Nº 11 Summer 2022
Study: MA plans fall short in coverage of mental health, substance abuse services
Senate committee to probe deceptive Medicare Advantage marketing practices
Nº 11 - Summer 2022
The RISE initiative on third party marketing organizations in MA News
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As noted above, I am thinking about a completely different topic I want to highlight for you: opportunities to shift the paradigm of health care delivery to the home. The pandemic initi ated a sudden and dramatic adoption of virtual health care that is here to stay. It occurred at a moment when, prior to the pandemic, the average person would have doubted such an enormous uptake would be possible even over a multi-year timeframe. And yet adoption swelled, as they say, due to necessity being the mother of invention.
I am reading more and more about the movement to bring “hos pital at home” to reality, such as a recent collaboration between Sena Health and Salem Medical Center in New Jersey. Indeed, a recent survey by the Chartis Group found the number of sys tems exploring hospital-at-home programs to double over the next five years. Beyond that, however, a simpler and still pro found movement has already begun in the Medicare Advantage world: caregiver visit benefits. I recently reviewed data that showed 26 percent of all Medicare Advantage members now enjoy some level of in-home visit allowance for caregiver ser vices. I have recently done some consulting in this field and decided it was a very important and worthwhile issue to pursue.
Of course, this article gets my goat, as it might do to you, as well. However, the point is not lost on me that the visibility and manipulative advertising referred to in the article casts the Medicare Advantage program in a negative light and invites wider criticism. It stokes cynicism about the merits and virtues of a program that benefits millions of seniors and disabled beneficiaries. The most frustrating thing about this is that the bad actors running these TV commercials are outside the regu latory reach of the Centers for Medicare & Medicaid Services.
The RISE task force on Third Party Marketing Organizations (TPMOs) has produced a researched analysis and set of recom mendations for Medicare Advantage Organizations (MAOs) to take in view of the ongoing misbehavior of these unscrupulous advertisers. [See p.7]. I strongly advise you to review this piece and take to heart these suggestions. RISE intends to reach out to all the MAOs to promote the recommended Medicare mar keting compliance steps and whitelisting of TPMOs that pledge to comply with these measures.
LETTER FROM THE CHAIR OBSERVATIONS IN HEALTH CARE: MA MARKETING AND OPPORTUNITIES FOR PLANS TO SHIFT THE PARADIGM OF CARE DELIVERY TO THE HOME
I recently read an article in the news with the headline, “It’s time to stop the Medicare ‘Advantage’ scam before Medicare is dead” by Thom Hartmann in Raw Story. It calls for passing a law to stop the deceptive advertising of Medicare Advantage plans, and the article includes an embedded link to an advertise ment featuring Joe Namath. The article goes on to rant about numerous other complaints about the Medicare Advantage pro gram itself, including some points that are grounded in factual issues but, in this case, exaggerated to enflame public opinion.
There are two things on my mind that I want to share with you in this column. The first has to do with the infamous “Joe Namath” TV commercials, a seemingly never-ending blight on our indus try and our Medicare beneficiaries. The other is a more positive observation about opportunities available to our organizations to serve and deliver on the promise of ever-better health care coverage and value.
While most of these caregivers are companion visitors, unskilled personnel who help members who are often “shut-in” and suffer ing from loneliness and isolation, there is a need for additional levels of support. For example, for members who need help with activities of daily living, lifting support and toileting, there are non-skilled personnel with certifications as home health aides and certified nursing assistants, who can attend to these needs. This kind of support can make all the difference in mem bers’ ability to continuing living at home and maintaining some Theseindependence.caregivers
Particularly for members whose health care is impaired by issues of social determinants, having a caregiver support person can make all the difference in getting them the services they des perately require. It is an idea that excites me a lot. It reminds me of the reason I got into health care in the first place: find ing better ways to improve the lives of seniors and to ensure they get high quality, affordable health care they need. Isn’t that why most of us signed up for this gig? I wish you all much success in the upcoming AEP season. Kind regards to all, Kevin Mowll, Chair RISE Medicare Member Acquisition & Experience Community
can also do a lot more. They can make sure that necessary physician visits or therapy visits get scheduled and, if need be, transport the members to complete the visits. They can also help ensure that members take their medications and that in-home clinical visits or even risk adjustment health assessments get completed. In short, by having a trusted care giver in the home, the health plan can complete an important link in the member etngagement chain to fulfill the necessary steps in care management.
