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46–954 2010

MEDICARE ADVANTAGE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON WAYS AND MEANS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

FEBRUARY 28, 2008 

Serial No. 110–72 

Printed for the use of the Committee on Ways and Means 

( 


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COMMITTEE ON WAYS AND MEANS 

CHARLES B. RANGEL, New York, Chairman 

FORTNEY PETE STARK, California 

SANDER M. LEVIN, Michigan 

JIM MCDERMOTT, Washington 

JOHN LEWIS, Georgia 

RICHARD E. NEAL, Massachusetts 

MICHAEL R. MCNULTY, New York 

JOHN S. TANNER, Tennessee 

XAVIER BECERRA, California 

LLOYD DOGGETT, Texas 

EARL POMEROY, North Dakota 

STEPHANIE TUBBS JONES, Ohio 

MIKE THOMPSON, California 

JOHN B. LARSON, Connecticut 

RAHM EMANUEL, Illinois 

EARL BLUMENAUER, Oregon 

RON KIND, Wisconsin 

BILL PASCRELL JR., New Jersey 

SHELLEY BERKLEY, Nevada 

JOSEPH CROWLEY, New York 

CHRIS VAN HOLLEN, Maryland 

KENDRICK MEEK, Florida 

ALLYSON Y. SCHWARTZ, Pennsylvania 

ARTUR DAVIS, Alabama 

JIM MCCRERY, Louisiana 

WALLY HERGER, California 

DAVE CAMP, Michigan 

JIM RAMSTAD, Minnesota 

SAM JOHNSON, Texas 

PHIL ENGLISH, Pennsylvania 

JERRY WELLER, Illinois 

KENNY HULSHOF, Missouri 

RON LEWIS, Kentucky 

KEVIN BRADY, Texas 

THOMAS M. REYNOLDS, New York 

PAUL RYAN, Wisconsin 

ERIC CANTOR, Virginia 

JOHN LINDER, Georgia 

DEVIN NUNES, California 

PAT TIBERI, Ohio 

JON PORTER, Nevada 

JANICE MAYS, Chief Counsel and Staff Director 

BRETT LOPER, Minority Staff Director 

SUBCOMMITTEE ON HEALTH 

FORTNEY PETE STARK, California, Chairman 

LLOYD DOGGETT, Texas 

MIKE THOMPSON, California 

RAHM EMANUEL, Illinois 

XAVIER BECERRA, California 

EARL POMEROY, North Dakota 

STEPHANIE TUBBS JONES, Ohio 

RON KIND, Wisconsin 

DAVE CAMP, Michigan 

SAM JOHNSON, Texas 

JIM RAMSTAD, Minnesota 

PHIL ENGLISH, Pennsylvania 

KENNY HULSHOF, Missouri 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Ways and Means are also, published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

Page 

Advisory of February 21, 2008, announcing the hearing ..................................... 2 

WITNESSES 

Kerry Weems, Acting Administrator, Centers for Medicare and Medicaid 

Services, U.S. Department of Health and Human Services ............................. 7 

James C. Cosgrove, Acting Director, Health Care Issues, U.S. Government 

Accountability Office ............................................................................................ 15 

Byron Thames, M.D., Member, Board of Directors, American Association of 

Retired Persons, Orlando, Florida ...................................................................... 108 

Jim Mattes, President and CEO, Grande Ronde Hospital, La Grande, Oregon 112 

David Lipschutz, Interim President and CEO, California Health Advocates, 

Los Angeles, California ........................................................................................ 118 

Daniel C. Lyons, M.D., Senior Vice President, Government Programs, Independence Blue Cross, Philadelphia, Pennsylvania ............................................ 127 

SUBMISSIONS FOR THE RECORD 

Association for Community Affiliated Plans, statement ...................................... 155 

Cathy Roberts, statement ....................................................................................... 157 

Kathy Castor, statement ......................................................................................... 158 

The Senior Citizens League, statement ................................................................. 159 


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MENTAL HEALTH AND 

SUBSTANCE ABUSE PARITY 

THURSDAY, FEBRUARY 28, 2008 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON WAYS AND MEANS, 

SUBCOMMITTEE ON HEALTH, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 10:01 a.m., in 

Room 1100, Longworth House Office Building, Hon. Fortney Pete 

Stark [chairman of the subcommittee] presiding. 

[The advisory announcing the hearing follows:] 


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ADVISORY 

FROM THE COMMITTEE ON WAYS AND MEANS 

FOR IMMEDIATE RELEASE CONTACT: (202) 225–3943 

February 21, 2008 

HL–20 

Health Subcommittee Chairman Stark 

Announces a Hearing on Medicare Advantage 

House Ways and Means Health Subcommittee Chairman Pete Stark (D–CA) announced today that the Subcommittee on Health will hold a hearing on the costs 

seniors and people with disabilities pay through the Medicare Advantage Program. 

The hearing will take place at 10:00 a.m. on Thursday, February 28, 2008, 

in the main committee hearing room, 1100 Longworth House Office Building. At the hearing, the Government Accountability Office (GAO) will release and 

discuss findings of a new report on cost-sharing changes under Medicare Advantage 

plans. 

In view of the limited time available to hear witnesses, oral testimony at this 

hearing will be from invited witnesses only. However, any individual or organization 

not scheduled for an oral appearance may submit a written statement for consideration by the Committee and for inclusion in the printed record of the hearing. 

BACKGROUND: 

Of the 43 million Medicare beneficiaries, 8.8 million (20%) are enrolled in what 

are currently known as Medicare Advantage (MA) plans. These private health plans 

must provide benefits ‘‘actuarially equivalent’’ to those covered under traditional feefor-service (FFS) Medicare (Parts A&B). However, Medicare Advantage plans can 

and often do limit the network of providers that are available to beneficiaries, and 

often have higher cost-sharing requirements for selected services and different premiums than traditional FFS Medicare. MA plans can provide additional benefits 

that are not covered by traditional Medicare, such as eyeglasses and yearly physical 

exams. However, some of these same plans charge higher cost-sharing for covered 

Medicare services. 

The number of private plans available to Medicare beneficiaries and enrollment 

in such plans have grown steadily since 2003, as plan payments and options have 

increased. There are now eight different types of MA plans: Health Maintenance Organizations (HMOs); Provider Sponsored Organizations (PSOs); Preferred Provider 

Organizations (PPOs); Regional PPOs; Private Fee For Service Plans; Cost Contract 

Plans; Special Needs Plans (SNPs); and Medical Savings Account plans. 

According to the Medicare Payment Advisory Commission (MedPAC), MA program payments were on average 113 percent of FFS expenditure levels in 2007. To 

create financial neutrality between private plan and FFS payment rates, MedPAC 

has recommended setting MA benchmarks equal to 100 percent of FFS. For many 

years, plans were paid at 95 percent of FFS rates, reflecting industry claims that 

private plans were more efficient. Only in recent years have payments risen to be 

substantially higher than local FFS payments. 

‘‘I am concerned that seniors enrolling into Medicare Advantage plans 

may be unaware that under certain circumstances, they may be charged 

more than traditional Medicare,’’ said Chairman Stark in announcing the hearing. ‘‘I look forward to hearing from CMS, GAO and our other witnesses 

about the costs associated with Medicare Advantage plans, and the steps 

that the Administration is taking to ensure that these costs are accurately 

explained. I also think we need to get a better sense of what services plans 

are actually providing with the extra dollars, instead of more rhetoric 


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about what is offered. It’s an important distinction that deserves a full discussion.’’ 

FOCUS OF THE HEARING: 

The hearing will focus on the structure, costs and oversight of the Medicare Advantage program. 

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS: 

Please Note: Any person(s) and/or organization(s) wishing to submit for the hearing record must follow the appropriate link on the hearing page of the Committee 

website and complete the informational forms. From the Committee homepage, 

http://waysandmeans.house.gov, select ‘‘110th Congress’’ from the menu entitled, 

‘‘Committee Hearings’’ (http://waysandmeans.house.gov/Hearings.asp?congress=18). 

Select the hearing for which you would like to submit, and click on the link entitled, 

‘‘Click here to provide a submission for the record.’’ Once you have followed the online instructions, completing all informational forms and clicking ‘‘submit’’ on the 

final page, an email will be sent to the address which you supply confirming your 

interest in providing a submission for the record. You MUST REPLY to the email 

and ATTACH your submission as a Word or WordPerfect document, in compliance 

with the formatting requirements listed below, by close of business Thursday, 

March 13, 2008. Finally, please note that due to the change in House mail policy, 

the U.S. Capitol Police will refuse sealed-package deliveries to all House Office 

Buildings. For questions, or if you encounter technical problems, please call (202) 

225–1721. 

FORMATTING REQUIREMENTS: 

The Committee relies on electronic submissions for printing the official hearing record. As always, submissions will be included in the record according to the discretion of the Committee. 

The Committee will not alter the content of your submission, but we reserve the right to format 

it according to our guidelines. Any submission provided to the Committee by a witness, any supplementary materials submitted for the printed record, and any written comments in response 

to a request for written comments must conform to the guidelines listed below. Any submission 

or supplementary item not in compliance with these guidelines will not be printed, but will be 

maintained in the Committee files for review and use by the Committee. 

1. All submissions and supplementary materials must be provided in Word or WordPerfect 

format and MUST NOT exceed a total of 10 pages, including attachments. Witnesses and submitters are advised that the Committee relies on electronic submissions for printing the official 

hearing record. 

2. Copies of whole documents submitted as exhibit material will not be accepted for printing. 

Instead, exhibit material should be referenced and quoted or paraphrased. All exhibit material 

not meeting these specifications will be maintained in the Committee files for review and use 

by the Committee. 

3. All submissions must include a list of all clients, persons, and/or organizations on whose 

behalf the witness appears. A supplemental sheet must accompany each submission listing the 

name, company, address, telephone and fax numbers of each witness. 

Note: All Committee advisories and news releases are available on the World 

Wide Web at http://waysandmeans.house.gov. 

The Committee seeks to make its facilities accessible to persons with disabilities. 

If you are in need of special accommodations, please call 202–225–1721 or 202–226– 

3411 TTD/TTY in advance of the event (four business days notice is requested). 

Questions with regard to special accommodation needs in general (including availability of Committee materials in alternative formats) may be directed to the Committee as noted above. 

f 

Chairman STARK. Good morning, and thank you for joining us 

on this hearing this morning as we review the value of Medicare 


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Advantage overpayments. We will commence our hearing in a moment. 

We are now overpaying Medicare Advantage plans around 13 

percent, on average, according to MedPAC’s latest analysis. In 

some areas, we are overpaying them by 50 percent. The President 

just sent us a budget with more than half a trillion dollars in cuts 

to Medicare over the next decade, but none of those cuts came from 

Medicare Advantage. The overpayments in that budget remain 

firmly in place. 

The President’s budget also sent to Congress a legislative response to the so-called Medicare trigger. Again, the President’s 

plan protects the special interests of the Medicare Advantage plans 

and puts all the costs or the cuts of meeting what I think is an irresponsible trigger policy squarely on the backs of America’s seniors by increasing prescription drug premiums for millions of beneficiaries. 

Clearly, the administration believes that these overpayments are 

warranted. We asked the GAO, the Government Accountability Office, to report back to us regarding to what extent these overpayments translate into reduced cost-sharing or extra benefits, and if 

any or if so, whether this is an efficient way to achieve any goals 

that were inherent in these reduced costs or extra benefits. 

The report was requested jointly by the Committee on Ways and 

Means, our subcommittee, Energy and Commerce, and the Government Oversight Reform. I don’t want to steal the GAO’s thunder, 

but I think it is worth highlighting a few of the things that the report will discuss today. 

First, we have no idea what beneficiaries actually receive in 

Medicare Advantage plans because there is absolutely no requirement that the Medicare Advantage plans turn over any data on the 

services actually rendered to the government or to beneficiaries. 

The only way GAO could analyze the different benefits was to rely 

on projections from the Medicare Advantage plans with respect to 

how they said they would spend their subsidies. That is not acceptable. That is just like no-bid contracts in Iraq. We ought to know 

what we are getting, and it would be a simple matter for CMS to 

request that data. 

Second, if you look at the Medicare Advantage plans’ own projections, the GAO finds that beneficiaries can spend more in a Medicare Advantage plan than they would in fee-for-service Medicare. 

They can spend; they don’t necessarily all spend more. The services 

most often associated with higher co-payments are home health 

and hospitalizations, two services that are vital to sick people and 

are obviously more of a burden to low-income people. If plans successfully cherry-pick healthy seniors, which they do, and the payments are based on averages, it means we are overpaying them 

even more than we think. 

Third, the report shows that MA plans invest 3 percent in Part 

B premium reductions, and that is the only improvement that is 

guaranteed to be valuable to every enrollee. 

Fourth, the Medicare Advantage plans are far less efficient than 

fee-for-service Medicare, which essentially operates with a 98 percent medical loss ratio. In contrast, in the average Medicare Advantage plan, the medical loss ratio is 87 percent. But nearly oneVerDate Nov 24 2008 14:19 Dec 10, 2010 Jkt 046954 PO 00000 Frm 00008 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\46954.XXX GPO1 PsN: 46954

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third of the plans have a medical loss ratio of less than 85 percent. 

It would be good to know how low the medical loss ratios actually 

go. CMS has actually refused to release that data to GAO, and my 

hope is that they will be able to explain why they won’t release the 

data and perhaps change their minds. 

GAO’s findings raise serious questions about the value of lavishing subsidies on Medicare Advantage plans as a means to ‘‘help’’ 

Medicare beneficiaries. Today’s second panel will reveal what is 

happening to Medicare beneficiaries in the real world as they attempt to navigate the confusing world of Medicare Advantage and 

the shoddy sales practices that their shyster-like sales people foist 

on frail and often confused Medicare beneficiaries. 

Our witnesses will confirm that many Medicare beneficiaries are 

unaware that their costs may be higher than they would in traditional Medicare. They believe that they are enrolling in a Medigap 

plan under which they would never pay more, and they are 

shocked when they learn how much they have to pay. These issues 

are only a small part of the oversight needed in the Medicare Advantage plans. 

I would be remiss not to highlight that the CHAMP Act, which 

we passed out of the House last year and is still pending in the 

Senate, addressed many of these concerns. It leveled the playing 

field on payments to Medicare Advantage plans. It required plans 

to meet a medical loss ratio of 85 percent to participate. 

It ensured that beneficiaries wouldn’t pay more in Medicare Advantage than they would in traditional fee-for-service Medicare. 

And it provided states with the tools they need, and the Federal 

Government refuses to use, to regulate marketing of Medicare Advantage plans to protect consumers. 

It may sound differently, but I am not against private plans in 

Medicare. My district has perhaps the highest penetration of Medicare Advantage in the country. Half of the people in my district— 

not half of the insured, half of the people—in my district belong to 

Kaiser Permanente, a credible managed care plan. And they should 

have the choice to join that. 

But the rest of us shouldn’t be subsidizing the people who choose 

to go into Kaiser. Plans should compete on a level playing field and 

preserve many of the core choices that really matter to beneficiaries. 

I think that managed care and multi-discipline group practice 

will be the medical delivery plans of the future, but I see no reason 

that they have to be grossly overpaid and under-regulated. 

Mr. Camp? 

Mr. CAMP. Well, thank you, Mr. Chairman. And what are the 

benefits of Medicare Advantage plans and what they provide to 

beneficiaries is an important question. So thank you for having this 

hearing. It really goes to the heart of the debate about Medicare 

Advantage. 

Unfortunately, most of the witnesses today are going to use the 

highly selective data and hypothetical scenarios to draw negative 

conclusions about the benefits provided by Medicare Advantage 

plans. This stilted analysis does not reflect the experience of most 

Medicare Advantage enrollees or the actual value of the plans they 

provide. 


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Medicare Advantage plans provide significant savings for their 

enrollees compared to what is charged in traditional Medicare. According to the GAO, beneficiaries in Medicare Advantage would expect to pay $804 less this year in out-of-pocket expenses than those 

in traditional Medicare. 

And these findings were echoed in a recent Kaiser Family Foundation report that examined actual beneficiary health spending. 

The Kaiser report found that, on average, beneficiaries enrolled in 

Medicare Advantage coordinated care plans would save nearly 

$550, and beneficiaries who use the most healthcare services would 

save nearly $4,200 compared to those in fee-for-service Medicare. 

Anyone who doubts that Medicare Advantage plans provide real 

savings to beneficiaries need only look at the rapid growth in enrollment in these plans. If beneficiaries did not see the real value 

in these plans, enrollment in Medicare Advantage would not have 

doubled since 2003, bringing total enrollment in these plans to 

nearly nine million beneficiaries. 

Fee-for-service Medicare fails to protect beneficiaries from catastrophic healthcare costs, and often forces them to pay large 

deductibles and cost-sharing payments. This reality is the reason 

why approximately 40 percent of Medicare beneficiaries have either 

enrolled in Medicare Advantage or have otherwise purchased 

Medigap plans. 

Instead of attacking programs that provide choices and quality 

care, we should be looking at ways to perform the traditional Medicare, which provides less. This is exactly what the Republican majority did when it created Medicare Advantage in 2003. I am disappointed by the analysis in GAO’s report, which fails to reflect the 

real-world experience of the beneficiaries enrolled in Medicare Advantage. 

In fact, GAO’s report does not reflect the reality of a single beneficiary in any Medicare Advantage plan. The report only looks at 

hypothetical beneficiaries who use only certain types of services 

and enroll in a narrow selection of plans. I frankly expected more 

from the GAO. 

At the conclusion of this hearing, I intend to send a letter to the 

Comptroller General asking that GAO undertake a new study. I 

hope this study will review the actual services used by real beneficiaries and compare that to the benefit packages of the most popular Medicare Advantage plans. I suspect that this analysis will 

give a much fairer and more representative view of the savings 

that Medicare Advantage plans provide to Medicare beneficiaries. 

Critics of the program will undoubtedly use this report to attack 

Medicare Advantage and assert that it fails to provide real benefits 

to program enrollees. In doing so, they will ignore the reality that 

the vast majority of plans actually provide much better cost-sharing benefits. They will also ignore the fact that GAO found that 

half a million beneficiaries have chosen to enroll in plans that have 

no cost-sharing on inpatient hospital visits. 

Some opponents of seniors being able to choose their healthcare 

instead of government believe that seniors are not smart enough to 

make choices about their healthcare. I fundamentally disagree, as 

do the 18 million seniors who have chosen Medicare Advantage and 


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Medigap plans, as I said, more than 40 percent of all Medicare 

beneficiaries. 

If we give them the opportunity, seniors will choose the plan that 

best fits their needs and provides them with the best benefits. And 

if we are really concerned about seniors not getting access to the 

best possible cost-sharing protections, perhaps we can agree to improve the comparative data that we provide to all Medicare beneficiaries. If everyone in Medicare could see how much they could 

save by enrolling in Medicare Advantage, I believe that even more 

beneficiaries would enroll in this important program. 

Thank you, and I yield back the rest of my time. 

