Medicare Advantage

Background

Private health plans are entities that contract with MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). to provide services to enrollees. The term includes managed care plans and other models, such as private fee-for-service plans. Private health plans have been available in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). almost since the program began. When Congress first authorized private plans in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). , its intent was to contain the growth in spending and improve the payment method for certain providers. It also sought to provide beneficiaries, including those residing in rural areas, with more choices and enhanced benefits. These objectives remain relevant. Medicare AdvantageMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. ( MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. ), also known as MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Part C, is MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). ’s private plan program and is an alternative to Traditional fee-for-service (original) MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). . MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans must cover all MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). benefits (except hospice) and may also provide additional benefits. Most MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans offer Part D drug coverage as well.

To be eligible for an MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plan, a MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiary must be eligible for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Parts A and B. All MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans are required to establish enrollee out-of-pocket spending limits that do not exceed annual maximums established by the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services. Maximums vary by plan type. The Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services (CMS) sets a voluntary and a mandatory cap with the former being lower. CMS permits MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans greater flexibility in establishing cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for Parts A and B services if they use the lower, voluntary limit. For 2018, a typical voluntary annual limit can be no higher than $3,400, while the mandatory maximum may not exceed $6,700 for in-network services.

MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. has several plan types: health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), preferred-provider organizations (PPOs), regional PPO plans, special-needs plans (SNPs), private fee-for-service (PFFS) plans, and medical savings accounts A federally authorized health insurance plan consisting of both a savings account and a high-deductible health insurance policy. MSA plans are available in the private insurance market and are included among the Medicare Advantage options. ( MSAs A federally authorized health insurance plan consisting of both a savings account and a high-deductible health insurance policy. MSA plans are available in the private insurance market and are included among the Medicare Advantage options. ). Most, but not all, rely on a specific network of covered or preferred providers rather than covering all MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). participating providers.

Health maintenance organizations: An HMOA type of health insurance plan that usually limits coverage to care from physicians who work for or contract with the HMO. The plan generally will not cover out-of-network care except in an emergency. may also offer a point-of-service option that allows an enrollee to obtain services out of network for higher out-of-pocket costs. MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. HMOs may include different models of HMOs, including staff model, group model, or network model HMOs.

Provider-sponsored organizations: Similar to HMOs, PSOs are organized and operated by physicians and hospitals. They provide most services within their organized network.

Preferred-provider organizations: PPOs are networks of physicians and hospitals that have agreed to discount their rates for plan members. Enrollees may obtain services from non-network health professionals but must pay higher out-of-pocket costs if they do.

Regional PPO plans: Similar to local PPOs, regional PPOs cover a larger service area. They feature a single deductibleThe amount that individuals must pay for services covered under an insurance plan before the insurer pays benefits. Not all out-of-pocket spending counts toward the deductible. for Part A and Part B services and an out-of-pocket limit for in-network care and expenditures for benefits also offered by Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… .

Special-needs plans: SNPs focus on the needs of individuals who are institutionalized, are dually eligible for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. , or have severe or disabling chronic conditions. Most SNPs are HMOs.

Private fee-for-service plans: PFFS plans are risk-based plans that closely resemble Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… but are operated by private insurance companies. They permit enrollees to go to any MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). -approved doctor or hospital willing to accept the plan’s payment. Unlike other MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. options, physicians in PFFS plans may balance-bill 15 percent above the plan’s fee schedule. This and other PFFS plan features have the potential to cause confusion for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries and make it difficult for them to distinguish this option from Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… .

Medical savings accounts A federally authorized health insurance plan consisting of both a savings account and a high-deductible health insurance policy. MSA plans are available in the private insurance market and are included among the Medicare Advantage options. MSAs A federally authorized health insurance plan consisting of both a savings account and a high-deductible health insurance policy. MSA plans are available in the private insurance market and are included among the Medicare Advantage options. have two components. The first is an MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plan with a high yearly deductibleThe amount that individuals must pay for services covered under an insurance plan before the insurer pays benefits. Not all out-of-pocket spending counts toward the deductible. (which varies by plan) with premiums paid by MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). ; the plan pays for covered benefits once the deductibleThe amount that individuals must pay for services covered under an insurance plan before the insurer pays benefits. Not all out-of-pocket spending counts toward the deductible. has been met. The second is a tax-free savings account to which both MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and beneficiaries contribute. It may be used to cover deductibles and coinsuranceA form of health care cost sharing in which a percentage of covered expenses must be paid by the insured. In contrast, a copayment is a specific dollar amount that must be paid for a specific service. charges or to pay for health services that MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). does not cover. Beneficiaries who choose the MSA option may not have Medicare Supplement InsuranceGovernment-regulated private insurance—also called Medigap insurance—that can be purchased by Medicare beneficiaries to pay their deductible and cost sharing obligations, which can be substantial if they a serious health condition. .

Private health plans in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). pose both opportunities and risks for the program and its beneficiaries. The wide array of private health plan options gives beneficiaries greater opportunity to find plans that meet their needs and preferences. But giving beneficiaries more choices makes the task of selecting coverage more complicated and may be so confusing for some that it leads to poor decisions.

This concern is supported by behavioral economics research findings that indicate greater choice does not necessarily lead to better decisions. Although consumers value choice, it is necessary to balance the desirability of a wide range of complex choices with the cognitive burden of having to select from among too many. Experts advise that one strategy for improving consumer decision-making is to reduce cognitive burden by limiting the number of choices and by creating accessible and easy-to-interpret materials that allow clear comparisons of various choices.