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Wyden also cited a recent survey of state insurance commissioners conducted by the National Association of Insurance Commissioners (NAIC) that noted an increase in complaints from seniors about false and misleading adver tising and marketing of MA plans. In May, the NAIC sent a letter to Congress asking lawmakers to give the association the authority to regulate MA marketing. The association cited misrepresentations in marketing, inappropriate or confusing marketing practices that have led to members to enroll in MA plans without understanding the coverage they were enrolling into and disenrolling from Original Medicare, aggressive sales practices, and improper enroll ment into plans of individuals with Alzheimer’s Disease or dementia, mentally incapacitated, and those with limited English proficiency.
Senate Finance Committee Chair Ron Wyden, D-Ore., has launched an inquiry into potentially deceptive Medicare Advantage (MA) marketing tactics that may take advan tage of seniors looking for Medicare coverage.
from seniors regarding MA plans in 2021 than it did in 2020. Last fall CMS issued a memo that outlined best practices for Medicare marketing campaigns conducted by third parties in response to misleading advertisements.
Senate committee to probe deceptive MA marketing practices
The letter was sent in the wake of recent reports from the Centers for Medicare & Medicaid Services (CMS) that it has received more than twice the numbers of complaints
“I have heard alarming reports that MA and Part D health plans and their contractors are engaging in aggressive sales practices that take advantage of vulnerable seniors and people with disabilities,” Wyden wrote . “I write seeking information about potentially deceptive market ing practices being conducted by insurance organizations offering Medicare benefits under the Medicare Advantage program and the Part D prescription drug program.”
Late last month Wyden released the letter he sent to 15 state insurance commissioners and state health insurance assistance programs requesting data about MA market ing complaints and other information.
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Wyden sent the August 18th letter to state insurance commissioners and state health insurance assistance pro grams in Arizona, California, Colorado, Florida, Georgia, Illinois, Massachusetts, Michigan, Missouri, New York, North Carolina, Ohio, Oregon, Pennsylvania, and Texas. He asked that they provide the following information to his office by September 16:
of plans, reimbursements, benefits, premiums, cost sharing, supplemental benefits, or other features
• Examples of potentially false or misleading marketing materials and advertisements in MA or Part D, including mailers, robo-calls, websites, television commercials, and online advertisements
• Certain types of organizations, such as TPMOs, health insurance carriers, pharmacies, or provider organizations, that account for a disproportionate share of complaints
Meanwhile, the Better Medicare Alliance (BMA), an advocacy and research organization supporting MA, pushed back on the criticism, noting that MA marketing materials are already subject to regulation and must be approved by CMS. “With a 94 percent percent consumer satisfac tion rate, it is clear that this program consistently lives up to its promise for seniors, Mary Beth Donahue, president and CEO of BMA, said in a statement . “Policymakers must take action to modernize Medicare enrollment in ways that offer more transparency in coverage choices and empower consumers, rather than criticizing those standing in the gap to help beneficiaries navigate this difficult and com plicated process.”
• Qualitative data on certain types of complaints about marketing materials
• Certain parent organizations or other market participants that have provided false or misleading materials
• Certain parent organizations or other market participants that account for a disproportionate share of complaints
• The responsibilities of the agent or broker in the state to protect consumers from potentially false or misleading marketing
• Certain MA or Part D product types that may be more likely to complaints
• Any trends in complaints of unsolicited contacts of beneficiaries or the methods of contacts, such as telemarketers, SMS texting, online outreach, or online targeted advertising
• Complaints about MA and/or Plan D marketing (segmenting complaints by third-party marketing organizations or TPMO) that they received in 2019, 2020, 2021, and 2022
• Geographic regions where complaints are more common
• Common MA or Plan D marketing practices that the Senate Finance Committee should know about Michael Adelberg, providers and plans lead, Faegre Drinker Consulting, who recently spoke about federal marketing oversight at the RISE AEP Medicare Readiness Summit, said that the feedback from the state insurance commissioners could be used to hold a hearing on MA marketing this fall, right before the start of mar keting. Congressional attention could, said Adelberg, “push CMS to enforce marketing rules more strictly” during enroll ment season.