Chairman STARK. As between bureaucracies, if my friend would 

yield, I would like a report also about what beneficiaries receive, 

not what they are offered, and have asked CMS repeatedly to give 

us that information. They can tell you they don’t have it and they 

don’t collect it. 

The GAO would love to do the report for us, and the data doesn’t 

exist. So I would be delighted to join with my colleague to say, let’s 

require this data. And I am not sure who would be able to better 

use it for their position. But the fact that we are not getting the 

data, I think, is that we are kind of legislating in the blind. 

And I hope you would agree that we can require that data to be 

forthcoming, and it could be sanitized so we protect competitive advantage and that sort of thing. 

Mr. CAMP. I think being able to use real data from real plans, 

and not hypothetical plans—this report purports to be an analysis 

of cost-sharing and Medicare Advantage, and it does nothing of the 

kind. 

Chairman STARK. But let us hear from the people who have 

been wrestling with this. And we will start with Kerry Weems. Administrator Weems is the acting administrator for the Centers for 

Medicare and Medicaid Services, affectionately known as CMS, 

from the U.S. Department of Health and Human Services. 

Why don’t you proceed to enlighten us, Mr. Weems, in any way 

you would like. 

STATEMENT OF KERRY WEEMS, ACTING ADMINISTRATOR, 

CENTERS FOR MEDICARE AND MEDICAID SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Mr. WEEMS. Thank you. Good morning, Mr. Chairman, Mr. 

Camp, members of the committee. 

Mr. Stark, you said you would be delighted, so let me add to your 

delight today. I have directed our Center for Beneficiary Choices to 

begin collecting the data that you request on additional benefits. 

We will collect it for past benefit years. 

There will probably be some data analysis that we will have to 

do. But going forward, we will collect the data in a regularized format so that we can all understand it. I agree with the chairman 

and with the ranking member. Let’s have a discussion about the 

facts, and let’s get the facts on the table. It is time to do that. I 

hope to be able to provide that information to this committee, to 

the GAO, and to others, again respecting proprietary information. 

Medicare Advantage is providing an affordable, high-value choice 

to roughly nine million beneficiaries. In 2008, plans offer an averVerDate Nov 24 2008 14:19 Dec 10, 2010 Jkt 046954 PO 00000 Frm 00011 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\46954.XXX GPO1 PsN: 46954

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age of over $1,100 in additional value to enrollees beyond original 

Medicare. For example, plans offer such benefits as routine eye 

care, hearing exams, additional inpatient hospital days, reduced 

cost-sharing for many services, and unlike original Medicare, MA 

enrollees do not face separate cost-sharing for physician and ancillary services when hospitalized. 

I would like to now discuss GAO’s findings in their report released today, and focus on one important Medicare benefit, inpatient hospital stays. At the risk of having warring charts, I did 

bring some charts with me today, and I would ask the committee’s 

indulgence as I discuss them. 

If we would first turn to the one to my right, your left, this is 

a complex chart but I think it—— 

Chairman STARK. Kerry, do we have—— 

Mr. CAMP. I am hopeful that you do, sir. 

Chairman STARK. Thank you. 

Mr. CAMP. Let’s start with the first column that says ‘‘One 

Day,’’ and then we will focus on—for a one-day hospital stay, for 

a Medicare Advantage plan—I am sorry. Do we all have it? Do we 

have enough to go around? Thank you. 

For a one-day hospital stay, the average cost-sharing for a Medicare Advantage enrollee is $237, as opposed to $1,108 under regular fee-for-service Medicare. And then if you take that and weight 

it by population, for a one-day it is $225 as opposed to the $1,108. 

And then we show the various plans at various percentiles, the 

25th percentile, the median, the 95th percentile. Even at the 95th 

percentile, for a one-day stay you can see that the cost-sharing is 

considerably less than what it is for fee-for-service Medicare. 

And in fact, if you now turn to the green boxes at the bottom, 

you have to get to the 98th percentile of Medicare Advantage plans, 

and still there is lower cost-sharing. And the lower cost-sharing 

there is $952. 

Then weight that by enrollment, and that is the very last row. 

Ninety-nine percent of beneficiaries have chosen an insurance product where their inpatient hospital copay for a one-day stay is less 

than fee-for-service Medicare. And in fact, now taking that bottom 

row, you can look across and see how beneficiaries have chosen 

through this choice to protect themselves against catastrophic or 

very high cost-sharing that you can see in fee-for-service. 

So take pretty close to the average—the average inpatient hospital stay is about five and a half days. So at six days, the expected 

Medicare cost would be about $1,400. 87.5 percent of Medicare 

beneficiaries enrolled in a Medicare Advantage plan have chosen a 

plan which protects them against those higher costs. And then you 

can see how that plays out, even on very long outliers. And this is 

weighted by the actual plan choices that beneficiaries make. 

This chart to my left, the bar chart, shows essentially the same 

data, but it is unweighted by beneficiary. The most telling piece, 

just for this one benefit, is the choices the beneficiaries have exercised to protect themselves against very high out-of-pocket costs. 

So I think that lays a good foundation for our discussion today. 

I will stop there. 


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[The statement of Kerry Weems follows:] 


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f 

Chairman STARK. Okay. We can continue this in our inquiry. 

And I would now turn to James Cosgrove, who is the acting director of healthcare issues—do you direct the issues or the department that looks at the issues—at the GAO. And I guess you have 

to suffer as the author of this. Right? 

Mr. COSGROVE. I wouldn’t say I suffered. I think my team 

worked long hours to put it together. So maybe they suffered. 


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Chairman STARK. All right. Well, why don’t you expand on the 

report, which we have all had a chance to at least see a summary 

of, and enlighten us in any manner you choose. 

STATEMENT OF JAMES C. COSGROVE, ACTING DIRECTOR, 

HEALTHCARE ISSUES, U.S. GOVERNMENT ACCOUNTABILITY 

OFFICE 

Mr. COSGROVE. Thank you, Mr. Chairman and Ranking Member Camp and members of the subcommittee. I am pleased to be 

here today to discuss our findings on cost-sharing and additional 

benefits in Medicare Advantage plans. In 2006, Medicare paid $59 billion to plans, which was an esti- mated $7.1 billion more than would have been spent if plan enrollees had instead received care through the fee-for-service program. 

So an important question is: What do beneficiaries and taxpayers 

get for this additional spending? Our report and my testimony 

today attempts to shed some light on this issue. 

Our findings largely pertain to the rebates that plans received. 

As you know, plans submit bids for providing Medicare covered 

services. Plans that bid less than established amounts receive rebates up to 75 percent of the difference. And plans must use those 

rebates to reduce cost-sharing, reduce premiums, or add benefits. 

Because the benchmarks are set relatively high, plans may submit bids that exceed fee-for-service spending and still receive substantial rebates. Plans may also charge beneficiaries a premium 

and use that money to reduce cost-sharing or add benefits. 

In our report being released today, we analyzed how plans projected they would spend the rebates and premiums they received 

in 2007. As has already been discussed this morning, these are 

plan projections because the data currently do not exist to know 

how plans actually spent the money or the services that they actually provided. 

Nearly all the plans in our study received a rebate, which aver- aged $87 per member per month. And on average, plans projected 

allocating their rebates as follows: 69 percent to reduce beneficiary 

cost-sharing; 20 percent to reduce premiums; and 11 percent to add 

some coverage for benefits that are not provided under traditional 

fee-for-service. 

For example, plans projected spending about $4 per member per 

month on some dental care. Plans projected spending lesser 

amounts on other types, such as vision care or health education. 

Because Medicare pays significantly more for Medicare Advantage beneficiaries and plans project using much of that additional 

money to reduce cost-sharing, it is no surprise that, on average, 

plans’ overall expected cost-sharing is relatively low. However, we 

found that beneficiaries in some plans could pay much more for 

certain important services than they would have paid if they had 

remained in fee-for-service. 

And this is because plans are allowed, within limits set by CMS, 

to establish their own cost-sharing requirements. So, for example, 

about 19 percent of Medicare Advantage enrollees were in plans 

that required cost-sharing for home health services. In contrast, 

beneficiaries in the traditional fee-for-service program pay nothing 

for that care. 


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We also found that beneficiaries in some plans could face expensive cost-sharing for inpatient services depending on how long they 

were hospitalized. So, for example, as our chart shows, some plans 

charge $275 or more for the first ten days of care. This is an example of one plan, but there were 15 or 16 other plans like it. In fact, there were 80 plans that charged more than $200 a day, some as much as $375 a day. Some charged for more than ten days 

of care. Of the 80 plans, they enrolled half a million beneficiaries. 

Many of these plans had maximum out-of-pocket limits, but many 

of these plans also had maximums that excluded certain services. 

As our chart also shows and as Mr. Weems has pointed out, 

beneficiaries in those same plans might pay relatively less for either short hospital stays or extremely long ones. Nearly half the 

plans we reviewed projected using some of their rebates to limit 

beneficiaries’ annual out-of-pocket spending for cost-sharing. But as 

I just mentioned, many plans excluded certain services from those 

maximums; for example, physician specialists, mental healthcare, 

outpatient substance abuse treatment, home health services, prosthetics, and durable medical equipment. 

So in closing, it is important to remember that there is no free 

lunch when it comes to Medicare Advantage. Any reductions in 

cost-sharing or premiums and any increases in benefits have largely been made possible only through the infusion of billions of extra 

dollars into the Medicare Advantage program. 

These extra dollars have resulted in a greater burden on taxpayers and higher Part B premiums for all beneficiaries, including 

those in the fee-for-service program. And in spite of these extra dollars, some beneficiaries may face higher cost-sharing for important 

services. 

As Congress considers the design and the cost of the Medicare 

Advantage program, it is important to remember to balance the 

needs of all beneficiaries and ensure the program is sustainable. 

Mr. Chairman, this concludes my prepared remarks. I am certainly happy to respond to any questions that you or other members might have. 


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[The statement of James C. Cosgrove follows:] 

Statement of James C. Cosgrove, Acting Director, Health Care Issues, 

U.S. Government Accountability Office 


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f 

Chairman STARK. Thank you. Is it your feeling, Mr. Cosgrove, 

that if we required data from the plans, obviously retroactively, as 

to what they actually provided—and I guess I would like to make 

this distinction, Mr. Weems and Mr. Cosgrove—a benefit offered is 

a different cat than a benefit used. 

In other words, take a look at me and you could offer me a lifetime membership in a weightlifting club, and as valuable as that 

might be to my young, vigorous ranking member, it would be absolutely useless to me. And so while it has a value if I used it or if 


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I could sell it to somebody, so if you offer—I was looking at the 

dental benefit, for example. Four bucks a month, that is less than 

$50 a year. Now, I don’t think you can get your teeth cleaned for 

$50 any place. As I recall, it is maybe $100 and change, as I think. 

So, I mean, I think that if we had some figures as to what was 

actually spent and used by our beneficiaries, we would have a better ability to assess the value of these plans. Is that—— 

Mr. COSGROVE. Absolutely. We have no information on utiliza- tion. I want to point out that the dental benefit, the $4 per member 

per month, was on average the most expensive additional benefit 

the plans offered. And $1 of that $4 is actually paid by beneficiaries through additional premiums. 

Chairman STARK. Also, we skipped over here. But according to 

your full report, a third of the private fee-for-service plans—and I 

am sure our guests will learn that there are kind of two plans, I 

think, or two types of plans—charge more for home healthcare 

than stand-alone fee-for-service Medicare, and if they offer an outof-pocket cap, they often exclude things like mental health, home 

healthcare, the most valued for very sick people and probably the 

most expensive for them to provide. 

Is that a fair assessment of—— 

Mr. COSGROVE. Overall, roughly half of beneficiaries are in 

plans that have a cap, but half of those are in plans that have a 

cap that excludes something. And home health is frequently one of 

the services that are excluded, yes. 

Chairman STARK. And we are talking generally across the spectrum about a medical loss ratio of 85 percent, some perhaps a little 

higher, a third of the plans or 30 percent of the plans lower. 

Mr. COSGROVE. That is correct. 

Chairman STARK. And just for the record, what that means is 

that 85 percent of what the plans take in in premiums or subsidies 

or government payments, whatever, for every dollar, they spend 85 

cents on medical care and the other 15 cents can be most anything. 

Mr. COSGROVE. Well, the other 15 cents is going to administrative expenses and profit. 

Chairman STARK. And if you compare that with Medicare, our 

medical loss ratio there is north of 95 percent, probably 97, 98 percent. Is that fair, Mr. Weems? 

Mr. WEEMS. According to the trustees’ report, it is approximately 98 percent. 

Chairman STARK. So what we are saying is for every buck the 

taxpayers and the beneficiaries pay into Medicare, they are getting 

97 or 98 cents’ worth of medical care. And I think that is important 

to compare. 

And I know, Mr. Weems, you have suggested that in the services 

offered—and again, I don’t want to beat this dead horse—but when 

you say that two-thirds of the plans have coverage for eyeglasses, 

you don’t mean that they get a pair of eyeglasses every year? 

Mr. WEEMS. No. 

Chairman STARK. All right. And they are often a limited dollar 

amount? 

Mr. WEEMS. Typically. 

Chairman STARK. And so that for any of my colleagues who, as 

I do, have Blue Cross, and they give you a list of places where you 


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think you can get eyeglasses for 50 bucks, guess again. I mean, 

maybe $500, unless you go to Wal-Mart or Costco. But we don’t 

have, I think—and I think we will hear from witnesses later—either defined benefits and/or marketing restrictions that would prevail in most States. 

We have pretty defined benefits under the old Medigap rules. I 

mean, what, are there 11 plans? 

Mr. WEEMS. Right. 

Chairman STARK. And when we wrote that bill, I think we had 

pretty much agreement among all the insurers who were writing 

Medigap at the time, including AARP and whoever else was in the 

business, that with those 11 plans, that gave them enough leeway 

to provide a variety of coverage for people to choose from. 

Why wouldn’t something similar to that be useful to the beneficiaries in Medicare Advantage? Let’s say that we said, look. If you 

have got how many thousand plans here, let’s design a set of benefits within which, these parameters, they could operate and compete, come back to you or to us for additional benefits if necessary. 

But why wouldn’t that simplify your lives for keeping track of it, 

ours for understanding what the beneficiaries are entitled to. 

Do you have an objection to that, Mr. Weems? 

Mr. WEEMS. Mr. Chairman, at its heart, the Medicare Advantage program is about choice. And restrictions on the benefits 

would limit those choices. And I think we should be in a position 

of giving our beneficiaries a large number of choices. One of the 

things that we have done is to move to make sure that those 

choices are more understandable and presented to beneficiaries in 

a more standardized fashion. 

Chairman STARK. But you don’t think they should be limited in 

number? 

Mr. WEEMS. No, sir. 

Chairman STARK. Well, then, in Part D, you would suggest that 

anybody signing up for a Part D drug plan should be able to buy 

any drug they want? 

Mr. WEEMS. Well, not any drug. We want to make sure that 

they are FDA approved. 

Chairman STARK. I will spot you that one. What is next? 

Mr. WEEMS. Well, and then we allow plans to provide choices 

through various formularies. 

Chairman STARK. But you allow them to limit my choice, don’t 

you? 

Mr. WEEMS. The same way that Medicare Advantage plans 

allow a range of choices through different benefit arrangements. 

Yes, sir. 

Chairman STARK. Okay. Mr. Camp? 

Mr. CAMP. Thank you. 

Mr. Cosgrove, let me first begin by saying I appreciate the GAO 

staff briefing the minority staff earlier in the week on this report. 

I am disappointed we couldn’t get the full report before today’s 

hearing, yet apparently the New York Times did not have this 

problem as there is a story in today’s paper quoting from the report. So they had things that the minority staff didn’t have. If we 

are going to have a meaningful discussion, I think we do need full 

information. 


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Now, just let me move on to the thrust of the report as I understand it in this short time frame. I am concerned that your report 

isn’t an actual representation of beneficiaries enrolled in Medicare 

Advantage plans but instead, again, this hypothetical scenario for 

beneficiaries using a single type of service for a small subset of 

plans. 

So let me ask you: In your testimony, you included a chart that 

showed how Medicare beneficiaries could pay more for inpatient 

services. Is it true that this just reflects one plan out of over 2,000? 

Mr. COSGROVE. No. It is a representative plan out of 80 plans 

that we found. 

Mr. CAMP. I believe it is a representative of one plan out of over 

2,000 plans beneficiaries have choices of. Let me ask you again: Is 

it true that 84 percent of beneficiaries are enrolled in plans where 

they could pay less cost-sharing for input services than in traditional fee-for-service? 

Mr. COSGROVE. Well, as we point out in the report—— 

Mr. CAMP. I believe the answer is ‘‘Yes’’ to that, and I guess I 

would prefer just a simple answer there. I am correct, am I not? 

Mr. COSGROVE. Yes. 

Mr. CAMP. Is it also true that over half a million beneficiaries 

are enrolled in plans that charge no cost-sharing for inpatient hospital stays? 

Mr. COSGROVE. Yes. That is in our report. 

Mr. CAMP. I think it is important to understand that many 

beneficiaries who are buying insurance are buying protection 

against catastrophic events, even if they don’t use it. And from 

what I can understand, the services that you have chosen to look 

at are used less often. And, frankly, services such as physician office visits, which are used more often, are less likely to have a 

higher copay. 

So I think we have to look at the kinds of comparisons that are 

being made. And, frankly, your report looks at inpatient hospital 

and home health and ignores physician office visits, which 97 percent of beneficiaries experience, 8.5 percent experiencing home 

health and 25 percent experiencing inpatient hospital. 

You know, it is my view that this report ignores reality. And I 

think if we are going to have a meaningful discussion—and I appreciate, Mr. Weems, your comments that you are going to get 

some actual data to us so that we can really have a meaningful discussion about this. So thank you for that. Thank you for your testimony as well. 

So I guess I think it is important that we get a report that is 

real, that we have an opportunity to review so that we can have 

a meaningful discussion. I think this really is a fake report with 

fake conclusions, and we are having this fake hearing about it so 

we can all run to the media and make certain pronouncements. 

I think healthcare is too important. I think our seniors are too 

important. I think the choices that they want to make are too important to conduct the people’s business in this way. 

So again, I am going to send a letter to the Comptroller General. 

I look forward to his response as soon as possible. Thank you, Mr. 

Chairman. 


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Chairman STARK. Well, you are welcome. I am sure that there 

will be others here who don’t like the report, and I will reserve my 

comment until a second round and ask Mr. Thompson if he would 

like to inquire. 

Mr. THOMPSON. Thank you, Mr. Chairman. 

Mr. Cosgrove, we have heard in testimony before this committee 

in the past, and we heard it again today, that Medicare Advantage 

plans, especially private fee-for-service plans, are rapidly increasing in enrollment. 

And your testimony notes that the Medicare Advantage plans 

were originally envisioned as a potential source of savings. Is that 

correct? 

Mr. COSGROVE. That is correct. What was once called the risk 

program started in the 1980s, yes. 

Mr. THOMPSON. Are they currently achieving savings for today’s Medicare program? 