Another problem is that many beneficiaries may not be aware of certain risks associated with MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans. This includes provisions that plans may terminate their relationship with MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). in any given year. They may change the premiums, cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. charges, or benefits from year to year as well, including drug coverage. They may also drop physicians from their networks during the year. Beneficiaries may also be unaware that if they voluntarily leave an MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plan and return to Traditional fee-for-service MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). , they may be subject to medical underwritingA process in which a health insurer uses an applicant's medical history to decide whether to offer a policy and whether the policy will include pre-existing condition exclusions and/or a premium that's higher than the standard rate. for a MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). supplement (Medigap) policy. This underwriting may result in their being refused a policy or being required to pay higher rates.

Additionally, by having multiple coverage options and two pathways to coverage ( MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. and Traditional), the MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). risk pool is segmented. There is some evidence that the healthiest beneficiaries are more likely to enroll in an MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. option, leaving the sicker, more expensive beneficiaries in the Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… program. This results in higher premiums for Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… . Among the MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plan options, PFFS and MSA plans are likely to attract the healthiest beneficiaries of all.

The tendency of healthy beneficiaries to join MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans underscores the importance of risk-adjusting MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). payments to these plans. An accurate risk-adjustment mechanism can help to mitigate the effects of risk segmentation by increasing payments to health plans for high-cost or high-risk enrollees and reducing payments to plans with healthier enrollees. Without these corrections, MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). will overpay providers with a larger proportion of healthier beneficiaries and underpay those with a larger proportion of sicker beneficiaries.

MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans are an important alternative for many MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries, especially those with low incomes. Data from the 2015 MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Current Beneficiary Survey indicate that:

  • 38 percent of African American beneficiaries and 48 percent of Hispanic beneficiaries were in MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans; and
  • 53 percent of beneficiaries in MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans had incomes of $30,000 or less (compared with 46 percent of all MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries).

MEDICARE ADVANTAGE: Policy

MEDICARE ADVANTAGE: Policy

Choice of Medicare coverage options

MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries should have a genuine choice among MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). coverage options and providers. The Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… program should remain viable and affordable. Within the Medicare AdvantageMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. ( MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. ) program, there should continue to be an adequate number of private health plan options (for information on choice of private plans, see also Private Health Plans: Managed Care Policy).

Medical savings accounts A federally authorized health insurance plan consisting of both a savings account and a high-deductible health insurance policy. MSA plans are available in the private insurance market and are included among the Medicare Advantage options. and private fee-for-service plans should not be included as MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). coverage options.

CMS should actively monitor private plan performance and report on comparisons by plan type that examine beneficiary access, out-of-pocket spending, and the impact on total MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). spending.

Congress should consider whether private fee-for-service plans and medical savings accounts A federally authorized health insurance plan consisting of both a savings account and a high-deductible health insurance policy. MSA plans are available in the private insurance market and are included among the Medicare Advantage options. provide added value in MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). , particularly whether these plan types attract healthier enrollees than others or prove costly for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). to sustain. Policymakers should assess the value of offering an excessively large number of plans (for more information on choice of plans, see Private Health Plans: Managed Care Policy).

Consumer protection and enrollment assistance

Policymakers should evaluate the reasonableness of any significant increase in the premium or cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. charges of private health plans.

Congress should facilitate switching from one MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). coverage option to another. It should also ensure access to Medigap policies for beneficiaries seeking to change their enrollment from an MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plan to the Traditional MedicareTraditional Medicare, also known as Original or Fee-For-Service Medicare, works on a fee-for-service basis. This means that you can go to any doctor or hospital that accepts Medicare, anywhere in the United States, and Medicare will pay its share of the bill for any Medicare-covered service it… program.

In managed care plans that contract with multiple medical groups, enrollees should be allowed to select providers from among all participating medical groups. If this is not feasible, beneficiaries enrolled in health plans offering multiple medical groups must be fully informed about limitations on access to providers in other groups. Plan enrollees should be permitted to change providers whenever they choose.

Congress should adequately fund the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services outreach and education programs to ensure that MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries understand both the advantages and disadvantages of enrolling in an MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plan. These programs should advise beneficiaries about a private health plan’s rights to terminate its relationship with MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). on an annual basis, to annually change the benefits (including drug coverage) it offers or the premiums and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. it charges, and to drop providers during the contract year. Beneficiary education also should include information comparing the benefits, cost, and quality of available coverage options.

Ombudsman programs

Consumers should have access to an independent, nonprofit ombudsmanAn ombudsman in health care and long-term care settings is a person who investigates and resolves complaints on behalf of older people who are residents of nursing homes and residential care settings. program with a sufficient number of personnel and resources to meet the need. The program should receive federal or state funding.

OmbudsmanAn ombudsman in health care and long-term care settings is a person who investigates and resolves complaints on behalf of older people who are residents of nursing homes and residential care settings. programs would:

  • assist consumers in understanding a plan’s marketing materials and coverage provisions,
  • educate members about their rights within health plans,
  • help identify and investigate enrollee complaints,
  • assist enrollees in filing formal grievances and appeals,
  • operate and staff a telephone hotline, and
  • report to and advocate before appropriate regulatory bodies on issues of concern to consumers.

Health plans should be required to cooperate with such programs.

Insurance counseling

Government-supported insurance counseling programs should have sufficient funding to provide adequate staff training to meet the demand for assistance among beneficiaries.