RISE has also expressed concerns with marketing compliance practices, particularly the fallout from Medicare television commercials featuring Joe Namath, and last year formed a workgroup to address these concerns. Since then, the workgroup has met regularly to develop a set of rec ommendations for MA organizations, which can be found on p. 7 of this newsletter.
The actions of a few “of these bad actors” casts the MA program in a negative light and invites wider criticism, said Kevin Mowll, who chairs the RISE Association’s Medicare Member Acquisition & Experience Community and leads the marketing workgroup. “It stokes cynicism about the merits and virtues of a program that benefits millions of seniors and disabled beneficiaries,” he said. “The most frus trating thing about this is that the bad actors running these TV commercials are outside the regulatory reach of CMS.”
• Misleading information about certain aspects of a product, such as provider networks, provider acceptance
• Certain benefits associated with the complaints, such as meals, scooters, $0 cost sharing or premiums, dental services, over-the-counter cards
• Quantitative and qualitative data on fraudulent activity, such as beneficiaries who were enrolled without any contact with a producer, sales practices like crossselling, and improper enrollment
• Whether enrollment in the products would result in a greater number of prescriptions being filled in a particular pharmacy or pharmacy chain
• Any marketing materials comparing MA and Medicare supplemental insurance products that are false or misleading in nature
• Differences in reports of complaints of false or misleading marketing among groups of Medicare beneficiaries (lower income, dual eligible, Black or Hispanic beneficiaries, and beneficiaries with disabilities)
• Overall customer satisfaction with MA plans is 809 (on a 1,000-point scale), which is up 3 points from 2021 and up 15 points during the past five years
Among the key findings of the study:
• Just 27 percent of members say they have enough coverage for substance use disorder services
• Thirty-eight percent of MA plan members say they have enough coverage for mental health treatment, down from 39 percent a year ago
• Among those who have used the telemedicine technology, 48 percent say they are very likely to use it again, an increase of five percentage points from last year
“Older adults have been affected by loneliness and social isolation that increased throughout the pandemic. For some health plans, coverage can be improved. For others, increasing customer understanding of mental health ben efits may be the bigger opportunity as beneficiaries might be aware that some coverage is available but may not fully understand which services and medications are covered,” he said. “But coverage does not always guar antee access, as finding providers who accept Medicare may be a challenge in some areas.”
• Twenty-four percent of MA members say they used telemedicine during the past year, down from 35 percent in 2021
• Fourteen percent, however, have registered for the portal but never logged in
Study: MA plans fall short in coverage of mental health, substance abuse services
• Most (82 percent) of MA members have registered for their plan’s member portal —up four percentage points from a year ago
Improvements in billing and payments, cost, and pro vider choice have led to an increase in overall customer satisfaction with MA plans this year, but there are some concerning factors brewing beneath the surface, according to the J.D. Power 22 U.S. Medicare Advantage Study SM . Most notably, a majority of MA plan members say they do not have enough coverage for mental health and substance use disorder services.
• Ninety-one percent of members say they have enough coverage for routine diagnostics and 89 percent report they have enough coverage for preventive and wellness services
• Overall customer satisfaction scores are 72 points higher (823) when customers register and log-in to the portal than when they do neither (751)
A new study released by J.D. Power finds that overall member satisfaction with Medicare Advantage (MA) plans is on the rise, but the plans appear to miss the mark on mental health and substance abuse disor der services.
