For more than two decades, Medicare has increasingly relied on private Medicare Advantage plans to coordinate and manage care for a growing share of Medicare beneficiaries. While this model has expanded options and introduced new benefits, it has also created operational and administrative challenges for beneficiaries and the providers who care for them.   This post is the first in a series intended to identify proposed changes, via legislation et al., to reduce the obstacles that beneficiaries and the organizations that serve them face in Medicare Advantage. 

The House of Representatives has been working on four bills that fit together as part of a broader Medicare Advantage reform package. They are all aimed at increasing transparency, improving oversight, and reducing administrative barriers that can delay or impede patient care. All things that would be beneficial for those dealing with MA Plans, including home health agencies.  Following are summaries of four of the most recent bills moving through Congress: 

1. H.R. 3514 – Improving Seniors’ Timely Access to Care Act

Purpose:

Modernizes and standardizes the Medicare Advantage prior authorization process.

Key provisions

• Requires electronic prior authorization (ePA) capabilities.
• Establishes standardized electronic transactions.
• Requires Medicare Advantage plans to provide greater transparency regarding prior authorization decisions.
• Requires reporting of approval, denial, appeal, and response time data.
• Seeks to reduce unnecessary administrative burden while preserving plans’ ability to use prior authorization when clinically appropriate.

Why providers care

For HHAs and other providers, this legislation could:

• Reduce delays in starting care.
• Reduce staff time spent chasing authorizations.
• Improve predictability.
• Provide much-needed visibility into MA plan performance.
• All significant issues that all Medicare providers must deal with

2. H.R. 5243 – Increasing Data Transparency for Supplemental Benefits Under Medicare Advantage

Requires Medicare Advantage plans to report far more detailed information about the supplemental benefits they advertise and provide.

Purpose:

Examples include:

• Transportation
• Meals
• Vision
• Gym Memberships
• Home modifications
• Caregiver supports
• In-home services
• Other supplemental benefits

Key provisions

• More detailed reporting on which benefits are offered.
• Better reporting on how often beneficiaries actually use them.
• Improved data for Congress and CMS to evaluate whether these benefits are delivering value.
• Greater transparency regarding the effectiveness of supplemental benefits.

Why providers care

Many supplemental benefits are increasingly being used by Medicare Advantage plans as competitive differentiators. Better utilization data could influence future benefit design, reimbursement policy, and partnerships with post-acute providers.  Are these ‘differentiators’ providing real value to the beneficiary, or are they window dressing for a sale that are not widely utilized, nor beneficial to the beneficiaries of the Plan? 

3. H.R. 9392 – Medicare Advantage Cost Transparency Act

Purpose:

Requires Medicare Advantage organizations to provide greater transparency regarding the actual costs and financial impacts of prior authorization and utilization management.

Key themes

• Increased reporting of utilization management costs.
• Greater transparency into administrative expenses.
• Better information for policymakers regarding how Medicare Advantage dollars are spent.
• Helps determine whether administrative practices are improving care or simply reducing utilization.

Why providers care

This bill shines a light on one of the least transparent aspects of Medicare Advantage—how much administrative management actually costs versus the savings it generates. That information could influence future Medicare Advantage policy.  Additionally, this could help identify ‘hidden costs’ that the MA Plans require the beneficiary to pay, and whether the beneficiary was made aware of their liability for these costs prior to the service being provided (a significant issue troubling many Medicare beneficiaries in MA Plans). 

4. H.R. 9396 – Prior Authorization Accountability Act

Purpose:

Increases accountability for Medicare Advantage plans’ prior authorization practices.

Key themes

• Additional oversight of prior authorization decisions.
• More detailed reporting of denials and appeals.
• Greater accountability when authorization practices create unnecessary barriers to medically necessary care.
• Increased CMS visibility into plan performance.

Why providers care

Providers have long argued that prior authorization is too often used as a utilization management tool rather than a clinical necessity review, and too often delays necessary care. This legislation seeks to make those practices more transparent and measurable.

Overall Takeaway

Taken together, these bills represent a significant push toward greater transparency and accountability within Medicare Advantage. While each addresses a different aspect of the program, they collectively aim to:

• Modernize prior authorization.
• Improve oversight of utilization management.
• Increase transparency into administrative practices.
• Better evaluate the value of supplemental benefits.
• Improve beneficiary access to medically necessary care.

From a Home Health Perspective

For home health agencies, these proposals are especially noteworthy because they target some of the most common operational challenges associated with Medicare Advantage:

• Delays in starting care due to prior authorization.
• Administrative burden on clinical and billing staff.
• Limited visibility into MA plan decision-making.
• Inconsistent utilization management practices across plans.
• Growing importance of supplemental benefits that support care in the home.

Summary

Although it is hard to say what the chances are of any of these bills making it through the legislative process and becoming law, it does signal that Congress is taking more interest in the quality and effectiveness of Medicare Advantage Plans for Medicare beneficiaries.  This would seem to indicate that Congress is hearing the pain points that many MA beneficiaries and the organizations providing their care have been expressing for many years. Now, maybe the tide has turned, and MA Plans will need to be as responsive and transparent as traditional Medicare. 

Note: There is a hyperlink to each specific bill in the section title (1-4). Hover your cursor over the “H.R. ####” and your cursor will change (maybe to a finger pointer), and if you right-click the cursor, it will open a window with that bill displayed in its entirety via the ‘congress.gov’ website.