Medicare Advantage supplemental health plans draw scrutiny
Studies question value of some Medicare Advantage supplemental coverage
Medicare Advantage plans lure customers with television ads promising plans with dental, vision and hearing benefits that traditional Medicare doesn’t offer.
But in a series of reports, experts and advocates question the actual value of those benefits to enrollees, who often find they still have to pay significant amounts out of pocket.
“They’re expecting to be able to get dentures or crowns or bridges — really expensive dental work — and they might end up in a plan that covers cleaning and an X-ray and that’s it,” said Julie Carter, senior federal policy associate for the Medicare Rights Center.
She said the organization’s hotline has increasingly received calls from Medicare Advantage beneficiaries complaining about their dental benefits.
Medicare Advantage, a private alternative to Medicare offered by insurance companies, now covers half of Medicare enrollees, in part because of the supplemental benefits they offer.
While some enrollees are happy with their coverage, others say they feel misled about the comprehensiveness of their plan’s dental benefits.
“How much is it coverage in name only and how much of it is used as a marketing device rather than a means to provide tangible benefits?” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit that supports access to comprehensive Medicare coverage.
“We have actually been hearing from Medicare Advantage enrollees who are disappointed in their dental coverage,” Lipschutz said.
While 94 percent of Medicare Advantage enrollees in 2021 were in plans that include dental coverage, studies have shown that they are just as likely as traditional Medicare beneficiaries to face trouble accessing needed oral health care.
Overall, 13 percent of all Medicare beneficiaries 65 and older said they could not get dental, hearing or vision care in the past year, according to KFF, a health research organization.
Those statistics don’t differ between Medicare Advantage and traditional Medicare enrollees, studies show, despite the vast majority of Advantage plans claiming they cover dental services.
“We saw that the pattern was pretty similar between people who enrolled in traditional Medicare, which doesn’t have a dental benefit, and Medicare Advantage, which may have a dental benefit,” said Lisa Simon, co-author of a study published in HealthAffairs in February.
That study found that dental care decreases after people age into Medicare, regardless of whether or not they are in an Advantage plan.
That could be because enrollees aren’t aware of their dental benefits, there aren’t enough dentists accepting those plans or the coverage might not be very generous, Simon said.
Costs and coverage
Another study published last year in JAMA Network Open found that low-income adults in traditional Medicare and Medicare Advantage faced similar challenges accessing dental care because of costs.
Medicare Advantage plans typically cover preventive care like annual cleanings without cost-sharing, but more extensive dental services usually require enrollees to pay for a portion of their care or aren’t covered at all.
Plans also typically cap how much they will pay for care in a given year, with more than half of Advantage enrollees in a plan with a maximum dental benefit of $1,000 or less, including amounts spent on preventive care, according to KFF.
Lipschutz said one woman that his organization is working with has an Advantage plan with a $2,500-per-year cap on dental care.
When she got treatment for an oral infection, her services, including X-rays, were not covered, despite the dentist and plan telling her it would be.
“Even if you have a generous out-of-pocket cap, it may not mean that much of the dental care you need will actually be covered,” Lipschutz said.
An information black hole
Part of the problem, experts say, is the lack of transparency and standardization about what supplemental benefits must cover, meaning benefits can vary between the thousands of Advantage plans on the market.
Medicare.gov’s plan finder tells people limits might apply to a plan’s supplemental benefits, but doesn’t go into specific details.
And Advantage plans don’t typically report information to the federal government about how often those benefits are used, what types of services are covered or how much beneficiaries pay out of pocket for that care.
That creates an information black hole about how useful those benefits are to beneficiaries, despite the fact that taxpayers are paying for it.
In 2022, rebates that plans got from the government to cover those benefits totaled $164 per enrollee per month, according to MedPAC.
“The line of sight on the offerings, what is being used and what the value is to the beneficiary is very hazy,” said Mark Miller, executive vice president of health care at Arnold Ventures and a former executive director of the Medicare Payment Advisory Commission.
Miller said he wants the Centers for Medicare and Medicaid Services to collect data on what supplemental benefits cover, whether they are being used by beneficiaries and how much plans are spending on those benefits. Benefits should also be standardized across plans so beneficiaries can make easier decisions, he said.
The Government Accountability Office has also recommended that CMS clarify guidance to Medicare Advantage plans on what kind of data must be submitted, including data about the usage of supplemental benefits.
CMS said it does require plans to submit that information, but that it will issue guidance clarifying those requirements. Three Medicare Advantage organizations told the GAO they do not report that information because they are not required to.
The Senate Finance Committee’s majority staff has recommended that CMS provide model language for Medicare Advantage plan marketing to explain the out-of-pocket costs and network limitations for extra benefits such as dental, vision and hearing.
The issue has led the American Dental Association to complain to CMS that their patients thought they had more comprehensive coverage than they actually have.
“Dentists often must explain to patients how the misleading marketing tactics have resulted in the purchase of a plan that does not deliver the dental benefits patients thought it did,” a spokesperson said. “Many dentists have reviewed the [Medicare Advantage] plan materials their patients bring to them only to find out it only covers a dental cleaning and not comprehensive care, or that the cost of the plan is not worth the benefit of the services covered.”
Because of the way plans are paid, government spending per beneficiary is typically higher in Medicare Advantage plans than in traditional Medicare.
Some lawmakers argue that the government should reduce payments to Medicare Advantage plans and use the savings to expand dental coverage to the entire Medicare population.
“We could use this money to provide the dental care that people across this nation need,” Sen. Elizabeth Warren, D-Mass., said at a Senate Finance Committee hearing in March focused on oral health.
(This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and the The NIHCM Foundation.)