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With an estimated 1.7 million Medicare beneficiaries living with a diagnosed substance use disorder and one in four Medicare beneficiaries living with a mental health condition, there is a big opportunity for MA plans to support more patients and families in need, Christopher Lis, managing director, global healthcare intelligence at J.D. Power, said in the study announcement.
The findings are based on the responses of 3,094 mem bers of MA plans this summer across the United States. The study, now in its eighth year, measures member sat isfaction with MA plans based on six factors (in order of importance): coverage and benefits; provider choice; cost; customer service; information and communication; and billing and payment.
Consumer Journey
RISE is pleased to have sponsored this important industry work. We would like to thank our board and contribu tors Kyal Moody, MyPlanAdvocate, and Manny Zuccarelli, Quote Velocity, as well as Michael Adelberg, PrincipalFaegre Drinker Consulting at Faegre Drinker, for their recommendations incorporated in this document.
For the purposes of this discussion, the lead generation process is generally facilitated via:
Point of Origin
The RISE workgroup on third party marketing organiza tions (TPMO) recently developed an analysis and set of recommendations for Medicare Advantage Organizations (MAOs) to consider in light of advertising tactics that mis lead and confuse MA beneficiaries. We hope you’ll embrace these recommended Medicare marketing compliance steps.
Inbound Calls: Consumer-initiated calls generated from websites or publicly displayed phone numbers including direct mail.
Three primary factors underlie the unique experience a consumer will go through via any of the aforementioned Third Party Marketing Organizations (TPMO) processes.
• Web Leads: An online application consisting of data collected through a website
THE RISE INITIATIVE ON THIRD PARTY MEDICAREORGANIZATIONSMARKETINGINADVANTAGE
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Consumers may be influenced by advertisements or com munications in a myriad of ways, and the way their data is used or manipulated, as well as what they experience, is largely dependent on their unique Consumer Journey. This Journey is affected by everything from their Point of Origin as well as how they are handled up to the point in which they speak with a service provider.
Lead generation is an all-encompassing term used to describe the process of obtaining consumer interest and information with the intent to direct that consumer to an appropriate service provider.
Points of Origin may include web leads generated from websites, internet display ads with toll-free numbers, inbound calls from websites, or offline traffic (direct mail, Currently,TV).
The initial marketing copy consumers see is heavily weighted toward the Consumer Journey.
• Calls•
• Warm Transfers: Contact-center generated transfers are produced by calling consumer data, generally in the form of Web Leads.
• Outbound calls: unsolicited “robo-calling”
ECOSYSTEM
the Centers for Medicare & Medicaid Services (CMS) monitors the Point of Origin with the requirement of standardized material identifications (SMIDs) for all benefits-based marketing. As you will read below, it is our suggestion that CMS and plans require all Points of Origin to be approved, including outbound calls, and require that this data be passed along to service providers.
With each degree of separation the possibility of the consumer experience as well as the persistency rate of enrolled consumers deteriorating increases dramatically. The illustration below suggests that Carriers or Contracted Agencies/Brokers are one and the same.
1 DEGREEST Carriers (not shown in visual above) • Consumers who engage directly with Carriers • Consumer » Carrier/Agency 2 DEGREEND TPMOs / Agencies / Brokers • Consumers who engage directly with TPMOs • Consumer » TPMO » Carrier 3 DEGREERD Lead Generators / External Marketing • Generates Medicare leads via internal traffic to O&O properties (Paid Search, Direct Mail, Social, SEO, TV…). Directly in
point of contact and provides those inquiries
able to best ensure that the consumer is not misled at any point in the process.
Agency/Carrier partners. • May or may not directly manage and own a Contact Center. • Consumer » Lead Generator » TPMO » Carrier 4 DEGREETH Lead Aggregator • Purchases or aggregates leads
Lead Generator.
• May or may not directly
The single most important factor in maintaining quality control over a consumer journey is based on how many entities are involved in the process from the initial point of contact to delivery of that consumer via Web Lead or Call.
