Why HHS Says It’s Focusing on Disenrollment Data in MA Plan Oversight

Mon, Sep 18, 2017 --


Sicker patients seem to be dropping out of some Medicare Advantage (MA) plans, according to a Government Accountability Office (GAO) report from April 2017. Here’s a closer look at the report and the entities involved.

A Brief Look at MAs and Their 17.6 Million Beneficiaries

CMS contracts with private entities to cover Medicare beneficiaries under the MA program, sometimes called Medicare Part C. MA enrollment was at 17.6 million in 2016, nearly a third of all Medicare beneficiaries. MA organization (MAO) plan offerings can change from one year to the next, but contracts are not allowed to use health status to limit coverage. An MAO contract is specific to a plan type, such as an HMO (which usually restricts patients to in-network providers) or PPO (which allows access to out-of-network providers at a higher cost). But each contract can have different benefit packages.

GAO Checks In About Disenrollment Stats

GAO, the auditing arm of Congress, examined 126 contracts with higher than usual disenrollment rates than other plans in 2014. The finding was 35 contracts with health-biased disenrollment, meaning sicker patients (those with higher projected healthcare costs) were more likely to end enrollment. On average, sicker beneficiaries were 47 percent more likely to end enrollment when compared to beneficiaries in better health, but percentages ranged from 27 to 126 percent. This sort of difference in rates raises the question of whether sicker beneficiaries face issues with healthcare access and quality.

What Do the 35 Have in Common?

The contracts identified as having health-biased disenrollment were more likely than other plans to have these characteristics:

  • Lower enrollment
  • Higher percentage of HMOs
  • Higher proportion of beneficiaries in SNPs, which provide care for individuals with special needs (e.g., chronic conditions)
  • Fewer years in the MA program
  • Lower overall quality ratings from CMS’s MA Five-Star Rating System.

Why Did Beneficiaries Leave?

Beneficiaries leaving these contracts were more likely to say disenrollment related to access to care and preferred providers. Beneficiaries leaving contracts other than those 35 tended to say cost of care was the reason for leaving.

What Did GAO Recommend?

GAO recommended that CMS strengthen oversight by analyzing disenrollment data taking into account health status and the reason beneficiaries gave for leaving. HHS concurred, saying it uses disenrollment data in MA quality and performance reviews, but it will continue to consider ways to include the data in MP plan oversight.

What About You?

Do you see patients switching from MA to Medigap or other options?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.


1 Comments For This Post

  1. Andrew C Says:

    In our practice we’ve seen patients switched to Medicare Advantage plans without their full knowledge, or at least with a confusing rollout. A large company in town switched all their retirees taking insurance to an Advantage plan and most of them seemed to have no idea. So they didn’t show us their new cards, pay their new copays, or have their visits billed to the right insurance. It was a nightmare for a while. For these older patients who haven’t had to pay us a dime in years, showing up to the office with $10 was at times quite confrontational. It made for a rough start to the year.

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