Mr. COSGROVE. No, absolutely not. According to the MedPAC 

analysis, the average plan bid for simply providing A and B services is 101 percent of fee-for-service. And on top of that, plans get 

rebates. 

Mr. THOMPSON. I would like to talk about something that 

hadn’t been brought up yet, and that is the impact that these plans 

are having, and if we don’t do some sort of reform to the Medicare 

Advantage plans, will continue to have on Medicare’s trust fund 

solvency. 

Can you speak to that at all? 

Mr. COSGROVE. As I mentioned in my statement, in 2006, for example, we paid an additional $7.1 billion extra to Medicare Advantage plans that would not have been paid if those beneficiaries 

had been in fee-for-service. It is true that beneficiaries in those 

plans did receive lower cost-sharing and additional benefits. But 

there is not a free lunch. That came out of the $7 billion. 

Mr. THOMPSON. And it is my understanding that the Medicare 

Advantage overpayments and rebates, had it not been for those, 

the Medicare trigger never would have been pulled. Can you comment on that at all? 

Mr. COSGROVE. I have heard that. I haven’t looked at the numbers. According to the Medicare actuary, it certainly has reduced 

the life of the HI trust fund. And it certainly has contributed to 

higher Part B for all beneficiaries. 

Mr. THOMPSON. And your report also found that plans are allocating 20 percent of their rebates, or $17 per month, on reducing 

premiums. However, you note that 41 percent of the beneficiaries 

are charged an additional premium for the privilege of participating in a Medicare Advantage plan, and that the additional premium averages about $58 per month. 

So at the end of the day, are the beneficiaries who are charged 

an additional premium actually seeing any savings on their premium cost? 

Mr. COSGROVE. Well, they are seeing—the average beneficiary 

is seeing savings overall, but not on the premium cost, no. 

Mr. THOMPSON. And how about in comparison to traditional 

Medicare? 

Mr. COSGROVE. I am sorry. The question is? 


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Mr. THOMPSON. The savings, the cost savings over beneficiaries in traditional Medicare? 

Mr. COSGROVE. Well, again, it depends on whether you are 

talking about the average beneficiary or some beneficiaries. The average beneficiary would see, overall, some cost savings. But there 

are beneficiaries in plans who could see higher expenses. 

Mr. THOMPSON. Mr. Weems? 

Mr. WEEMS. Good morning, sir. 

Mr. THOMPSON. I am perplexed that the budget, the administration budget, paid a lot of attention to Medicare spending and 

solvency, specifically in the areas where they tried to strengthen 

Medicare such as cutting physician rates by over 10 percent or cutting hospital payments billions of dollars, so severely, I might add, 

that in California our hospitals alone would see a loss of over $800 

million in 2009. And yet there is no mention of any payment reform for Medicare Advantage plans. 

GAO stated that these plans achieve no savings. CBO has stated 

that reforming the Medicare Advantage payment rates would improve trust fund solvency. And MedPAC has stated that there is 

no policy-based merit for these overpayments. 

Why do you think these plans deserve such special treatment 

when it is clear that they don’t yield any special results? And if you 

guys aren’t listening to the GAO and the CBO and MedPAC, which 

experts are you listening to when you develop your policy for the 

Medicare Advantage policies? 

Mr. WEEMS. Thank you, Congressman. Medicare Advantage at 

its heart is about choice. You note the growth in private fee-forservice. That growth is in rural areas, where the kinds of services 

and benefits that Medicare Advantage offers has not been available. 

As for our budget, our budget protects those kinds of choices but 

goes directly to the kinds of solvency issues that you mention. If 

our budget were enacted, the solvency of the Part A trust fund 

would be extended by ten years. 

Mr. THOMPSON. I would like to see your budget come to a vote 

of this full committee and to a vote of the full House because I 

don’t think there are three votes for it. You cannot tell me that if 

we cut by over 10 percent physician rates and decimate funding for 

hospitals, and those are hospitals that are also in rural areas, that 

somehow that is good for the people who need healthcare in not 

only rural areas but urban areas as well. 

And to the question of who you listen to, who you get your information from in developing these policies? 

Mr. WEEMS. Congressman, we get information from a variety of 

sources, including the GAO, the Congressional Budget Office, outside groups. 

Mr. THOMPSON. And MedPAC? 

Mr. WEEMS. And MedPAC. 

Mr. THOMPSON. But they have all said contrary to what your 

policies are proposing. 

Mr. WEEMS. Those are financial analyses. The Congress, when 

it enacted this bill, made a policy choice about choice. And that at 

its heart is what Medicare Advantage is. It is about giving beneficiaries choices. 


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Mr. THOMPSON. Thank you. 

Chairman STARK. If the gentleman would yield, I believe, Mr. 

Weems, your own actuary said we are paying too much for Medicare advantage. 

Mr. WEEMS. Our own actuary would say that—— 

Chairman STARK. He may not phrase it that way. 

Mr. WEEMS. He would say that Medicare Advantage is paying 

above the fee-for-service rate. Yes, sir. 

Chairman STARK. Well done. You are not going to fire him. 

Mr. Becerra, would you like to inquire? 

Mr. BECERRA. Thank you, Mr. Chairman. And thank you for 

coming to testify today. 

Let me see if I can ask Mr. Cosgrove to make something clear 

to me. The gentleman from Michigan, Mr. Camp, took umbrage to 

the fact that your report was based on projections and did not in 

one instance talk about the reality for one particular individual 

who receives his or her care through the Medicare program’s Medicare Advantage system. 

And just to be clear, Medicare Advantage is an HMO-type setting 

where, through an insurance program, through an insurance company, a senior receives his or her care versus the senior receiving 

traditional Medicare, which is where the senior can go to any doctor or any hospital to receive the care because he or she is a Medicare beneficiary and can go anywhere he or she likes. But if you 

go to the insurance company and that insurance company system, 

you have to stay within that system, and you accept that package 

that that system offers you. 

But again, Mr. Camp took offense that your report was based totally on hypotheticals, on projections. 

Mr. COSGROVE. Yes. 

Mr. BECERRA. My understanding is you had no choice but to 

base it on hypotheticals and on projections because the law doesn’t 

require CMS to talk about real people. And so therefore, your analysis has to be based on what you get from CMS. Is that correct? 

Mr. COSGROVE. That is absolutely correct. Plans are not required to provide any data on what they actually spent or the benefits they actually provided. The only data that we have available 

are the data the plans submit annually, and that is in their bid 

proposals and their plan benefit packages. 

Mr. BECERRA. And so, Mr. Cosgrove, your projections and analysis of these hypothetical patients under these Medicare Advantage 

plans that Mr. Camp took offense to are the actual projections or 

based on the actual projections provided by the plans themselves 

to CMS? 

Mr. COSGROVE. Yes. That is true. 

Mr. BECERRA. So our difficulty—and I agree with Mr. Camp, 

we should be talking about real people. Your problem is when the 

Congress in early 2000, or 2002 or so, passed this law on Medicare 

Advantage under the then-Republican-controlled Congress, it did 

not require CMS to collect data on real people. In fact, CMS has 

no authority under statute to collect information on real people 

under the Medicare Advantage plans. Is that correct? 

Mr. COSGROVE. That is correct. And that contrasts with the situation in Medicaid, where many States contract with managed care 


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plans and require those plans to provide data so that States can 

know whether their Medicaid beneficiaries are receiving preventive 

care and other services. 

Mr. BECERRA. So I think all of us probably on this dais would 

agree with Mr. Camp that we should be talking about real people, 

which would require that the plans do what other medical programs that get government subsidies do, and that is to report on 

real people, what their outcomes are. And I think it will be fair to 

ask for that and then base some of our judgment on that. 

A few years ago—actually, a number of years ago—we would con- stantly hear stories about the 3- or 4- or $500 toilet seat that the 

Department of Defense was buying for this or that plane or facility, 

how we are paying tens of dollars for a screw. And we just found 

that things weren’t being done well, and lots of waste in the Department of Defense. 

We are being told by the plans that they will do certain things 

with the money we are giving them, and including the rebate, 

which is above and beyond what a doctor or hospital would receive 

under traditional Medicare. 

Mr. COSGROVE. Right. 

Mr. BECERRA. But we have no guarantee, as I think Mr. Camp 

pointed out, what in fact real people are getting from these plans. 

And so while it may not be the same as a $500 toilet seat, in many 

ways we can’t determine if we are getting a $500 toilet seat or not 

out of some of these plans, can we? 

Mr. COSGROVE. That is absolutely correct. There is no way to 

determine that. We would certainly welcome the request from Mr. 

Camp, and we would welcome the ability to get data from plans. 

Mr. BECERRA. And I think it is important for us to get that information because many of us are in some of these health plans, 

or have family or friends who are in these health plans. My parents are in a Medicare Advantage plan, in Kaiser—Mr. Stark mentioned Kaiser—in Sacramento, California. They have been in Kaiser. They enjoy having Kaiser as their provider. And so there are 

a lot of plans that are doing some great work. 

And so I think what we want to do is get the facts so that we 

don’t disparage the good folks who are providing good services. And 

that way we could distinguish between those that are providing the 

best of services. 

My final question is this: I believe, Mr. Weems, you mentioned 

at the end, right before I started my questioning, that in fact the 

actuary for CMS has said that Medicare Advantage plans are receiving a greater reimbursement amount or dollar amount than are 

traditional fee-for-service providers. 

Mr. WEEMS. That is correct. 

Mr. BECERRA. And I believe, Mr. Cosgrove, you said that total 

$59 billion more is going to Medicare Advantage than would go for 

the same services under a traditional Medicare service program. 

Mr. COSGROVE. No. That was total spending in 2006. The additional spending amounted to $7.1 billion in one year. 

Mr. BECERRA. Okay, $7.1 billion. And so we are talking real 

money. Whatever the amount is, we are talking real money. And 

those are billions of dollars that we spent, taxpayers spent, to provide Medicare services to seniors. Not really sure how it was spent. 


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In some cases we think it was spent well. Other cases we are wondering. 

But given that we are in this crisis and everyone is talking about 

how the sky is falling for healthcare, and Medicare in particular, 

I think we do have to get the real numbers. So I think, Mr. Weems, 

we are looking forward to receiving that information. And I think 

Mr. Camp’s request is legitimate, and I hope we all join in requesting that information so that we can base our aim on the facts. 

So I thank the gentlemen, and the chairman for the time. 

Chairman STARK. And before I recognize Mr. Pomeroy, I would 

like to—Mr. Camp is carrying the whole other side of the dais here, 

and I would like to give it to him for a few minutes. 

Mr. CAMP. I certainly appreciate it, Mr. Chair. I just want to 

comment. 

I didn’t ask to be yielded to during your time, Mr. Becerra. But 

it is part of it that it is not just real people, but it is also the problem that it is only inpatient and home health. And those services 

that are used more often, which are not included in this report, 

have a higher cost-sharing. 

So I think it is not just the people. It is the focus of the report. 

I would also like to see them include physician office visits and 

other portions, not just inpatient and home health. 

So thank you, Mr. Chairman. 

Chairman STARK. Mr. Pomeroy, would you like to inquire? 

Mr. POMEROY. Yes, Mr. Chairman. Thank you. 

I have the greatest respect for the administrator. He has come 

to North Dakota. He has helped us with the hospital problem. A 

career man, ultimately appropriately on merit advanced to the No. 

1 slot. And I am very pleased—truly, I am very pleased with his 

leadership. This is a no-nonsense, get-it-done guy. And we know 

that representing the administration, he has to defend Medicare 

Advantage. 

What I want to focus on is what we are getting for the extra 

money we are paying. So, Mr. Administrator, you don’t contest the 

$7 billion in extra payment as opposed to if we had run those same 

benefits through Medicare. We paid $7 billion extra to have the insurance companies involved. 

Do you agree with GAO’s comment on that? 

Mr. WEEMS. That there are additional costs associated with the 

additional benefits and additional choice; that, right now, Medicare 

Advantage plans are above the fee-for-service rate. 

Mr. POMEROY. And because of the variety on the plans that are 

not fee-for-service, let’s just talk about Medicare Advantage Private 

fee-for-service. It is generally believed that we are paying somewhere in the neighborhood of 12 to 17 percent more per dollar of 

benefit administered in order to have the private entity make that 

payment. Do you contest that? 

Mr. WEEMS. It is not just the private entity make that payment. 

It is also the insurance value of the product that is being purchased by the individual, by Medicare, at that point. It is not just 

simply an administrative processing. 

For instance, a private fee-for-service plan offers in some cases, 

for instance, a known co-payment for a doctor’s visit. So a regular 

doctor’s visit will, say, cost $20, not 20 percent, or $10, or $5. So 


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the additional benefits may come in the certainty of cost-sharing, 

the same way many of us have that certainty in our own private 

insurance that we have rather than a percentage, which would now 

be the case for—— 

Mr. POMEROY. Although Medigap insurance has existed for decades that covers the unknown of the other coverages. And people 

can choose that if they care to. But as a system, we are paying 17 

percent more to have the private insurance companies administer 

that benefit, and the rationale is, it is about choice. Is that basically your position? 

Mr. WEEMS. Again, with respect I take issue with the ‘‘administer the benefit.’’ They offer additional benefits also. But yes, it is 

about choice. It is about offering these type products in areas 

which, before, they were not able to be offered. 

Mr. POMEROY. I just take such issue with the administration’s 

assessment of priorities within the Medicare program, as reflected 

in their budget. I have got a whole page here of provider cuts, deep 

and painful provider cuts. The total in North Dakota would be devastating to the healthcare delivery system sustained across our 

rural reaches. 

You close a rural hospital, you have taken away choice. You drive 

physicians out of accepting Medicare because they are reimbursed 

so far below costs they just don’t want to do that any more, and 

we are really believing we are about on the edge on that with some 

of our providers, you remove choice. 

So in my opinion, you really take a meat axe to provider payments. I agree with my colleague Mike Thompson when he says 

there wouldn’t be any support for this on either side of the aisle 

because of the fear of that. 

But on the other hand, you don’t take anything out of the overpayment to insurance companies that you acknowledge runs 12 to 

17 percent. GAO tells us in one year we spent $7 billion just to the 

insurers. If Medicare administers the benefit, we are $7 billion better off in one year, $35 billion over five at that rate. And the fiveyear figure actually is going to be much larger than that because 

of the marketing growth of Medicare plans. 

Mr. WEEMS. Absolutely. 

Mr. POMEROY. And I want to focus on that growth in my final 

comments. We have been exchanging correspondence trying to get 

a handle on the consumer protection capability within CMS. You 

are aware, of course, that this choice that you defend includes insurance agents making cold calls on the homes of senior citizens. 

Is that correct? 

Mr. WEEMS. Yes. 

Mr. POMEROY. There are not too many people I represent that 

choose to have that kind of visit. They would just as soon choose 

not to have that kind of visit. 

Mr. WEEMS. Congressman—— 

Mr. POMEROY. But what worries me most about it is you don’t 

have much ability to oversee it, and you keep State regulators out 

of the picture. 

Do you see a resolution there? How are we going to get more consumer protection for the people that are getting the cold calls from 


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the insurance companies paid 17 percent more for what they are 

doing than what Medicare does? 

Mr. WEEMS. Thank you, and this is an important issue. No beneficiary should be deceived into accepting one of these products. 

And CMS has taken a number of steps, and have a number of steps 

underway, to prevent this. 

First of all, beginning in September, we built a rather substantial surveillance system. And as you may know and others may 

know, we spend a lot of time and effort doing secret shopping and 

actually sitting in the marketing campaigns. I sat in on them in 

rural areas and in urban areas with a baseball cap on. They didn’t 

know who I was. And immediately after those marketing campaigns, if there was a violation, we fed that right back to the plan. 

In some cases sanctioned them. And we saw a steady reduction in 

the amount of complaints. 

We are not done yet. We have some additional actions that we 

are going to take in the very near future that deal with exactly the 

same kinds of things that you are concerned about: how an insurance company makes contact with a beneficiary, what their commission structure looks like, and then also clarifying some of our 

civil and monetary penalties. 

Mr. POMEROY. I will just say—because I know my time is up— 

I mean, I used to do this for a living. I was an insurance commissioner. I wrote the Medicare standards that are now in place 

through the States as we enforce Medigap sales. 

To me, what you are describing is very kind of happenstance. It 

is not a comprehensive regulatory system. The protections that you 

just described are available in State insurance departments and in 

State law, and I believe this administration ought to advance—I 

mean, for one thing, we try to get you more resources, the President vetoes the bill. 

So you don’t have enough resources internally. I believe you need 

to work with State insurance departments. And I would like to see 

more from CMS in terms of working arrangements there. 

My time is expired, Mr. Chairman. Thank you. 

Chairman STARK. Thank you. 

Mr. CAMP. Thank you, Mr. Chairman. I have heard of being in 

the minority before, but this is—— 

Chairman STARK. Kind of a lonely day. [Laughter.] 

Mr. CAMP. So thank you. Mr. Weems, I just wanted to say that 

I have heard some reports about some of the unacceptable behavior 

by agents and brokers who are selling some types of Medicare Advantage plans, and I think there is bipartisan agreement these activities need to be stopped. 

What are you and CMS doing or going to do to stop this and protect beneficiaries from these kinds of individuals and plans? 

Mr. WEEMS. Well, beginning in September, as I said, we built 

a rather substantial surveillance system, which included not only 

the secret shopper program but also a system of calling beneficiaries. Did you know you signed up for a plan? Do you know exactly what you signed up for? To ensure the beneficiaries understand the choices that they are making. 

We also made it very, very clear to insurance companies that we 

are not going to tolerate this kind of abuse. In fact, one company, 


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we suspended. We had them suspend enrollment and marketing for 

the entire period of enrollment and marketing because there were 

systematic errors in the way that they were marketing the product, 

and it was completely unacceptable. 

And there are still additional steps that we are going to take in 

the areas of the way that the commission structure works—beneficiaries should not be churned year to year; in the way that the 

insurance companies come into contact with the beneficiary; and 

then lastly, clarifying our own ability to level civil and monetary 

penalties. 

Mr. CAMP. Also, if you could comment. Thank you for that answer. By purchasing a Medicare Advantage plan with a cap on 

cost-sharing, can beneficiaries protect themselves against catastrophic costs? And isn’t that what insurance is about, is protecting 

yourself against something that you think might happen but may 

not necessarily happen? 

Mr. WEEMS. Absolutely. And in fact, that is what this chart 

demonstrates, is that beneficiaries can make choices about where 

they would like to protect themselves. Even at the very, very long 

stays that we have on here, you ask yourself, well, what is the 

probability of that? What would cause that? 

Well, our experts say that yes, there are some of those very long 

stays, and the things that cause them are substantial 

comorbidities. You are a very, very ill individual. But even being 

very, very ill, using a Medicare Advantage program, you can protect yourself from some very substantial out-of-pocket costs. 

Mr. CAMP. Well, and I think nearly half of Medicare Advantage 

beneficiaries are in plans that cap their out-of-pocket costs. And is 

that something that is available in traditional Medicare, the ability 

to cap catastrophic healthcare costs? 