A vertically integrated Lead Generation company responsible for the entire customer journey from the Point of Origin to the delivery of that consumer to a service provider is the most ideal scenario. In this busi ness model, the Lead Generation company has complete control over what the consumer sees and hears and is
*The levels of separation between the Carrier/TPMO and the consumer could be reduced by any number of the above columns through a direct relationship. control of what the consumer sees as the initial directly to from a Lead Aggregation well. Many Lead Aggregators operate contact centers, domestically and internationally. manage
teams may also generate leads as
both
DEGREES OF SEPARATION
and own a Contact Center. • Consumer » Lead Generator » Lead Aggregator » TPMO » Carrier 5 DEGREETH Lead Clearinghouse • Purchases leads from a Lead Generator or Lead Aggregator with the sole purpose of selling the lead to the highest bidder. • Consumer » Lead Generator » Lead Aggregator » Contact Center » TPMO » Carrier 8 MAE COMMUNITY NEWSLETTER
TheAgency.fundamental
issue lies in marketing agencies having little to no recourse for unethical marketing practices with large financial upside given the high response senior market. Dozens of new plans with highly competitive ben efits create a perfect storm inviting marketing agencies to engage consumers without the responsibility of the acute and downstream effects of such practices. We recognize that April’s CMS regulation is clear that MA plans are responsible for any bad conduct from any entity that inter acts with members on their behalf, no matter how many layers separate the plans from the activities. However, we are concerned that all these factors above make it very challenging to create a “chain of custody” that transpar ently tracks and links the activities to specific members and their affiliated MA plans.
• Questionnaires
• Ownership and control of health-based websites
Prohibit Incentivized Traffic
Some of the current tactics being utilized include:
• Non-Medicare based websites intended to generate a consent action for a Medicare call
Any and all marketing assets should require CMS approval and/or the approval of plans directly.
• Sweepstakes entries
Ideally, a whitelisting process for vendors who have passed certification for their ability to provide marketing services would be in place. This process should provide oversight for compliance and security requirements including but not limited to:
EXAMPLE CONSUMER JOURNEY
• Security compliance measures, e.g. SOC-2 or equivalent
• Much like the mortgage vertical which requires lead generators to be licensed as mortgage brokers due to their being considered part of the loan origination process, it is our suggestion that CMS follow the same requirements for lead generators. In all practicality, lead generators who produce Medicare leads should be considered part of the plan enrollment process, and therefore should be required to maintain the same licensing standards and CMS approved certification that a licensed agent would. This has the much desired second-order effect of ensuring that those who lead these marketing agencies are well educated on not just the ethical and compliance requirements, but actual product knowledge as well.
• Non-Medicare interest cross-sales
Incentivized traffic, generally in the form of digital traffic where consumers are encouraged to complete an online application in return for some sort of compensation in the form of money or gifts should be explicitly prohibited.
Many of the coregistration (“coreg”) web leads that are generated begin with an incentivized offering or “survey” which lures consumers to complete online applications while obtaining a multitude of data points that are then “sold” in the form of individualized web leads.
• Unsolicited outbound calling
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• Generally proliferated via offshore contact centers
CMS has no history of going after lead generators and will punish MA plans for the sins of those third parties, as noted earlier. However, the Federal Trade Commission and state attorneys general have the authority to go directly after lead generators and likely will receive referrals from CMS when bad conduct is discovered.
• Access to and submission of assets to CMS for approval
• Internal contact center operations
Tactics
WhitelistingSOLUTIONSofVendors
• Non-specific lead generation websites intended to gather many data points on a consumer with the intention of selling the data to a dozen or more sources
• E.g. car insurance discussion which routes consumer to Medicare agent
POTENTIAL
*This diagram may extend to the nth degree depending on how many times a consumer’s information is passed from one organization to another before reaching a Carrier /
All Assets Requiring CMS Authorizations such as Approval
• Co-registration lead generation (e.g., “Are you 65 or older?”)
• Generally highly incentivized to lure consumers
• Licensing in health insurance
• Extended and other warranties
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