem Proposed Law Solutions
Patient Access Denials, Increased Prior Authorization Requirements & Unregulated AI Automation Pose Significant Threats to Seniors in Medicare Advantage The Medicare Advantage Denials Act (MAD Act)
  • Ban the use of AI-driven treatment denials without human medical review.
  • Require transparency and independent audits of algorithms used for claims reviews.
  • Require greater documentation to override provider decisions on medical necessity.
  • Require greater documentation to override/switch from provider-prescribed drugs.
  • Codify MA plan requirements to complete reviews of prior authorizations within 72 hours for routine cases and 24 hours for urgent ones (current Medicaid standard).
Billions in Medicare Advantage Overpayments & Coding Abuses Being Imposed at Patient & Taxpayer Expense The Medicare Advantage Payments Act (MAP Act)
  • Require HHS/CMS to deploy AI tools to detect/monitor fraud and overpayments.
  • Reform Quality Bonus Program to eliminate artificial scoring abuses.
  • Prohibit duplicate insurer payments for veterans primarily receiving care via the VA.
  • Cap MA benchmarks at 100% of local FFS costs outside of areas with low MA penetration.
  • Require annual external audit of Medicare overpayments and set new penalty fees.
  • Codify risk adjustment data validation (RADV) audit and overpayment recovery regs.
  • Increase penalties for fraudulent billing via improper Medicare Advantage upcoding.
  • Require transparent patient opt-in approvals prior to insurer home visits/consultations.
  • **Require post-home visit/consultation reports documenting any coding adjustments or medical determinations be provided to both patients and primary care providers.
Medicare Advantage Plans Limiting Access to Essential Services The Medicare Advantage Services Act (MAS Act)
  • Require MA plans that don’t meet minimums for home health/skilled nursing care in traditional Medicare to offer them as a supplemental benefit.
  • Improve end-of-life care access by capping co-pays for related care (ex.: palliative).
  • clear up-front disclosures of access restrictions to high-cost specialty care (ex.: oncology and cardiology) via network design, utilization management, and benefit design.
Insurers Adversely Impacting Non-Subsidiary Providers, Pharmacies & Other Health Entities Due to Low Reimbursements & Delays The Medicare Advantage Reimbursement Act (MAR Act)
  • Require MA plans to clearly disclose their ownership structures and any significant financial relationships with providers and pharmacies within their networks.
  • Require MA plans to offer an alternative option with equal payments to non-subsidiaries and non-preferred pharmacy networks.
  • Expedite MA payments to providers (ex.: pharmacies, nursing/home health, etc.) in 30-day window (equalize window for both insurers’ subsidiaries and external providers).
  • Penalize insurers that intentionally or consistently underpay or delay payments.
Industry Consolidation and Volatility Limiting Medicare Advantage Options & Benefits The Medicare Advantage Competition Act (MAC Act)
  • Direct beneficiaries to choose either FFS or MA rather than enroll them in FFS by default.
  • Require added review/approval on insurer consolidations that reduce competition.
  • Eliminate insurer-PBMs’ exemptions from federal anti-kickback corruption laws.
  • Establish standards to prevent integrated insurer/health services providers from manipulating MLR requirements and to promote greater competition.
  • Incentivize insurers to offer plans in rural areas via targeted reimbursement policies.
Medicare Advantage Lacks Appropriate Consumer Protections & Transparency The Medicare Advantage Transparency Act (MAT Act)
  • Prohibit integrated insurer-health services companies from steering MA patients to subsidiaries or financially-tied enterprises without transparent opt-in approval.
  • Require parent companies to clearly identify themselves as the providers of specific Medicare Advantage plans in enrollment materials and plan statements.
  • Require providers owned by Medicare Advantage companies or their parent companies to clearly identify themselves to MA enrollees at the point of care.
  • ***New guardrails and increased penalties on misleading MA plan marketing practices.
  • Require longer notification and special enrollment periods before insurers can eliminate plans and allow enrollees to switch to traditional Medicare more easily.

** Note: Additional/Clarifying Reforms:

  • Require plans to provide an annual care plan for diagnoses identified, especially through in-home risk assessments, and an annual report on care interventions adopted.

  • Require the implementation of an encounter data-based risk adjustment model, so as to limit the effect of upcoding.

  • Require the adoption of a variable coding intensity adjustment that penalizes MA plans based on their level of upcoding.

  • *** Note: Additional/Clarifying Reforms

  • Establish a whitelist of third-party marketing organizations for MA plans to utilize, and curtail the use of bad actors.