Mr. WEEMS. No. No, it is not available in traditional Medicare. 

Mr. CAMP. All right. Thank you. Thank you very much for your 

indulgence, Mr. Chairman. I appreciate it. 

Chairman STARK. Mr. Kind, would you like to inquire? 

Mr. KIND. Thank you, Mr. Chairman. And I want to thank the 

witnesses for your testimony today. 

This is just an incredibly important issue back home. And Mr. 

Weems, I know you cited La Crosse, Wisconsin, which is in the 

heart of my congressional district in western Wisconsin, to make 

a point on—— 

Mr. WEEMS. A lovely city. 

Mr. KIND. Right. I agree—to make a point on some of the regional differences in payments. And you compared it with Dade 

County, Florida. 

But when you talk to the providers in western Wisconsin, they 

are always extremely frustrated that they are receiving, in their 

view, a lower reimbursement rate. And part of that is based on the 

efficiency and lower utilization that is taking place there. Yet study 

after study after study shows high quality of outcomes in the care 

that seniors are receiving under traditional fee-for-service. 

And so I am not quite sure the regional differentiation that you 

are making in your testimony really applies all that well. It seems 

to be you are saying, listen. You got to look at the regional price 


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differences in order to explain the overpayments for MA plans 

today, and you use La Crosse as an example. 

And in order to entice private plans to come into that area, in 

essence you have to bribe them above what the fee-for-service providers are getting in reimbursements. And I am not sure that is 

a real accurate apple-to-apple comparison to make under the circumstances. 

My question is, and maybe Mr. Cosgrove, since you are the one 

releasing the study today, is what has been frustrating with the 

MA plans is the lack of hard data that we have access to. Is there 

any way that you can get your hands on quality of outcomes or performance base with what the MA plans are providing with seniors 

today? 

*Mr. COSGROVE. There is relatively little information available 

on that. Certainly, under Medicare Advantage, plans do have to 

submit some things. And I think Mr. Weems mentioned it in his 

testimony in terms of satisfaction surveys and a health outcome 

survey to cover Part C of beneficiaries. Those surveys tend to measure very narrow things and not basic quality. 

Mr. KIND. What about utilization data? Can we get any information at all from the myriad of MA plans out there on what utilization is taking place? 

Mr. COSGROVE. I am sure MA plans have it. As you know, the 

plans that serve rural areas tend to be the private fee-for-service 

plans. These plans pay claims just like the traditional program 

does, and so they certainly would have the data. They just don’t 

have to submit any of that. 

Mr. KIND. And that is the rub, isn’t it? I mean, that is really 

the crux of the problem here, is that they don’t submit it. And yet 

CMS—and I think, Mr. Weems, you are saying in your testimony 

that in 2008, MA plans will offer, on average, over $1100 in additional annual value to seniors that they cannot get under fee-forservice in the form of cost savings and added benefits. 

Mr. WEEMS. Correct. 

Mr. KIND. But if we can’t get utilization data, if we don’t know 

what type of services are being provided, how can you define value? 

How can you make that claim that there is $1100 of additional 

value if we are not getting the basic data that we need in order 

to calculate the costs? 

Mr. WEEMS. Well, Congressman, we are not completely blind to 

the utilization. It is in the bid tools. We do audit plans. We do have 

some sense of this. Nonetheless, I made a commitment today to the 

chairman to provide utilization information on the extra benefits, 

and to do that in an expedited way. And we will have a discussion 

about the facts. 

Mr. KIND. That would be helpful. But I was astounded to hear 

your response to Mr. Thompson’s earlier question when he was 

asking, what is CMS basing their defense and justification of these 

MA plans if you are going to choose to ignore GAO information, 

choose to ignore CBO information, choose to ignore MedPAC information, and your response was, well, it is all about choice. 

That is a philosophy, but it is not based on hard data. And that 

is really what I think we are scrabbling to get our hands on right 

now, is these reporting requirements that should be in place so we 


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can go into these plans and find out what is being offered. What 

are the true cost savings, if any, to the customers? What is the 

value that they are receiving? The utilization that is taking place? 

And ultimately, I believe that we have got to move to an outcomesbased type of reimbursement system as quickly as possible so we 

are rewarding the outcomes, the quality of services being provided, 

and also the efficiency in which it is being provided. 

And we are not getting that from the MA plans. Choice is great 

in a theoretical world. But when you have got a 70-year-old senior 

having to compare over 70 different plans in the State of Wisconsin 

that are continually shifting on them, whether it is copays or premiums, they are not the ones wrapping their arms about this whole 

choice philosophy. It is incredibly complicated. They are subject to 

marketing tactics that are unfair and it is taking advantage to 

them. And we need to tighten this up. 

And it is also astounding to me that we have an administration 

willing to take a whack in their proposed budget with the providers 

across the country, and they don’t look for one dollar of savings 

with these MA plans in the budget that was just sent up. 

And Mr. Camp, I congratulate you for at least sitting here during 

this hearing. Where is the rest of the dais on your side? We are 

having, I think, a very important hearing on the state of MA plans, 

and yet there is no one on the Republican side other than yourself 

showing up to question the validity of it and whether the taxpayers 

are getting our dollars’ worth through these plans. And yet over $170 billion of proposed cuts with healthcare providers—well, and I know he is campaigning hard—— 

Chairman STARK. One of them is running for the Senate in Wisconsin. You had better watch your step. 

Mr. KIND. That is right. That is right. But I am only reflecting 

the frustration that I am hearing back home from the providers, 

from the seniors, those who are in the plans right now, and for us 

as policy-makers. And we are trying to make some policy determinations, and we lack the hard data that I think is necessary. So 

hopefully, with CMS’s cooperation, we are going to be able to do a 

better job in the future. 

Thank you, Mr. Chair. 

Chairman STARK. I would like to recognize Mr. Emanuel. And 

if I could get our witnesses, we will have a couple of votes at about 

11:15, and we will come back after those votes and allow the other 

members to inquire, if I can impose—presume on the witnesses to 

stick around for a few minutes while we vote. 

Mr. Emanuel? 

Mr. EMANUEL. I will try to be quick so maybe one of our other 

colleagues can get in before the votes are called. 

I didn’t expect you guys or anybody in the audience to see this, 

but the other day we had a debate among four Democrats and four 

Republicans over at George Washington University. And the congressman, Mr. Chairman, that you referred to from Wisconsin did 

acknowledge at the debate that he would take seriously and look— 

I think I am quoting him accurately; Paul said this, in fact—that 

he would look seriously at taking—that we shouldn’t be 125 percent of fee-for-service as long as it didn’t go into expanding coverage but dealt with the short fan of Medicare. 


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And when you get out of here and get out of posturing, he was 

honest about, you shouldn’t be paying 120 percent. I mean, there 

is a reason this is called Medicare Advantage. It is a real advantage for the HMOs. There is just no doubt about it. 

And this is a ideology trumping good judgment. Everybody always tells us government should do what business does. So here 

you got a case where you could save on money, but we are supposed to pay 120 percent. And I happen to have been there in the 

1990s in the White House when the HMOs said they could deliver 

it for 95 percent of fee-for-service because they could do a better 

job of managing costs. So we are getting the same service now for 

120 percent of fee-for-service. 

There were some mistakes made in the 1990s, no doubt. But the 

notion that we are going to try to figure out how to deal with the 

trust fund, but something everybody independent analyzed says 

that could save $50 billion over five years, $150 billion over ten 

years, that is off the table, you are never going to get an honest 

discussion of everybody some skin in the game and putting something on the table. 

You cannot have a serious discussion about Medicare’s trust fund 

if the elephant in the room is not going to be discussed. And it is 

not the only elephant; we have got to look honestly at how we pay 

fee-for-service, whether there should be more flexibility. Some of 

the things the administration is pointing to are worth looking at. 

They are not going to be wholesale thrown out. 

But the notion that this big item that you are overpaying for 

can’t be looked at on the start gate means that you are never going 

to have a serious discussion and it is just going to be political. And 

at some point, ideology cannot trump good judgment. It just can’t. 

And if you did it all on HMO, Peter Orszag and others have acknowledged it would add three years to the trust fund. Three 

years. That is something that has to carry the whole burden here. 

But the notion that you would start off by saying, this can’t be part 

of any solution, is ridiculous. It doesn’t hold up. And people know 

it. 

And that means every other good recommendation from the administration won’t be considered. You have tainted it because you 

basically have said ideology and politics and partisanship trump 

getting a good judgment and a good result. And that is unfortunate 

for all the other good decisions you have made in some of the recommendations because they won’t get a fair hearing. You have hurt 

yourself that way. 

Second is, as Orszag testified in this committee the other day, we 

don’t know what is in these plans and whether we are getting our 

money’s worth. It is just like a blank check, something my kids 

would like to have. We wouldn’t do that. 

And you can’t keep treating taxpayers as dumb money. You can’t 

ask them to pay 120 percent for what you can get for 100 percent. 

You know, I spent a short time on Wall Street, and when people 

would make investments like that, you would call them dumb 

money. 

So my recommendation is: Let’s everybody put their cards on the 

table. There are good recommendations in the administration’s proposal that are worth looking at. But if you start off by saying, we 


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won’t look at this and that is an absolute, that means every other 

judgment you have made won’t get a fair hearing, and you have 

hurt the cause of trying to look at what does it take to deal with 

the Medicare trust fund insolvency. 

Thank you, Mr. Chairman. I hope I have left some time for my 

colleagues. 

Chairman STARK. Ms. Schwartz, would you like to inquire? 

Ms. SCHWARTZ. Yes. Thank you, Mr. Chairman. I really appreciate your courtesy in allowing me to ask a question or two. 

And I appreciate following up on my colleagues. I think they 

have made it very clear, and I agree with them, that we are taxpayers, and actually 80 percent of beneficiaries under Medicare are 

paying more in order to give 20 percent of Medicare beneficiaries 

choice. You made that very clear. 

The issue is we don’t really know that they are getting more 

services. You can’t tell us that. You can’t really tell us whether 

they are actually having any improved outcomes. We have no idea. 

You are going to try and get us that data; that would be useful. 

But the point was made that maybe—and Mr. Camp said this— 

that maybe we really haven’t looked at real people here, that 

maybe real people are getting benefits and we just don’t know it, 

but they are getting some additional benefits. They are happier because they have choice. I think when we talk about healthcare, we 

ought to make sure that they are healthier also. 

But I want to talk about a particular experience in southeastern 

Pennsylvania in my district. One of the things that we have seen 

in the last year is really an incredible growth in the Medicare Advantage Private fee-for-service. That has been the strongest growing effort. I know the discussion was it was supposed to really be 

in rural areas; I don’t represent a rural area. It is an urban/suburban area. We have seen an increase of—we went, actually, from in 

Pennsylvania totally, 24,000 in just the fee-for-service plan to almost 50,000 people in the last year. In my own district, we have 

gone from 1,000 to almost 4,000 beneficiaries. 

Now, if you can say that they are actually getting more services, 

they are healthier, maybe we would be able to feel better about 

this. But what I want to tell you is that three of the major hospital 

systems in the Philadelphia area have decided to no longer accept 

the Medicare Advantage fee-for-service patients. Theoretically expanding choice; in fact, as is pointed out, we are seeing a denial 

of fewer hospitals taking it. These are not just hospitals here; they 

are really these health systems. 

And they say the reasons that they are doing that are manyfold. 

But one of the principal reasons is that the beneficiaries and the 

providers do not know, when they refer to physicians, whether in 

fact those physicians will be covered. So there is greater—they 

don’t know. They have no way of getting that information. The 

beneficiaries don’t. The hospitals don’t. So they make referrals, and 

they have no idea whether this is going to be an appropriate referral or not. They may show up at that physician’s office, get the 

services, and have to pay 100 percent out of pocket. 

So I ask this question because we are paying 20 percent more on 

average for these patients. 

Mr. WEEMS. No. 


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Ms. SCHWARTZ. Well, I can tell you, in Pennsylvania the private fee-for-service plan in my district are paid, on average, 18 percent more than it costs to provide actually the same services to 

Medicare beneficiaries. That is the numbers we have. This is in 

southeastern Pennsylvania in my district. So we are paying 18 percent more, and people are going to see less care. They are seeing 

it already. And they are actually not getting the information to be 

able to make choices, and nor are their providers. 

So this seems to me not just a bad idea but a disaster. So how 

do you defend that? How can you justify that as either good public 

policy or good healthcare, good outcomes, or anything that is positive? And some way we are going to fix this. 

Mr. WEEMS. Thank you for the question. The first thing is, we 

know that—I would have to look at the private fee-for-service programs in your area. But for the most part, many provide protection 

against very high out-of-pocket costs. That is a protection that people get as a matter of insurance. 

Now, it is true that providers don’t have to accept private fee-forservice. And if it turns out that providers in that area aren’t doing 

that, then people are going to leave those programs and go into 

products that are going to be much better for them. The plans have 

considerable outreach into the community. 

Ms. SCHWARTZ. So how quickly can they make that change? 

Not quickly. Next year. 

Mr. WEEMS. Next year. 

Ms. SCHWARTZ. Right. So for a year, they may actually have 

no access to care. 

Mr. WEEMS. Not no access to care. They may—— 

Ms. SCHWARTZ. Or possibly, if the hospital and the providers 

are not accepting it. They are stuck in a plan that has higher costs 

and no access to care. But they have choice. 

Mr. WEEMS. I wouldn’t suggest that it is even higher cost. They 

may be in a plan that has lower costs, and they—— 

Ms. SCHWARTZ. But it is theoretically possible they are in a 

higher cost? 

Mr. WEEMS. Many things are theoretically—— 

Ms. SCHWARTZ. If they need more outpatient, for example, 

than hospital care, it could be higher cost for them during that 

year. And they could not change for a year. 

Mr. WEEMS. Depending on which plan they chose. That is the 

nature of insurance, yes. 

Ms. SCHWARTZ. Well, it is a very different ideology to say that 

we are moving this to a private insurance model rather than one 

where we are looking at for seniors, and we have said to seniors 

under Medicare, that we are going to help ensure that they have 

access to healthcare. 

We would like it to be quality healthcare. We would like it to be 

cost-efficient. Right? And we think the taxpayers shouldn’t have to 

pay more for less. But you are saying as long as they have choices, 

if they have made a bad choice, too bad. This is an insurance 

model. 

Mr. WEEMS. Well, in many cases, the regular Medicare program 

may not be their best choice. 

Ms. SCHWARTZ. It may not be. But the—— 


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Mr. WEEMS. In which case it is just too bad there, too. 

Ms. SCHWARTZ. Well let me add, and I will give back to the 

Chairman, but the idea here is not to say—I don’t think any of us 

are saying, let’s limit this to one option. We have never said that. 

We have talked about 11 Medigap plans. We have talked about the 

fact that even under Medicare Advantage, if we were paying the 

same and getting more benefits and people are getting better outcomes, it may even be worth paying more, although I think there 

is a lack of justification for why just some people should get that 

and not all. 

But we are not talking about an either/or here. We are talking 

about better oversight. Accountability. Right? Knowing what we 

are doing. Making sure we are getting what we should for our taxpayer dollars. And that Medicare recipients are not actually disadvantaged by this rather than advantaged. 

So it is simply not good enough to say, wait a minute. If we ask 

hard questions, you are going to say, well, then, we won’t do any 

of it? That is not an acceptable answer. 

Mr. WEEMS. If you are talking about reducing the payments, 

you are talking about an either/or situation in many parts of this 

country. 

Chairman STARK. I want to try, if the gentlelady will yield, to 

let Dr. McDermott inquire—— 

Ms. SCHWARTZ. Thank you, Mr. Chairman, and thank you for 

your indulgence. 

Chairman Stark.—before the votes ring down. Dr. McDermott? 

Dr. MCDERMOTT. Thank you, Mr. Chairman. I appreciate your 

taking the time. And I just have a couple of questions. 

My understanding from your report is that Medicare Advantage 

has a loss ratio of an average of 87 percent. Is that correct? 

Mr. COSGROVE. That is correct, yes. 

Dr. MCDERMOTT. And on the other hand, Medicare has a loss 

ratio of 98 percent. That is, 2 percent is going for administration, 

98 percent going for benefits. 

Mr. COSGROVE. According to the trustees, yes. 

Dr. MCDERMOTT. According to the trustees. Do you trust the 

trustees? 

Mr. COSGROVE. Absolutely. 

Dr. MCDERMOTT. So where does this 11 percent go, or where 

does it come from, or how does it occur? I mean, we are paying insurance companies, and they are giving less care. They are taking 

11 percent somewhere. Where does it go? 

Mr. COSGROVE. Well, plans obviously have expenses that the 

traditional program doesn’t have. Marketing expense—— 

Dr. MCDERMOTT. Like what? I mean, what is the benefit to the 

patient for those costs? 

Mr. COSGROVE. Well, marketing expenses would be—but that 

is not a benefit to the patient. 

Dr. MCDERMOTT. Well, you know, my mother is now dead. But 

I used to get about one a month of an advertising campaign for 

somebody, which I don’t think did much for a 96-year-old woman. 

I really think—the thing that really puzzles me is that a third of 

those plans, as I understand it, have loss ratios less than 85 percent. 


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Mr. COSGROVE. That is correct. 

Dr. MCDERMOTT. Can you give us the names of those? 

Mr. COSGROVE. In discussions with CMS, CMS obviously considers these data proprietary and very sensitive. So no, what 

we—— 

Dr. MCDERMOTT. This is taxpayer money. What do you mean, 

proprietary? You mean the Congress can’t know who is ripping old 

people off? We can’t look at the data? Is that what you are telling 

us? 

Mr. COSGROVE. Mr. Weems has the data, and it would be up 

to him to share it. 

Dr. MCDERMOTT. It is up to CMS to give it to us. Is that right? 

Mr. COSGROVE. They are the owners of the data. They shared 

it with GAO, and they gave it to us with some restrictions as to 

how we could report it. 

Dr. MCDERMOTT. And on what basis, then, Mr. Weems, do 

you—how do you hold this data back? 

Mr. WEEMS. These data are proprietary and may affect the competitive nature of the firms. 

Chairman STARK. Is there any reason we couldn’t see them in 

camera? 

Mr. WEEMS. I believe we could make it available under those 

circumstances, sir. 

Dr. MCDERMOTT. You believe we could. Is that a yes or a no? 

Chairman STARK. It probably is a yes. 

Mr. WEEMS. Yes. The answer is yes. 

Dr. MCDERMOTT. So we got an actual yes out of you. 

Chairman STARK. But you can’t talk about it, now. 

Dr. MCDERMOTT. Well, it is secret. That is right. Then we 

would be liable for suit. Is that right, if we talked about the data? 

Mr. WEEMS. I am not an attorney. I couldn’t say. 

Dr. MCDERMOTT. See, the problem here is—— 

Chairman STARK. If you gave it to the New York Times, maybe 

you would. 

Dr. MCDERMOTT. I know some guys at the New York Times. 

The fact is that we are—I admit I am a single payer advocate. I 

believe that a single payor system like Medicare is the way to go. 

And you are not giving me any reason—Mr. Kind asked on the 

basis of outcomes, which is what healthcare is supposed to be 

about. If you have healthcare, you are supposed to live longer than 

people who don’t have outcomes. 

So we have this Medicare Advantage. We pay them all this extra 

money. They should be getting better outcomes. But you have no 

data to prove that. All you have is 11 percent that is going into 

marketing and profits for insurance companies, I guess. I don’t 

know where else it is going. 

Mr. WEEMS. Congressman, through HEDIS data we do have 

outcome data, data that we don’t have for the fee-for-service side. 

Dr. MCDERMOTT. And can you share that data with us? 

Mr. WEEMS. Of course we can. Absolutely. 

Dr. MCDERMOTT. That is not proprietary? 

Mr. WEEMS. No. 

Dr. MCDERMOTT. I think the committee ought to be provided, 

Mr. Chairman, with that information so that we can actually look 


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at the proof that the Medicare Advantage program does any good 

for the heart of senior citizens because that is what this is really 

all about. It is not about choice and it is not—my mother didn’t 

want choice at 97. She just wanted to know she could call up the 

doctor and go see him when she was sick. 

Chairman STARK. Would the gentleman yield? 

Dr. MCDERMOTT. Yes. 

Chairman STARK. If you leave out dollars, copays, I don’t 

think—and I would ask Mr. Weems—I don’t think there is a plan 

in the country that has more choice of physicians and hospitals 

than Medicare. How many hospitals do you know that aren’t in 

Medicare? 

Mr. WEEMS. Very few. 

Chairman STARK. How many doctors are not in Medicare? Not 

many. So, I mean, when you talk choice—— 

Mr. WEEMS. Well, that is one kind of choice, yes. 

Chairman STARK. Yes, it is. But it is—— 

Dr. MCDERMOTT. It is the only choice that matters, Mr. Chairman. 

Mr. WEEMS. Now, catastrophic costs matter, too. 

Chairman STARK. Now, they may be limited by cost. That is a 

question, certainly. But on the other hand, some of the plans limit 

them by not recognizing the doctor—not having the doctor in the 

plan. 

So in defending the plan that Mr. Weems runs so well called 

Medicare—— 

Dr. MCDERMOTT. Yes. We like that one. 

Chairman Stark.—I would like to point out that he offers, what, 

80 percent of us Medicare beneficiaries broad choice. 

Mr. WEEMS. Well, we offer it to 100 percent. 

Chairman STARK. Thank you very much for—— 

Mr. WEEMS. We offer it to 100 percent. Eighty percent take us 

up on the offer, sir. 

Dr. MCDERMOTT. Both Mr. Stark and I are taking you up on 

it, and we enjoy it. 

Chairman STARK. I want to thank—you can stay here after the 

vote ends, Doctor. But I am going to thank Mr. Cosgrove and Mr. 

Weems for their patience, their indulgence, their forthcoming testimony. We will have you back. I want to discuss this some more. 

And we will excuse you gentlemen, and thank you very much. 

We will recess for approximately 15 minutes until we finish these 

votes. And if the second panel wants to come on up to the witness 

table or get a cup of coffee, we will be back and continue the hearing. Thank you. 

[Recess.] 

Chairman STARK. The committee will resume, and with apologies to the panel, who waited so patiently while Mr. Camp and I 

named three post offices after deserving citizens. And we can get 

back now to the important matters at hand. 

We are privileged to have with us Dr. Byron Thames, who is a 

member of the board of directors of the AARP from Orlando, Florida; Mr. Mattes—do I pronounce that—— 

Mr. MATTES. Mattes. 


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Chairman STARK. Mr. James Mattes, who is president and CEO 

of the Grande Rhode or Rhode—— 

Mr. MATTES. Grande Ronde. 

Chairman Stark.—Grande Ronde Hospital of La Grande, Oregon; 

Mr. David Lipschutz, who is interim president and CEO of the 

California Health Advocates in Los Angeles; and Dr. Daniel C. 

Lyons who is senior vice president, government programs, of the 

Independence Blue Cross in Philadelphia, Pennsylvania. 

I will ask you gentlemen if you would like to proceed in the order 

that I recognized you. And without objection, all of your prepared 

testimony will appear in the record. And if you would like to expand on it or enlighten us in any way, and then we can further 

get information during our inquiry. 

Dr. Thames? 

STATEMENT OF BYRON THAMES, M.D., MEMBER, BOARD OF DIRECTORS, AMERICAN ASSOCIATION OF RETIRED PERSONS, 

ORLANDO, FLORIDA 

Dr. THAMES. Thank you, Mr. Chairman, members of the committee. I am Byron Thames, a physician member of the board of 

directors of AARP. We thank you for the opportunity to present 

AARP’s views on the Medicare Advantage program. 

Let me begin by reaffirming a core principle. AARP is committed 

to the Medicare program. It is a vital component of financial retirement security for older Americans and many with disabilities. 

I also want to reiterate our support for Medicare Advantage. We 

believe it is important for people on Medicare to have genuine 

choices of how they receive services. To this end, beginning this 

year, most of United Health Care’s coordinated care Medicare Advantage plans will carry the AARP name. 

We emphatically believe choices must be genuine. Options should 

differ from one another and each offer high quality services. AARP 

believes that MA coordinated care plans hold the promise of improving the quality of care. 

We are less sanguine about the private fee-for-service option. We 

did not support its inclusion in Medicare because, one, these plans 

are not required to coordinate care for their enrollees or participate 

in quality improvement activities, two key requirements for other 

MA options. And two, these plans can set their own fee schedules 

and are not subject to Medicare’s important balanced billing rules. 

In addition, the marketing of these plans is fundamentally confusing to many beneficiaries. Just last week AARP was contacted 

by an anxious member. The hospital where her husband was scheduled for surgery would not accept his coverage once they learned 

that he was enrolled in a private fee-for-service plan. 

This member didn’t realize that the plan she enrolled in was not 

a supplement to traditional Medicare. She believed that she would 

still be able to freely choose doctors and hospitals. The marketing 

materials did not make the difference between traditional Medicare 

and the private fee-for-service plan clear. 

There are numerous reports of fraudulent marketing where beneficiaries have received inaccurate or misleading information about 

private fee-for-service plans. AARP urges action that will put a 

stop to these practices once and for all. 


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We commend CMS for the steps it took last summer to curtail 

questionable tactics, but further steps are needed. My written 

statement includes specific recommendations intended to improve 

consumer protections in the Medicare Advantage market. 

AARP also believes that Medicare Advantage plans should coexist with the traditional program on an equal footing. Currently, 

payment rates are, on average, skewed in favor of MA plans. This 

does not make economic sense for the program or for the people in 

traditional Medicare, who pay higher premiums for benefits they do 

not enjoy. 

MedPAC reports that, on average, payments to private fee-forservice plans exceed payments in the traditional program by 17 

percent. We see no justification for the substantial excess payments. 

Furthermore, because private fee-for-service plans are not required to coordinate care or participate in quality improvement activities, we question what value these plans bring to Medicare. It 

is not unreasonable to expect coordinated care plans to operate efficiently. 

We know that many beneficiaries appreciate the extra benefits 

and most cost-sharing that some MA plans offer. But these advantages should derive from savings from high quality care, eliminating waste and needless care, and cost-effective plan operation, 

not from Medicare excess payments that favor only the 20 percent 

of beneficiaries who have elected MA enrollment. 

AARP strongly concurs with the MedPAC recommendation of 

payment neutrality for all Medicare coverage options. Payments 

can be reduced gradually, without undermining beneficiaries’ confidence in MA. 

In summary, it is fair and reasonable for Medicare Advantage 

plans to bring real value to Medicare by providing high quality, 

cost-effective, and efficient care. We look forward to working with 

you and your colleagues on both sides of the aisle on policies that 

improve the options offered to Medicare beneficiaries. Thank you, 

Mr. Chairman. 

[The statement of Byron Thames follows:] 

Statement of Byron Thames, M.D., Member, Board of 

Directors, American Association of Retired Persons, 

Orlando, Florida 

Mr. Chairman and members of the Committee I am Byron Thames, a member of 

the AARP Board of Directors. AARP appreciates the opportunity to present our 

views on the Medicare Advantage program. 

Let me begin by reaffirming a core principle: AARP is committed to the Medicare 

program and believes it is essential that Congress continue to strengthen and improve Medicare for current and future beneficiaries. Medicare is a vital component 

of financial security for older Americans and many with disabilities, and we must 

ensure that the program continues to remain a viable and responsive part of retirement security for all Americans. 

I also want to reiterate our support for the Medicare Advantage program. We believe that it is important for people on Medicare to have genuine choices when it 

comes to how they receive Medicare benefits. To this end, beginning this year most 

of UnitedHealthcare’s coordinated care Medicare Advantage plans will carry the 

AARP name. 

However, while we support a choice of coverage options, we emphatically believe 

that the choices must be genuine, that the options differ from one another and, most 

importantly, that each option offers high quality services. 


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AARP believes that MA options in Medicare have the potential to bring real value 

to the program. The coordinated care plans available through Medicare Advantage 

in the form of health maintenance organizations (HMOs) and preferred provider organizations (PPOs) hold the promise of offering innovations in care delivery that can 

improve the quality of care as well generate savings. We know that many of our 

members enjoy the opportunity for care coordination available through integrated 

health plans, and we recognize that these types of plans can marshal resources to 

provide comprehensive care. 

Private Fee for Service Not a Good Option for Medicare 

We are less sanguine about the private fee-for-service (PFFS) option and did not 

support its inclusion as a Medicare coverage option. AARP does not support PFFS 

for several reasons. PFFS plans are not required to coordinate care for their enrollees or participate in quality improvement activities—two key requirements for other 

MA options. Further, PFFS plans can set their own fee schedules—not subject to 

Medicare’s important balance billing rules. And PFFS plans are not required to offer 

Part D prescription drug coverage. 

PFFS plans are also fundamentally confusing to beneficiaries. A PFFS plan appears to resemble the traditional Medicare program because enrollees can theoretically choose their providers. But this is not really the case. Enrollees cannot know 

in advance whether the doctors or hospitals they want to use will accept payment 

from a PFFS plan. Just last week, AARP was contacted by an anxious member who 

found that the teaching hospital where her husband was scheduled for surgery 

would not accept his coverage once they learned that he was enrolled in a PFFS 

plan. In talking to our member, it was quite clear that when she enrolled in her 

PFFS plan, she did not realize that this was not a supplement to traditional Medicare as she had purchased in the past. She believed that she would still be able 

to freely choose doctors and hospitals. She was confused by the apparent similarity 

between PFFS and the traditional Medicare plan because the marketing materials 

upon which she relied did not make the difference clear. 

Unscrupulous Marketing Tactics Must Be Stopped 

There is abundant research, including studies that were commissioned by AARP’s 

Public Policy Institute, that demonstrate that Medicare beneficiaries do not have an 

adequate understanding of the differences among Medicare’s coverage options. A recent study by investigators at the Research Triangle Institute concluded that an increased number of plan choices complicate the health plan decision making process 

for beneficiaries. This often leaves some beneficiaries vulnerable to questionable 

marketing practices. Here again, PFFS plans are often a problem. State regulators 

and beneficiary advocates have reported numerous incidents of fraudulent marketing where beneficiaries have received inaccurate or misleading information about 

PFFS benefits and charges. Some of the marketing problems did occur in other MA 

plans as well. State regulators have expressed frustration that they are not able to 

pursue these incidents. AARP urges action that will put a stop to these practices 

once and for all. 

We commend CMS for the steps it took last summer in its effort to curtail questionable tactics used to move beneficiaries into MA plans. But we think further 

steps are needed. In testimony before the Medicare Private Plans SubGroup of the 

National Association of Insurance Commissioners in September, 2007, AARP made 

several recommendations intended to improve consumer protections in the MA market. These include: 

• Outbound education and verification calls should be made to all new enrollees 

in Medicare private plans to ensure that beneficiaries understand plan rules. 

These rules should apply to PFFS as well as other MA options. 

• CMS should develop a mandatory national standardized Medicare training program for all agents who sell Medicare products. All such representatives should 

be required to pass a written test, based on standardized training, that demonstrates their thorough familiarity with Medicare and Medicare products (MA, 

PDP, Medigap) and how Medicare interacts with other coverage such as Medicaid, retiree health, VA, etc. 

• NAIC should develop model regulations, setting standards for agent conduct, 

and defining prohibited activities with respect to the sales and marketing of MA 

plans. CMS and the States should adopt these regulations, which would allow 

both the State and Federal Governments to enforce them. The guidelines should 

include standard timelines for CMS and the States to render decisions. 

• CMS and/or NAIC should continue ‘‘secret shopper’’ programs to determine 

whether their rules are followed by agents and plans. 


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• CMS, together with the States and the NAIC, should create a national database 

to provide and share information about agents and brokers who have been sanctioned or terminated by a health plan and for use in screening agents. 

• The financial incentives or commissions that individual brokers receive based 

on the type of product they sell (e.g., MA, PDP, etc) should be publicly disclosed 

on the CMS website and presented to a beneficiary before enrollment. A beneficiary should have the right to know if an agent has a financial incentive to 

recommend one product over another. 

• The same marketing and enrollment requirements should apply to all MA 

plans. PFFS should not have an unfair advantage in the marketplace, such as 

the extended open enrollment period that they now enjoy. 

• Special consideration should be given to the marketing of PFFS plans to dual 

eligibles. There have been widespread reports of dual eligibles who did not understand the consequences of their decision to join a PFFS plan and have lost 

important Medicaid benefits. Because of the special enrollment rules for dual 

eligibles (i.e., they can enroll on a monthly basis), they have been targets of 

abuse. 

• CMS and the States should vigorously enforce guaranteed issue protections that 

apply when agents misrepresent MA plans. Consumers who disenroll from an 

MA plan who wish to enroll in traditional Medicare within a certain period of 

time should have the opportunity to purchase Medigap. If someone had a 

Medigap policy other than one of the guarantee issue plans, he/she should be 

allowed to return to it with no break in coverage, and retroactively pay premiums for the elapsed period. 

Improvements Needed In Medicare’s Payment of MA Plans 

As noted earlier, AARP supports MA plans in the Medicare program. But we 

think they should co-exist with the traditional program on an equal footing. Currently, payment rates are, on average, skewed in favor of MA plans. This does not 

make economic sense for the Medicare program, nor is it fair to people on Medicare 

who opt for coverage in the traditional plan. The payment discrepancy between traditional Medicare and PFFS plans is particularly troublesome. The Medicare Payment Advisory Commission (MedPAC) reports that, on average, payments to PFFS 

plans exceed those Medicare makes on behalf of beneficiaries in the traditional program by 17 percent. The Commission cites two reasons: first, insurers offering PFFS 

plans tend to operate where payment rates are especially favorable, notably suburban and rural areas; and second, because their bids are relatively high, signaling 

more costly operations than those of HMOs, for example. In light of the fact that 

PFFS plans are not required to coordinate care for their enrollees and are not required to participate in quality improvement activities, such as reporting HEDIS 

quality data, we question what value these plans provide to Medicare. Furthermore, 

we see no justification for the substantial excess payments. 

HMOs were first introduced to Medicare because it was widely assumed from the 

experience of pre-paid group practice plans like Kaiser, Group Health Cooperative 

of Puget Sound, and others that by receiving a capitated payment, plans could oversee and manage care and operate efficiently. In fact, in the early days of the program, it was expected that private health plans would be able to operate with at 

least 5 percent less in payment than traditional Medicare. AARP believes that it is 

still not unreasonable to expect coordinated care plans to operate efficiently and cost 

effectively. We know that many beneficiaries appreciate some extra benefits and 

modest cost-sharing that many MA plans offer. But we believe that these advantages should derive from savings that accrue from high quality care, eliminating 

waste and needless care, and cost effective plan operation—not from Medicare excess payments that favor only the 20 percent of beneficiaries who have elected MA 

enrollment. 

As a policy matter, AARP strongly concurs with the MedPAC recommendation of 

payment neutrality for all Medicare coverage options. To rectify the situation excess 

payments can be reduced gradually without undermining beneficiaries’ confidence in 

MA, and without causing plans to precipitously withdraw from Medicare or dislocating or inconveniencing beneficiaries. 

In summary, AARP continues to support plan choices that include MA plans. 

However, we are convinced that it is fair and reasonable for these plans—particularly PFFS plans—to demonstrate that they bring real value to Medicare by demonstrating measurable advantages in the form of high quality and cost-effective and 

efficient care. We look forward to working with you and your colleagues on both 

sides of the aisle on policies that improve the options offered to Medicare beneficiaries. 


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Chairman STARK. Thank you, Doctor. 

Mr. Mattes? 

STATEMENT OF JAMES A. MATTES, PRESIDENT AND CEO, 

GRANDE RONDE HOSPITAL, LA GRANDE, OREGON 

Mr. MATTES. Good morning, Mr. Chairman and members of the 

subcommittee. Thank you for inviting me here today to tell the 

story of our hospital’s experience with Medicare Advantage plans. 

Grande Ronde Hospital is a community-owned, not-for-profit, 25- 

bed critical access hospital. We are located in the beautiful Blue 

Mountains of northeast Oregon in remote, rural, and isolated 

Union County. 

The closest tertiary facilities are located over mountain passes in 

Boise, Idaho, 177 miles to the east, and Portland, Oregon, 259 

miles to the west. The three closest hospitals are an hour or more 

away, providing the weather is good. Travel during the winter 

months is treacherous, and a normal winter storm can shut down 

the highways for hours. 

My priority first concern is for the people we care for in our hospital. A large number of seniors who have enrolled in Medicare Advantage plans, about one-quarter by our count, do not realize they 

have opted out of traditional Medicare. The senior citizens and providers of Union County are overwhelmed with 21 Medicare Advantage plans. We routinely counsel and assist confused and frustrated 

beneficiaries, many of whom thought they were signing up for a 

Medicare supplement, drug benefits, or some other supplemental 

coverage. 

Our experience with beneficiaries also shows that Medicare Advantage plans are unresponsive when it comes to resolving problems or answering routine questions about coverage. Poor customer 

service by multiple plans leaves my staff picking up the slack in 

helping seniors to resolve claim and coverage issues. This means 

my hospital is effectively helping foot the bill for these plans, while 

at the same time they are being paid more than traditional fee-forservice Medicare. 

Also, some senior citizens end up subsidizing Medicare Advantage plans. Several of our sickest and poorest patients, who require 

frequent care, end up paying more out of their own pockets because 

of daily hospital and home health co-payments. You can imagine 

how upset a patient can be when on top of the trauma and anxiety 

that an illness or injury can cause, they must pay more out of pocket than they had anticipated. 

The consumer advisory unit of the Oregon Insurance Division recently issued a consumer alert advising seniors that some unscrupulous insurance agents are preying on seniors by using misleading 

tactics. Many of the abuses are occurring in the marketing and 

selling of Medicare Advantage plans. 

One example of such abuse in Union County is a churning of 

Medicare plans sold to seniors. Observations on the part of my billing staff suggest that the majority of Medicare Advantage enrollees 

are sold a new plan every year. 


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Beneficiaries also are swept into problems created by Medicare 

Advantage plans. These plans have unusually high error rates, 

which delay the payment of claims and frustrate beneficiaries and 

providers. 

In a recent routine compliance audit, our facility randomly sampled Medicare Advantage payments and found the insurance carrier payment error rate exceeded 38 percent. Our hospital staff 

must review every claim for accuracy, and often must spend weeks 

or even months making phone calls and writing letters to straighten out a patient’s account. 

When they do finally decide to pay a claim, they do not pay us 

electronically even though the claim was made electronically. Compared to traditional Medicare, it takes roughly three times as long 

to receive payment, which compromises provider cash flow. 

Mr. Chairman, I want to take a step back for a minute and look 

at the impact of Medicare Advantage on providers, and then I will 

close. The capitated rates paid to Medicare Advantage carriers in 

many rural communities are well above costs. With the mission of 

maximizing profits, Medicare Advantage insurance carriers have a 

strong incentive to focus their marketing efforts on the most profitable regions of the country, which may explain the extraordinary 

levels of enrollment in Union County, Oregon. 

As enrollment grows in the Medicare Advantage, I am concerned 

these carriers will use market leverage to force discounts in provider payments, which will hurt small and rural hospitals and, ultimately, the patients who depend on us for medical care. 

Mr. Chairman, I conclude by saying, quite simply, America’s elderly and disabled deserve better. Medicare Advantage plans confuse and frustrate them, and poor communications and poor support leave them feeling abandoned. In many cases, they are unable 

to make an informed decision. Beneficiaries often end up bearing 

risk without an adequate understanding of whether or not they 

may be better off financially if they stayed with traditional Medicare. 

Rural hospitals and physicians also deserve better. The unchecked growth of Medicare Advantage plans and their rapid displacement of traditional Medicare is disrupting the healthcare mission of hospitals and physicians. Medicare Advantage plans underpay critical access hospitals in defiance of congressional intent. For 

Grande Ronde Hospital, this could soon exceed one million dollars 

per year. 

To sum up, these plans are hurting rather than helping some 

seniors and hospitals, and they are increasing the cost of care for 

everyone. Thank you. 

[The statement of James A. Mattes follows:] 

Statement of Jim Mattes, President and CEO, 

Grande Ronde Hospital, La Grande, Oregon 

Chairman Stark and distinguished members of the Committee, thank you for inviting me here today to share with you Union County, Oregon’s experience with 

Medicare Advantage plans. I am Jim Mattes, President and Chief Executive Officer 

of Grande Ronde Hospital in La Grande, Oregon, where I have served for the past 

24 years. 

My testimony draws on my community’s experience and my hospital’s experience 

with Medicare Advantage plans in Union County, Oregon. It is my hope that by 

sharing our experiences you will be able to see the adverse impact and long term 


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consequences Medicare Advantage plans will have on beneficiaries, Critical Access 

Hospitals, and the healthcare system. 

Union County, Oregon (2000 U.S. Census) 

Union County, Oregon has a population of approximately 24,530 people, dispersed 

over 2,039 square miles. Per capita income in Union County is $16,907. About 13.8% 

of the population is below the poverty line, including 9.5% of the population age 65 

and over. 

The County seat is La Grande, a small community of 12,327 people. We reside 

in the Blue Mountains of Northeast Oregon, a remote rural part of the State, with 

4,000+ foot elevation mountain passes in every direction. Travel during the winter 

months is treacherous, with winter storms sometimes closing our highways and 

making it impossible for people to leave the community. 

Grande Ronde Hospital 

Grande Ronde Hospital is a community owned, not-for-profit, 25-bed Critical Access Hospital (CAH). The closest tertiary facilities are located over mountain passes 

in Boise, Idaho (177 miles to the East) and Portland, Oregon (259 miles to the 

West). The closest hospitals are St. Elizabeth (42 miles to the East), St. Anthony 

(50 miles to the West), and Wallowa Memorial (68 miles to the North). Patients requiring transfer to a larger medical facility must travel two to four hours by ground 

ambulance. 

In order to sustain access to local medical services, our hospital has recruited and 

employed 12 primary care providers (i.e. ten physicians and two nurse practitioners) 

who practice in three provider-based clinics which are fully integrated with the hospital. Accordingly, our hospital’s experience with Medicare Advantage plans is amplified by the fact that our provider-based clinic revenue is integrated with hospital 

revenue, and our hospital-owned clinics currently care for the majority of Medicare 

patients in our community. 

Medicare Demographics in Union County, Oregon (2000 U.S. Census) 

Union County’s age 65 and older population of 3,949 makes up 16.1% of the County’s total population. Insurance agents in La Grande claim to have enrolled approximately 1,500 of these seniors into Medicare Advantage plans. This currently represents 38% of the County’s Medicare population. Based on the rapid growth in 

Medicare Advantage enrollment in Union County we project that within two years 

Medicare Advantage enrollment could be 2,500 or 63% of our Medicare population. 

[See EXHIBIT 1: Medicare Enrollee Estimates] 

Medicare Advantage Plans are Hurting Union County Seniors 

A large number of seniors who have enrolled in Medicare Advantage plans in 

Union County do not realize they have opted out of traditional Medicare—a frequent 

problem that we estimate occurs with one out of every four Medicare Advantage enrollees. At Grande Ronde Hospital, we routinely counsel and assist confused and 

frustrated beneficiaries. It is not uncommon to encounter patients who do not realize they have joined a Medicare Advantage plan. They simply thought they were 

signing up for a Medicare supplement, Medicare drug benefits or some other form 

of additional coverage. Beneficiaries are often upset to learn that they no longer 

have traditional Medicare coverage and that the ‘‘low cost’’ plan they opted for could 

potentially cost them more out of pocket than traditional Medicare. 

Illustration #1: Mr. Johnson (not his real name) pays more out of pocket 

Mr. Johnson signed up for the Advantra Freedom Medicare Advantage plan, believing he had purchased a Medicare supplement and that he still has traditional 

Medicare. On December 1st he was admitted to our hospital for 8 days and was discharged on December 9th. On December 15th Mr. Johnson was re-admitted to our 

hospital for 5 days and was discharged on December 20th. 

Mr. Johnson’s out of pocket expenses are analyzed below. 

Cost under Medicare Advantage Plan (Advantra Freedom 5) 

• $900.00 First Stay ($180/day 1–5 days) 

• $900.00 Second Stay ($180/day 1–5 days) 

• $55.00 Monthly Advantage plan premium 

• $96.40 Medicare Part B Monthly Premium (paid in addition to Medicare Advantage Plan premium) 

TOTAL OUT OF POCKET: $1,951.40 

Cost under Traditional Medicare: 


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• $1,024.00 Part A Deductible ($1,024.00 every 60 days) • $96.40 Part B monthly premium • $120.00 (20% Part B co-pay, since Part B charges total $600.00 for both stays). 

TOTAL OUT OF POCKET: $1,240.40 

As the information above illustrates, Mr. Johnson paid an additional $711.00 out 

of pocket with his Medicare Advantage plan coverage than he would have under traditional Medicare coverage. 

There are eight Medicare Advantage insurance carriers and 21 different plans in 

Union County for which our hospital and clinics have treated patients, and there 

are reportedly others being sold. [See EXHIBIT 2: Medicare Advantage Plan 

Growth; and EXHIBIT 3: Medicare Advantage Plan Options] Too many carriers, too 

many plans and too many benefit variables make due diligence comparison difficult 

and confusing, especially for the elderly—a setting that is vulnerable to abuse. The 

Consumer Advocacy Unit of the Oregon Insurance Division issued a ‘‘Consumer 

Alert’’ advising seniors to beware of abusive Medicare insurance sales practices, and 

included the following statement in their brochure for seniors: ’’ . . . some unscrupulous insurance agents are preying on seniors by using tactics that are confusing 

and misleading. Many of the abuses are occurring in the marketing and selling of 

Medicare Advantage plans . . . ’’ One such apparent abuse in Union County is the 

annual ‘‘churning’’ of Medicare Advantage plans sold to seniors. Our hospital billing 

staff estimates that the majority (more than 50%) of Medicare Advantage enrollees 

are sold a new plan each year by insurance agents reportedly going door-to-door. 

The churning of plans adds to the confusion and frustration of beneficiaries as they 

struggle with knowing which carrier is responsible for which claim. 

Anecdotal Story #2: Mr. Jones (not his real name) is unhappy 

Mr. Jones comes to the hospital ER admitting for medical treatment and presents 

both his Medicare and Medicare Advantage insurance cards. He insists that the 

Medicare Advantage plan is his secondary insurance. In an effort to avoid a dispute 

over coverage, the admitting clerk enters both plans into the system. 

When the billing department receives the patient’s insurance information they realize that the patient cannot have both traditional Medicare and Medicare Advantage coverage, so the patient account representative calls the patient. 

Mr. Jones insists that he has both plans—despite all efforts to convince him otherwise. Eventually the patient account representative assures a very upset Mr. 

Jones that she will determine which insurance was in effect at the time the services 

were rendered and that she will call the patient back. Mr. Jones leaves the hospital 

very fearful that he may have lost his traditional Medicare coverage and simply 

does not understand what is going on. 

The patient account representative calls the insurance carrier. After spending 20 

minutes on hold, the call is answered by an individual who struggles with English. 

With some difficulty, the patient account representative manages to confirm that 

the patient had Medicare Advantage coverage at the time the services were rendered. The patient account representative subsequently calls Medicare to verify that 

they have a record of the patient’s Medicare Advantage plan coverage. Medicare has 

no record of any other coverage, and reminds the patient account representative 

that CMS requires that only beneficiaries may update their records via phone, and 

the account representative is not permitted to act on their behalf. Since the patient 

is not present to put on the phone, the patient account representative is unable to 

verify coverage information. 

The patient account representative next contacts the patient and explains the situation to him, at which point Mr. Jones becomes very upset that he has lost his 

Medicare coverage and decides that he wants to terminate his Advantage plan membership. 

After several frustrating calls to the Advantage plan without results, Mr. Jones 

brings all his paperwork to the hospital billing department and asks the patient account representative for help with terminating his Advantage plan coverage. Several 

phone calls and 45 minutes later the patient’s Advantage plan coverage was successfully terminated and he is again covered by traditional Medicare. 

The hospital billing department may now submit the ER bill to the Medicare Advantage plan for payment. Bills for any services rendered after the date on which 

the Medicare Advantage plan is terminated will be billed to traditional Medicare. 

As previously noted, Union County is a poor county with 9.5% of its senior population below the poverty line. Because of this demographic, Medicare Advantage 

plans with reduced deductibles appeal to seniors in our market. Unlike traditional 

Medicare, some Medicare Advantage plans impose daily hospital copayments and 

daily copayments for home health visits. Sadly, some of our sickest beneficiaries 


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who require frequent care end up paying more out of pocket cost than traditional 

Medicare. 

Medicare Advantage plans also do a poor job of handling enrollee problems with 

claim and coverage questions. Insurance agents are not always available to beneficiaries to answer questions and resolve problems after a sale is finalized, and most 

of the Medicare Advantage plans operating in Union County have outsourced their 

customer service departments to foreign countries. When beneficiaries have a problem with a claim or want to discontinue their plan, they often have difficulty connecting with customer service personnel and routinely experience communication 

problems, including difficult language and accent barriers. Poor customer service, as 

illustrated in story #2 above, often results in our hospital and clinic employees being 

called upon to help seniors resolve claim and coverage issues. In doing so, we are 

effectively subsidizing these Medicare Advantage plans. 

Medicare Advantage Plans are Hurting Providers in Union County, Oregon 

While the focus of my comments relate to beneficiaries, I do want to mention several issues that our medical community is now facing with the explosion of Medicare 

Advantage plans in our area. 

There are two types of Medicare Advantage plans, Preferred Provider Organization (PPO) plans and Private Fee-for-Service plans. Both types of plans appear to 

have unfair leverage against rural providers. The capitated rates paid to Medicare 

Advantage carriers in some areas of the country, particularly in the rural western 

United States, are well above costs. With the mission of maximizing profits, Medicare Advantage insurance carriers have a strong financial incentive to focus their 

marketing efforts on the most profitable regions of the country, resulting in a disproportionate enrollment of rural Medicare beneficiaries. This may help explain the 

extraordinary levels of enrollment in Union County, Oregon. 

Medicare Advantage PPO plans pursue contractual relationships with providers, 

hoping to make them members of a PPO network. Grande Ronde Hospital has only 

one Medicare Advantage PPO contract, with negotiated payment rates which are 

nearly identical to the rates paid by Private Fee-for-Service plans in Union County. 

As with other commercial PPOs with a significant market presence, Grande Ronde 

Hospital is concerned that as enrollment grows, Medicare Advantage PPO carriers 

will use market leverage to force discounts in payment rates. Discounted payment 

rates for services provided to Medicare beneficiaries, hurt small and rural hospitals 

and undermine the Critical Access Hospital safety net intended by Congress. 

The other seven Medicare Advantage insurance carriers operating in Union County all sell Private Fee-for-Service plans. These carriers have forced Grande Ronde 

Hospital into becoming what is called a ‘‘deemed’’ provider. This means that without 

signing a contract, our hospital has agreed to accept the plan’s terms and conditions 

for a particular plan enrollee for a particular visit or admission, simply by treating 

a patient covered by one of these plans. Provider choices with Private Fee-for-Service plans are limited as follows: (1) provide the care these patients need and by 

doing so become a deemed provider or (2) refuse to provide treatment, but still comply with Emergency Medical Treatment and Active Labor Act (EMTALA) law. If 

Grande Ronde Hospital were to refuse to provide treatment, then these patients 

would be forced to leave town for their medical care. For the sake of our patients, 

the financial welfare of our hospital, and the good of our community we truly have 

no choice but to care for these patients. In our isolated rural setting with travel in 

and out of the community periodically shut down due to winter storms, a refusal 

to provide treatment could have serious consequences. 

Medicare Advantage Private Fee-for-Service plans sold in Union County are permitted to operate without a contracted network of providers. These plans are suppose to pay providers what Medicare would have otherwise have paid if the patient 

were a traditional Medicare patient. However, for CAH providers whose payments 

are ‘‘cost-based’’ under traditional Medicare, Medicare Advantage insurers are paying us the Medicare interim payment rate (i.e. the prior year cost-to-charge ratio 

plus 1%). Medicare Advantage insurers do not provide an inflation adjustment or 

a settlement process to reconcile actual costs against the interim rate, such as is 

proposed by Representative Ron Kind in the Rural Health Services Preservation 

Act. [H.R. 2159: ‘‘. . . Although this CAH reimbursement system was enacted by 

Congress to preserve access to hospital services for our rural seniors, many CAHs 

do not receive payments at these levels today for providing care to beneficiaries enrolled in the Medicare Advantage program. H.R. 2159 would ensure that CAHs are 

reimbursed at the same levels by private Medicare Advantage plans as they receive 

under the traditional Medicare program for inpatient, swing-bed, and outpatient 

hospital services.’’] Traditional Medicare retrospectively reimburses CAH providers 

based on ‘‘actual costs’’ following the conclusion of each fiscal year, with the actual 


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cost-to-charge ratio becoming the new interim rate for the subsequent fiscal year. 

Medicare Advantage plans do not provide an adjustment for inflation and there is 

no look-back (i.e. reconciliation of actual costs against the interim rate) which can 

capture any increase in the actual cost-to-charge ratio. 

Grande Ronde Hospital’s cost-to-charge ratios have been increasing in each of the 

past several years, including a 3.8% increase (i.e. 66.14% to 69.94%) from FY2007 

to FY2008. This means Medicare Advantage plans have underpaid us by an amount 

equal to 3.8% of patient charges, because there is no inflation adjustment or retrospective cost settlement process. [See EXHIBIT 4: Ratio of Cost to Charges] Many 

CAH providers have cost-to-charge ratios that are increasing, which typically occurs 

when net operating margins are declining. Grande Ronde Hospital’s 3.8% jump in 

its cost-to-charge ratio from FY2007 to FY2008 illustrates the significant financial 

impact which underpayment by Medicare Advantage plans can have on CAH providers. [See EXHIBIT 5: Medicare Advantage Plan Revenue; and EXHIBIT 6: Medicare Advantage Plan Underpayment Estimates] To this point in time, Grande Ronde 

Hospital has been able to absorb these underpayments, but in the future that may 

not be true for us or other CAH providers who are impacted by such cuts. It is well 

publicized that Medicare Advantage insurance carriers are making big profits because of the disparity between capitation payments and actual costs. However, few 

people know and understand that Medicare Advantage carriers are also making 

profits on the backs of small and rural hospitals as they force payment rates on providers which are below traditional Medicare payment rates. Even my hospital was 

caught off guard. It was my preparation for this hearing, over the past two weeks, 

that fully brought to light the magnitude of the shocking rise in Medicare Advantage enrollment in Union County and the impact that Medicare Advantage underpayment is having on my hospital. 

Another problem with Medicare Advantage plans is their very high payment error 

rates, which adversely impact provider productivity and increase healthcare costs. 

In a recent routine compliance audit we randomly sampled Medicare Advantage 

payments and found the insurance carrier payment error rate was 38.46%. Our hospital staff must review every claim for accuracy and often must literally spend 

weeks or even months of manual follow-up via multiple letters and phone calls to 

receive accurate payment for services rendered to beneficiaries. 

Poorly developed Medicare Advantage electronic or manual billing and claims 

processing systems also adversely impact hospital productivity and increase healthcare costs. All eight of the Medicare Advantage plans in Union County accept electronic billing, but none of them pay electronically, which appears to be an intentional method of improving Medicare Advantage carrier cash flow at the expense of 

providers. At my facility, Medicare Advantage claims are paid on average within 45 

days of submission of a clean claim, compared to traditional Medicare where a clean 

claim is often paid within 14 days of submission. This has caused a 6.65% increase 

(i.e. $292,417) in Medicare accounts receivable, and it has compromised our cash 

flow. 

Anecdotal Story #3: Hospital billing problems with Mr. Smith (not his real name) 

Mr. Smith is admitted to the hospital on December 25, and is an inpatient until 

January 4th. When Mr. Smith presented to the admitting department he provided 

his ‘‘Secure Horizons’’ Medicare Advantage card. 

After discharge the hospital billing department submitted Mr. Smith’s bill to Secure Horizons. Forty-five (45) days after claim submission, a denial is received via 

U.S. mail. The denial states ‘‘beneficiary not covered on these dates of service’’. 

The patient account representative phones the patient and notifies him of the denial and questions his coverage dates. The patient explains that effective January 

1 he has a new Medicare Advantage plan with ‘‘Today’s Options’’. The hospital biller 

must now ‘‘split bill’’ this service, sending the bill for the first portion of the patient’s stay to Secure Horizons, and the bill for dates of service after January 1 to 

the Today’s Options. Each of the bills are subsequently paid 45 days after submission, a total of 90 days in accounts receivable from date of discharge to final payment. 

Had the Medicare Advantage plan been subject to the same electronic payment 

rules as Medicare, the original claim denial would have been received 14 days after 

claim submission, and both claims would have been paid in full (provided there were 

no other errors) roughly 28 days after the first claim submission. [Total days for 

payment: Medicare Advantage vs. Traditional Medicare (90 days vs. 28 days).] 

Inefficiencies and increased workload caused by Medicare Advantage plans has required significant additional man hours from billing and collection staff, accounting 

and administration. Our costs have increased in response to all of the following: assisting the elderly with their complaints, plans, benefits and claims; managing 21 


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plans in addition to traditional Medicare, which sometimes require split billing; resolving frequent payment errors; and managing their slow payment practices. You 

may be surprised to learn that the additional payroll expense caused by Medicare 

Advantage plans are allowable costs on the traditional Medicare cost report for CAH 

hospitals, which means that Medicare is unwittingly subsidizing Medicare Advantage plans through the back door. Unfortunately for us, Medicare only reimburses 

each hospital based on the ratio of Medicare volume to total volume and the majority of these added costs must be shifted to other carriers or subtracted from the hospital’s bottom line. 

SUMMARY 

Senior citizens deserve better. They are confused and frustrated by the many benefit packages offered by Medicare Advantage plans; the elderly are often unable to 

resolve problems and make informed decisions because of poor plan communications 

and plan support; and some Medicare beneficiaries would be better off financially 

if they stayed with traditional Medicare. Medicare Advantage plans are structured 

so that enrollees are taking risk, but without an adequate understanding of the risk 

they are taking. Congress needs to assure that seniors are well-informed, decision 

making is made simple, and risks are mitigated. 

Rural hospitals and physicians also deserve better. The frightening growth of 

Medicare Advantage plans and their rapid displacement of traditional Medicare are 

having an adverse impact on our local healthcare system. Medicare Advantage plans 

appear to have unfair leverage against small and rural communities where costs are 

well below capitation rates, and they underpay CAH providers. The very high payment error rates, the delay in payments to providers, and the increased workload 

these plans impose on providers are collectively undermining the integrity of the 

Medicare program and increasing the cost of healthcare. 

Congress passed legislation to protect CAH providers and ensure access to care 

in rural communities. Somehow, it would appear, the Medicare Advantage program 

has been allowed to circumvent congressional intent. 

f 

Chairman STARK. Thank you. 

Mr. Lipschutz? 

STATEMENT OF DAVID LIPSCHUTZ, INTERIM PRESIDENT AND 

CEO, CALIFORNIA HEALTH ADVOCATES, LOS ANGELES, 

CALIFORNIA 

Mr. LIPSCHUTZ. Chairman Stark, Ranking Member Camp, distinguished committee members, thank you for the opportunity to 

testify today. My name is David Lipschutz, and I am interim president, CEO, and staff attorney of California Health Advocates, an 

independent nonprofit organization dedicated to education and advocacy efforts on behalf of Medicare beneficiaries in California. 

Our experience with Medicare is based in large part on our close 

work with California’s State health insurance program known in 

our State as HICAP, which is on the front line assisting Medicare 

beneficiaries. Of the various options within the Medicare program 

to access benefits, we recognize that some Medicare Advantage 

plans can work for some individuals. 

Other Medicare beneficiaries, however, can be disadvantaged by 

joining MA plans for a variety of reasons, including restriction of 

access to providers, high out-of-pocket expenses, and other barriers 

to care such as utilization management. 

My testimony will briefly focus on general issues faced by MA 

plan enrollees, new insurance products being sold to fill in the gaps 

of MA plans, and the experience of dual eligibles who enroll in MA 

plans. 

The staggering rise in the number, type, and variation of MA 

plans over the last two years, coupled with aggressive and misVerDate Nov 24 2008 14:19 Dec 10, 2010 Jkt 046954 PO 00000 Frm 00122 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\46954.XXX GPO1 PsN: 46954

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leading marketing, has greatly hindered the ability of Medicare 

beneficiaries to make informed decisions about how they want to 

access their Medicare benefits. 

Many beneficiaries are lured by MA plans with zero or low 

monthly premiums, corresponding offsets of their Part D premium, 

and extra benefits of often limited value. Once enrolled and in need 

of services, however, many find they are liable for cost-sharing on 

a par with or even greater than original Medicare. 

Since MA cost-sharing is commonly downplayed during sales, 

those with chronic conditions can face catastrophic costs they 

hadn’t anticipated, and realize too late that they would have been 

better off financially by purchasing a Medigap policy. 

For example, a HICAP counselor in southern California, who has 

extensive experience working with individuals with cancer, reports 

that most MA plans she deals with are charging at least 20 percent 

in cost-sharing for chemotherapy and radiation. Enrollees in these 

plans who receive cancer treatment often have thousands of dollars 

in monthly out-of-pocket expenses. 

Most cancer patients in this situation report that when they 

signed up with their MA plan, they thought that the co-payments 

for chemo would be between $35 and $50. Many tell the counselor 

that they would rather die than leave their families without 

money. 

Some who join MA plans are surprised to learn that providers 

who they had seen for years are not members of the plan’s network 

or, particularly in the case of private fee-for-service plans, refuse 

to accept the plan’s terms and conditions, leading to problems finding doctors who will treat them. 

Over the last year, much attention has been focused on appalling 

abuses surrounding the sale of Medicare Advantage plans. Despite 

this attention, though, we believe that far too little action has been 

taken by CMS, and as a result, such abuse appears to continue 

unabated. 

Despite industry claims that MA products are a good value for 

all beneficiaries, significant fissures in MA plan coverage have led 

to the emergence of a new insurance product aimed at filling those 

gaps. This product, sometimes called Advantage Plus, is designed 

to fill in the gaps in MA plans, including high out-of-pocket expenses for vital services such as inpatient hospital care, skilled 

nursing facility stays, durable medical equipment, and drugs covered under Medicare Part B. 

We believe that the existence of these products is a symptom of 

a more widespread disease afflicting the Medicare Advantage program, and underscores how far too many MA plans impose high 

cost-sharing while providing inadequate benefits. 

Individuals who are dually eligible for Medicare and Medicaid 

are entitled to a broad range of benefits provided by both programs. 

Enrollment in Medicare Advantage plans, though, can create problems for dual eligibles such as access to care issues and greater 

out-of-pocket expenses. 

Medicare Advantage special needs plans, or SNPs, are in theory 

designed to address the needs of duals and other designated populations. Without formal requirements mandating that they provide 


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care coordination, integration with Medicaid, and targeted case 

management, often SNPs remain special in name only. 

Unfortunately, many duals who were automatically enrolled in 

SNPs over the last two years have experienced significant problems 

with accessing care and coordinating coverage and payment with 

State Medicaid programs. 

Other MA plans, notably private fee-for-service plans, are generally ill-suited to address the complex needs of dual eligibles and 

often cause harm to this vulnerable population. Dual eligibles are 

targeted by some PFFS plan sponsors and agents without regard 

to the suitability of such plans, including meaningful comparison 

with Medicaid benefits already available to them and access to providers who accept both Medicare and Medicaid. 

Instead, duals are being targeted and convinced to enroll in 

PFFS plans based upon extra benefits that agents and plans say 

will save them money. Once enrolled, however, duals often find 

that their doctors won’t take their plan, and they are charged costsharing for services and items they did not previously have to pay 

for. 

We recognize and appreciate that the CHAMP Act would have 

addressed some of these problems, and we are disappointed it did 

not become law. 

For our specific recommendations on improving the MA program, 

we refer you to our written testimony and the various documents 

cited therein. Thank you. 

[The statement of David Lipschutz follows:] 

Statement of David Lipschutz, Interim President and CEO, 

California Health Advocates, Los Angeles, California 

I. INTRODUCTION 

California Health Advocates (CHA) is an independent, non-profit organization 

dedicated to education and advocacy efforts on behalf of Medicare beneficiaries in 

California. Separate and apart from the State Health Insurance Program (SHIP), 

we do this in part by providing support, including technical assistance and training, 

to the network of California’s Health Insurance Counseling and Advocacy Programs 

(HICAPs) which offer SHIP services in California. CHA also provides statewide 

technical training and support to social and legal services agencies and other professionals helping Californians with questions about Medicare. Our experience with 

Medicare is based in large part on our close work with the HICAPs and other consumer assistance programs that are on the front line assisting Medicare beneficiaries. 

Of the various options within the Medicare program to access benefits, we recognize that Medicare Advantage (MA) plans can work for some individuals. Other 

Medicare beneficiaries, however, are often disadvantaged by joining MA plans for 

a variety of reasons, including restriction of access to providers (including specialists), out-of-pocket expenses (sometimes greater than Original Medicare), and other 

barriers to care such as utilization management. Payments to MA plan sponsors and 

corresponding commissions and bonuses paid to agents combine to foster an epidemic of marketing misconduct; all too often, the best plan for the agent is sold 

rather than the best plan for the beneficiary. 

MA plans are, in theory, supposed to ‘‘fill in the gaps’’ of Original Medicare as 

well as provide additional benefits. Many plans, however, fail to provide protection 

against out-of-pocket expenses resulting in a new product—the MA gap plan—that 

is being sold to fill in expensive gaps in MA plans. In addition, certain beneficiaries 

can be harmed by joining MA plans—in particular, individuals dually eligible for 

Medicare and Medicaid—as well as other beneficiaries who are faced with 

unaffordable out-of-pocket expenses as a result of joining such plans. 

It is not our purpose to disparage all MA plans, but to call into question the value 

we are getting out of MA plans collectively, particularly given the amounts MA plan 

sponsors are paid over and above the costs to Original Medicare of providing care 


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1See California Health Advocates and Medicare Rights Center report ‘‘Informed Choice: The 

Case for Standardizing and Simplifying Medicare Private Health Plans (September 2007), available at: http://www.cahealthadvocates.org/advocacy/2007/09.html. 

to similarly-situated beneficiaries. We also question whether informed decision-making is impaired by lack of standardization, and the sheer number of plans combined 

with countless variations in benefits and cost-sharing that compete for beneficiary 

attention—particularly PFFS plans—and whether these plans are meeting the 

needs of all, or even a subset, of beneficiaries. 

This written testimony will focus on four areas: 

• general issues faced by MA plan enrollees, including plan benefits, cost-sharing, 

access to providers, trends in retiree coverage, and marketing misconduct; • new insurance products being sold to fill in the gaps of MA plans; • the experience of dual eligibles in MA plans; and • recommendations to address shortcomings of the MA program. 

II. GENERAL ISSUES FACED BY MEDICARE ADVANTAGE ENROLLEES 

Choosing the appropriate Medicare coverage for an individual’s particular circumstances has become tremendously complicated for most Medicare beneficiaries 

since the enactment of the Medicare Modernization Act of 2003 (MMA). Increased 

payment to insurance companies has led to a staggering increase in the numbers 

and types of Medicare Advantage plans. Across the country, Medicare beneficiaries 

face an unprecedented array of MA products, each with complex benefit variations, 

and differences in premiums and cost-sharing requirements. These variations tend 

to confound prospective enrollees, and often obscure the potential for out-of-pocket 

costs, making it difficult for consumers to compare costs and benefits both between 

plans and with Original Medicare. 

While some individuals do benefit from enrollment in Medicare Advantage plans, 

it largely depends on an individual’s plan and his/her individual needs. Conversely, 

others are significantly harmed by enrolling in MA plans. Not only do some people 

who join MA plans lose and have difficulty re-acquiring their Medigap and retiree 

plans, but the benefits of MA plans can quickly be erased if healthcare needs 

change, and people need care that is more expensive than under Original Medicare. 

MA Plan Benefit Packages and Cost-Sharing 

Through analysis of the Medicare Advantage marketplace, along with the collective experience of those who counsel Medicare beneficiaries, it is clear that there 

are serious deficiencies in the benefit packages of many Medicare private health 

plans. As discussed in a September 2007 report by California Health Advocates and 

the Medicare Rights Center, MA plan shortcomings include: 

• consumers with chronic illness can unknowingly incur widely varying levels of 

cost-sharing under different plans; 

• many MA plans do not provide a limit on enrollees’ annual out-of-pocket expenses for medical services, or they exempt certain services (such as chemotherapy) from such limits; and 

• many plans charge the same or higher cost-sharing than Original Medicare for 

specific, costly services, such as inpatient hospital care, nursing home stays, durable medical equipment and home healthcare.1

Using the great flexibility afforded by Medicare law and regulations, and under 

the guise of marketplace ‘‘innovation,’’ many plan sponsors design their benefits in 

such a way that front-loads cost-sharing for the most expensive items, (e.g., hospitalization, skilled nursing facility stays, Part B drugs)—services for which beneficiaries do not have a choice to forego, and are not susceptible to incentives to try 

other providers (e.g., to see primary care providers rather than specialists) or other 

treatment options. 

Despite these significant shortcomings in plan benefits, many beneficiaries are 

lured by plans with zero monthly premiums and/or ‘‘extra benefits,’’ only to find that 

once enrolled and in need of services, out-of-pocket expenses can equal or exceed 

Original Medicare. Cost-sharing for services is too often not made apparent when 

plans are sold, and those with chronic conditions often face catastrophic costs and 

are often better off financially by purchasing a Medigap policy. 

Example: A HICAP counselor in Southern California who has extensive experience 

working with individuals with cancer, reports that most MA plans she deals with 

are charging at least 20% in cost-sharing for chemotherapy and radiation. Enrollees 

in these plans who receive cancer treatment often have thousands of dollars in 

monthly out-of-pocket expenses. Most cancer patients in this situation report that 


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2 Also see an article in California Health Advocates’ August 2006 online newsletter re: chemo 

copays for cancer patients and the trend in MA plans towards charging full Part B cost-sharing 

vs. flat copays at: http://www.cahealthadvocates.org/newsletter/2006/08/cancer.html. 3 Correspondence between California Health Advocates and the California Medical Association, February 2008. 

when they signed up with their MA plan they thought the copayments for chemo 

would be $35–$50. Many tell the counselor that they would rather die than leave 

their families without any money.2

Many individuals who seek or already have Medigap policies enroll in Medicare 

Advantage plans because they are led to believe that MA plans either function just 

as Medigap plans do, or even better (some in fact enroll in MA plans believing them 

to be actual Medigap policies). Conned by slick marketing, new MA plan enrollees 

often do not understand that they no longer have the same out-of-pocket spending 

protections that they had in their Medigap policies, are astonished to find that they 

can no longer see their regular doctors and are hit with high medical bills. Also, 

unlike Medigap plans, which cannot change benefits year-to-year and are guaranteed renewable, every year MA plan sponsors can change benefits, cost-sharing and 

premiums, forcing enrollees to reanalyze their benefits annually. 

It is well documented that Medicare Advantage plans are paid more than Original 

Medicare rates, and, as partial justification, plan sponsors often tout ‘‘extra benefits’’ 

that are being provided to their enrollees. Many of the same plans that charge the 

same or higher cost-sharing than Original Medicare downplay those costs but heavily promote additional benefits of lesser value, ranging from eyeglasses, hearing 

aids, gym membership, to a monthly allotment of over the counter pharmacy supplies. From an individual beneficiary’s standpoint, these ‘‘extras’’ can provide limited 

value when compared with high out-of-pocket costs and problems accessing providers that accompany many plans. From a broader perspective, luring enrollees 

with ‘‘extra benefits’’ provided now, given that current payment rates are 

unsustainable, is setting enrollees up for a bait-and-switch scenario down the road 

if plan benefits are cut (or even the following year, as plans can fundamentally 

change their benefits annually). 

Access to Providers 

Unlike Original Medicare, coordinated care plans limit access to designated provider networks. Some who join MA plans are surprised to learn that providers who 

they had seen for years are not members of the plan’s network, or refuse to accept 

the plan’s benefits, forcing them to find new providers or get out of the plan when 

they are able to do so. 

The greatest risk of not being able to find a provider, paradoxically, seems to 

occur with MA Private Fee-for-Service (PFFS) plans that were created, in part, to 

allow enrollees to access a wide range of providers. Although enrollees can seek care 

from any provider willing to accept the plan’s terms and conditions, providers who 

do not have a contract with the plan can decide whether to continue to accept the 

plan with each visit or treatment. In many cases, PFFS plan enrollees struggle to 

find providers willing to accept the plan’s terms and conditions. For example, the 

California Medical Association reports low participation by its members in PFFS 

plans, and expresses concern that PFFS plan networks are inadequate, particularly 

for specialty referrals.3

Example: Ms. P., an 86-year old dual eligible from Central California, was enrolled in a PFFS plan without her knowledge by an insurance agent who knew she 

was a dual eligible. She was scheduled to have surgery at a local hospital to treat 

breathing problems and difficulty swallowing food due to a growth in her throat, but 

the hospital refused to accept the PFFS plan she was enrolled in. 

Retiree Coverage 

In addition to individuals who give up a Medigap plan in order to enroll in a 

Medicare Advantage plan, and have difficulty getting their Medigap plan back, some 

beneficiaries who have pre-existing retiree coverage are often in danger of losing 

such coverage when they enroll in a Medicare Advantage plan that does not contract 

with their retiree plan. 

Example: Mr. S., a Northern Californian who is 86 years old, had Medicare, MediCal (Medicaid) and a retiree plan. After several calls from an insurance agent, Mr. 

S. gave in and allowed the agent into his home. Although the agent was aware that 

Mr. S. had retiree coverage, she pressured him to enroll in an MA PFFS plan anyway. As a result, he lost his retiree coverage. The local HICAP program is working 

to try to help him get his retiree plan back. 


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4See, e.g., ‘‘Medicare Trend Raises Eyebrows’’ by Ricardo Alonso-Zaldivar, Los Angeles Times, 

2/11/08. 5Testimony of David Fillman, AFSCME, before the Senate Finance Committee on 1/30/08, 

available at: http://finance.senate.gov/hearings/testimony/2008test/013008dftest.pdf. 6See, e.g. issue briefs written by California Health Advocates and the Medicare Rights Center 

entitled ‘‘After the Gold Rush: The Marketing of Medicare Advantage and Part D Plans’’ (January 2007) and ‘‘The Reluctant Regulator: Centers for Medicare and Medicaid Services’ Response 

to Marketing Misconduct by Medicare Advantage Plans’’ (July 2007); also see California Health 

Advocates’ testimony before this Subcommittee on May 22, 2007 and before the House Energy 

& Commerce Subcommittee on Oversight & Investigations on June 26, 2007. All of these documents are available at: http://www.cahealthadvocates.org/advocacy/index.html. 

In contrast with retiree plans that do not coordinate with Medicare Advantage, 

other employers are increasingly looking to push their retirees into Medicare Advantage plans, leading to access to care issues, as well as strains on the financial viability of the Medicare program for all beneficiaries, not just those in MA plans. There 

is a growing trend of State and local governments, organizations and corporations 

attempting to save money by shifting their healthcare costs to the Federal government and enrolling retirees in Medicare Advantage products, particularly Private 

Fee-for-Service (PFFS) plans.4 This trend exacerbates the strain on Medicare’s finances already imposed by Medicare Advantage overpayments. The same problems 

encountered by other PFFS enrollees also confront retirees. Although plan sponsors 

market PFFS products as ‘‘nationwide’’ because they are not required to use a network, David Fillman of AFSCME notes that this claim is ‘‘false’’; PFFS plans ‘‘limit 

access to care and choice because significant numbers of doctors and hospitals have 

refused to accept [the patients enrolled in these plans], especially out-of-state.’’ 5

Example: The Center for Medicare Advocacy reports recently hearing from a Michigan retiree who is now living in Orlando, Florida, and can’t find a doctor or hospital 

that is willing to accept the PFFS plan his former employer forced him into. He reports that his Blue Cross Blue Shield plan is working on the problem, but in the 

meantime he can’t go to a doctor or hospital. 

Marketing Misconduct 

Consumer advocates, State insurance regulators, Congress and the media have all 

focused attention on appalling abuses surrounding the sale of Medicare Advantage 

plans over the last two years that have resulted in substantial harm to the victims 

of such abuse and financial gain to insurance companies and agents.6 While much 

attention has been paid to these abuses, in our view, far too little action has been 

taken by CMS, which, under the MMA, retains the sole jurisdiction over almost all 

regulatory issues concerning MA plans. Unfortunately, SHIP programs across the 

country report that marketing misconduct continues unabated. 

We refer the Subcommittee to the resources cited above which address marketing 

misconduct surrounding the sale of MA plans, including incentives pushing such activity. The following, though, serves as a typical example of marketing misconduct, 

this one impacting a member of the HICAP family in California earlier this month. 

Although this example is lengthy, it is illustrative in that it includes a number of 

the common lies, deceptions and distortions that agents still widely use to con people into joining Medicare Advantage plans. 

Example: Ms. T., a dual eligible with limited English proficiency living in California’s Central Valley, received a call from an insurance agent claiming to be from the 

‘‘health department’’ and said she wanted to come by and ‘‘check up’’ on her. Ms. T. 

asked her daughter, who works for a local HICAP program, to be present when the 

agent visited her home in early February 2008. The agent arrived wearing a badge 

that appeared very similar to a Medicare card, with the agent’s name handwritten 

on it, and declared that she was ‘‘from Medicare.’’ The agent lied that she was not 

an agent, and was not there to sell anything, but simply wanted to go over Medicare 

issues. The agent explained that Ms. T. has Medicare Parts A, B, and D, so now she 

needed to enroll in Part C. She stated that Part C ‘‘works with Medicare together’’ 

and she would have no copays. She stated that when ‘‘you go to the doctor, you show 

your Medicare and Medi-Cal card, but when you go to a doctor that doesn’t accept 

Medi-Cal, you would show your Medicare Advantage card—all 3 cards work together.’’ She added that ‘‘you do know that Medicare and Medi-Cal won’t cover nursing homes, so you need to enroll in Part C right away—you shouldn’t be long, you 

shouldn’t be without coverage.’’ When the agent pulled out an MA application, Ms. 

T’s daughter declined, but asked the agent to leave information. The agent refused 

to leave marketing material, stating that she only had one copy, but left her business 

card, indicating that she was indeed a broker selling MA products. Since Ms. T.’s 

daughter works for a local HICAP, she realized that just about everything said by 

the agent was a lie or deception at best, and prevented her mother’s enrollment in 


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7See a recent issue brief on this topic written by California Health Advocates entitled ‘‘There’s 

a Hole in the Bucket: New ‘‘Gap’’ Product Being Sold to Fill-in Medicare Advantage Deficiencies’’ 

(November 2007), available at: http://www.cahealthadvocates.org/advocacy/2007/11.html. 

this plan. The vast majority of Medicare beneficiaries do not have such accessible 

help when targeted by unscrupulous agents. 

Despite the claims of the insurance industry, this is not a matter of ‘‘rogue 

agents’’ or a ‘‘few bad apples’’—we are convinced that the payment incentives to 

plans, and, in turn, the commissions and bonuses paid to agents, drive this type of 

abuse. While states retain jurisdiction over agents selling Medicare plans, they lack 

authority to punish the plans for a range of misbehavior, including actions performed by agents selling their products. While a few MA plans have received nominal fines, enrollment suspensions and other more severe punitive measures are 

rarely meted out by CMS. As discussed below, in our experience, the most severe 

and prevalent marketing abuses continue to concern the sale of Private Fee-forService plans to dual eligibles. 

III. MEDICARE ADVANTAGE ‘‘GAP’’ PRODUCTS 

The insurance industry and CMS insist that Medicare Advantage products are a 

good value for all beneficiaries, in terms of ‘‘extra’’ benefits offered and out-of-pocket 

savings when compared with the Original Medicare program. Despite these assurances, however, significant fissures in MA plans have led to the emergence of a new 

insurance product aimed at ‘‘filling’’ those gaps. This product, sometimes called ‘‘Advantage Plus’’, is being marketed by plan sponsors to insurance agents as a ‘‘wraparound plan’’ that is ‘‘designed to fill in the gaps in Medicare Advantage Plans.’’ 7

These limited-benefit plans bundle a collection of insurance products, such as hospital indemnity plans and other piecemeal coverage, and pay cash benefits directly 

to enrollees of MA plans to cover out-of-pocket costs imposed by their MA plan. They 

are designed specifically to address high out-of-pocket expenses charged by many 

MA plans for vital services such as inpatient hospital care, skilled nursing facility 

stays, durable medical equipment and cancer/chemotherapy drugs covered under 

Medicare Part B. 

Companies offering these products encourage insurance agents to sell these ‘‘gap’’ 

plans alongside Medicare Advantage products. For example, one flyer directed towards agents boasts: ‘‘If selling Medicare Advantage Plans, be sure to check out our 

Wrap Around product section. Easily add an additional 50% in commissions to each 

Medicare Advantage Sale. Plan can be sold all year long!’’ Anecdotally, we have 

heard of agents encouraging MA enrollees who get a Part B premium rebate 

through their plan to apply those savings towards purchasing one of these gap products. 

The sale and promotion of these products exacerbates the confusion in the Medicare marketplace generated by enormous numbers of MA and Part D plans with 

multiple and complex plan designs. Further, we believe that the existence of these 

plans is a symptom of a more widespread disease afflicting the Medicare Advantage 

program, and underscores how far too many MA plans impose high cost-sharing 

while providing inadequate benefits. Part of the promise of allowing private insurance companies to offer plans within the Medicare program was that they could provide better benefits, more efficiently, for less money to both beneficiaries and the 

Medicare program. These gap products, though, that are sold to fill in gaps in coverage that MA plans are failing to fill themselves, starkly highlight the failures of 

the MA program to achieve these goals. 

IV. DUAL ELIGIBLES and MEDICARE ADVANTAGE PLANS 

Individuals who are dually eligible for Medicare and Medicaid are entitled to a 

broad range of benefits provided by both programs. This population, many of whom 

have significant and complex health needs and generally a lower level of health literacy, rely on overlapping coverage and payment through the Original Medicare 

program as primary payer and Medicaid as additional coverage. Many MA plans 

find dual eligibles to be attractive targets due to their right to enroll in and 

disenroll from plans on a monthly basis, allowing plans to ‘‘poach’’ enrollees from 

one another, and also because capitated payments to plans are generally higher for 

dual eligibles. 

Enrollment into a Medicare Advantage plan, though, can create problems for dual 

eligibles not encountered in the Original Medicare program, such as access to care 

(due to problems accessing providers and utilization management techniques) and 

greater out-of-pocket expenses. The issue of whether a State Medicaid program is 

obligated to pay the Medicare cost-sharing for dual eligibles enrolled in MA plans 

is a complicated one, and includes factors such as a ‘‘dual eligible’s coverage catVerDate Nov 24 2008 14:19 Dec 10, 2010 Jkt 046954 PO 00000 Frm 00128 Fmt 6633 Sfmt 6621 I:\WAYS\OUT\46954.XXX GPO1 PsN: 46954

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8 June 11, 2007 Memorandum from CMS, Center for Medicaid and State Operations, Disabled 

and Elderly Health Programs Group to All Associate Regional Administrators, Division of Medicaid and Children’s Health re: Medicaid Obligations for Cost-Sharing in Medicare Part C Plans; 

also see Center for Medicare Advocacy’s May 31, 2007 Weekly Alert entitled ‘‘Medicare CostSharing in Medicare Advantage Plans: Who Pays for Dual Eligibles?’’ at: http:// 

www.medicareadvocacy.org/AlertPDFs/2007/07l05.31.MAMcaidCostShare.pdf. 9 Alissa E. Halperin, Managing Attorney, Pennsylvania Health Law Project, author of a paper 

for the Center for Medicare Advocacy entitled ‘‘Medicare Advantage Special Needs Plans: A Beneficiary Perspective’’ (October 2007); also see, generally, Center for Medicare Advocacy’s Special 

Needs Plan Conference materials (October 2007), available at: http://www.medicareadvocacy.org/ 

SNP%20Conference/Home.htm. 10See, e.g., CHA’s prior testimony before this Subcommittee on May 22, 2007 re: PFFS 

plans, available at: http://www.cahealthadvocates.org/advocacy/2007/CHAlWaysMeansl testimonyl0522.html. 

egory, the type of cost-sharing, the options elected by the State, and payment limitations specified in the State Plan.’’ 8 In short, practically speaking, it appears that 

many States do not pay MA cost-sharing for duals in their State, and, as a result, 

dual eligibles are often charged these amounts. In addition to MA cost-sharing, 

some duals have to pay premiums for MA plans for coverage that is no different 

and sometimes worse than under Medicaid. 

Certain MA plans—Special Needs Plans (SNPs), are—in theory—designed to address the needs of dual eligibles, although it questionable how well many SNPs perform in this regard. Other MA plans, notably Private Fee-for-Service (PFFS) plans, 

are generally ill-suited to address the complex needs of dual eligibles, and often 

cause significant harm to this vulnerable population. 

Special Needs Plans (SNPs) 

The Medicare Modernization Act (MMA) authorized Medicare Advantage Special 

Needs Plans (SNPs) that can be designed to provide coverage for certain designated 

populations: dual eligibles; individuals who are institutionalized; and individuals 

with chronic and disabling conditions. Since 2006, enrollment in SNPs has increased 

exponentially, however many dual eligibles—most of whom did not seek out a SNP 

on their own but were automatically enrolled into one—have experienced significant 

problems with accessing care and coordinating coverage and payment with State 

Medicaid programs. 

While SNPs present the opportunity for better care coordination, integration and 

targeted care management, there are no formal requirements set out in law, regulation or CMS guidance that SNPs actually deliver these goals. In the words of one 

advocate with significant experience assisting dual eligible clients who encounter 

problems with their SNPs, ‘‘absent minimum standards for meeting the special 

needs of the populations they serve, labeling these plans as specially designed to 

do so is misleading.’’ 9

Private Fee-for-Service (PFFS) Plans 

While SNPs are designed to address the needs of dual eligibles (at least in theory), other Medicare Advantage plans enroll dual eligibles and even seek them out, 

even though enrollment in many plans appears to offer little tangible benefit, if any, 

and often leads to significant problems. Over the last two years, we continue to see 

a disturbing trend of PFFS plan sponsors and their contracting agents marketing 

PFFS plans to dual eligibles. In many cases, dual eligibles have been left worse off 

due to access to care issues (including loss of access to providers) and increased outof-pocket costs.10

In our experience, some of the worst and most widespread marketing violations 

have involved dual eligibles who are sold PFFS plans. Information about the suitability of MA plans for dual eligibles, including meaningful comparisons with Medicaid benefits already available to them, is not made available by the plans or is 

misleading, and, at best, glossed over during sales pitches. 

Example: Mr. C., age 74, is a California dual eligible who is very ill and dependent on oxygen. He was visited by an insurance agent recently who pushed him to enroll in an MA PFFS plan. The agent touted it as a plan ‘‘just for people on MediCal.’’ As a result of his enrollment, Mr. C. is now being billed for services he did 

not previously have to pay for, including about $4,000 from a durable medical equipment provider who was not paid by the plan. The local HICAP is assisting him with 

his enrollment and billing issues. 

Dual eligibles are being targeted and convinced to enroll in PFFS plans based 

upon ‘‘extra’’ benefits that agents and plans say will save them money. Duals are 

often enticed by $20 over the counter benefits, and ‘‘extra’’ hearing, vision and dental coverage, without regard to individual states’ actual Medicaid benefits that they 

might already be entitled to. 


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11Testimony of Francis S. Soistman, Jr., Executive Vice President, Coventry Health Care, 

Inc., before House Energy & Commerce Subcommittee on Oversight & Investigations, June 

2007, available at: http://energycommerce.house.gov/cmtelmtgs/110-oi-hrg.062607.Soistman-testimony.pdf. 12Testimony of Abby Block, Director of Division of Beneficiary Choices, CMS, May 22nd, 2007. 13See, e.g., documents cited in footnotes 1 and 6, infra, as well as CHA’s testimony before 

the National Association of Insurance Commissioners (NAIC) Senior Issues Task Force—Medicare Private Plans Subgroup, Public Hearing on Regulation of Medicare Private Plans (September 11, 2007), available on the NAIC website. 

Once enrolled, however, duals often find that their doctors won’t take their PFFS 

plan. If their primary doctor does take the plan many still find that they are 

charged for doctors’ visit copays, wheelchairs, walkers and other services and items 

they did not previously have to pay for. A large portion of duals encounter difficulty 

finding specialists who will agree to accept their plan. When HICAP programs try 

to help dual eligibles get out of plans that are not appropriate for them and untangle resulting complex billing issues, some beneficiaries are subject to harassing calls 

from agents upset that they are losing out on their commissions. 

At least one PFFS plan sponsor acknowledges that this plan type is not appropriate for dual eligibles. During a Congressional hearing wherein his company was 

criticized for the conduct of an agent selling his PFFS plan to dual eligibles, Coventry Vice President Francis Soistman admitted that’’ . . . PFFS plans may not be 

suitable for dual eligibles.’’ 11

Other plans, however, hold themselves out as specially catering to duals—notably 

WellCare Duet PFFS plans. When asked about the appropriateness of PFFS plans 

targeting dual eligibles for enrollment, a CMS official replied at a hearing before 

this Subcommittee that Medicare Advantage ‘‘is a market-based program and dualeligibles, like everyone else, have the option of choosing how they wish to obtain 

services and where they wish to be enrolled.’’ 12

V. RECOMMENDATIONS 

California Health Advocates, as well as a number of other beneficiary advocacy 

groups, has offered several recommendations for curing some of the current problems faced by Medicare Advantage enrollees.13 We recognize—and appreciate—that 

the Children’s Health and Medicare Protection (CHAMP) Act of 2007, passed by the 

House last August, addressed a number of these issues, and we are disappointed 

that it did not become law. Our recommendations range from broad changes to the 

structure and financing of Medicare Advantage, to specific proposals that can be implemented by CMS as the Federal regulator of these plans. In short, these recommendations include: 

• Create standard benefit packages for Medicare Advantage and Part D plans, including: 

• Establish no more than two annual limits for out-of-pocket costs • Prohibit separate cost-sharing for individual Part B services • Require that MA plans charge no more cost-sharing for services than what 

is charged under Original Medicare • Limit the number of plans offered in a given geographic area 

• Apply the standardization and simplification requirements of the National Association of Insurance Regulators (NAIC) Medigap Model Act and Regulation to 

all Medicare Advantage (and Part D) plans 

• These requirements should include loss ratio standards, guaranteed renewability requirements, suitability requirements and other consumer protections • Rescind the statutory preemption that prevents states from enforcing State 

laws on consumer protections and the marketing of insurance products • Neutralize payment between Original Medicare and the MA program (see, 

e.g., recommendations from MedPAC) and use the current excess payments 

to strengthen access to benefits in other areas of Medicare, such as expanding 

eligibility for the Medicare Savings Programs and the Part D Low-Income 

Subsidy • Ban the sale of PFFS and other MA products to dual eligibles unless plans 

can prove they offer meaningfully better and more comprehensive benefits 

than those available through State Medicaid programs, and that enrollees 

will not face diminished access to providers and/or new out-of-pocket expenses 

• Authorize NAIC to develop nationwide marketing guidelines, including: 

• Provisions that hold plans more accountable for the actions of agents selling 

their plan 


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• Prohibit plans from offering differential commissions based on what type of 

plan is selected by the enrollee 

• Prohibit agents from selling unrelated products 

• Develop more comprehensive disclosure documents with clear explanations 

about how certain choices can impact access to providers and other types of 

insurance coverage (e.g., retiree, Medigap, Medicaid) 

• Exclude plan sponsors culpable of egregious marketing and other violations 

from participating in the Medicare program for at least two years (similar to 

rules that apply to certain providers) 

VI. CONCLUSION 

While some Medicare Advantage plans do provide value for enrollees, we need to 

question the value provided by all MA plans—considering the sheer number of 

plans, variation in benefits and cost-sharing and the fact that the majority of Medicare beneficiaries in the Original Medicare program are subsidizing the extra payments meant to enrich the minority of beneficiaries enrolled in MA plans. Medicare 

Advantage is not the panacea for perceived shortcomings of Original Medicare, and, 

in many cases, can be to the detriment of enrollees, particularly the most vulnerable 

among us. At a time when MA plans are overpaid but many are providing inadequate coverage, Congress should carefully scrutinize the MA program that threatens the stability and integrity of the entire Medicare program. 

Thank you for the opportunity to provide these comments. 

f 

Chairman STARK. Thank you very much. 

Dr. Lyons? 

STATEMENT OF DANIEL C. LYONS, M.D., SENIOR VICE PRESIDENT, GOVERNMENT PROGRAMS, INDEPENDENCE BLUE 

CROSS, PHILADELPHIA, PENNSYLVANIA 

Dr. LYONS. Thank you, Mr. Chairman, Ranking Member Camp, 

and members of the committee. My name is Daniel Lyons, M.D., 

and I am senior vice president of government programs for Independence Blue Cross, and I do appreciate the opportunity to testify 

about the Medicare Advantage program. 

Independence Blue Cross is strongly committed to the long-term 

success of the Medicare Advantage program. We are proud to sponsor plans that offer many services and innovations that are not included in the Medicare fee-for-service program. Approximately 

240,000 Medicare beneficiaries in Philadelphia and southeastern 

Pennsylvania are enrolled in the plans we offer. 

Our Medicare Advantage plans serve a critical role in providing 

comprehensive, coordinated benefits for many seniors and disabled 

Americans. The fundamental difference between Medicare Advantage plans and the Medicare fee-for-service program is that our private plans have established an infrastructure for improving healthcare quality on an ongoing basis. 

At Independence Blue Cross, our plans focus on identifying members with important clinical needs, including those not receiving 

preventive care, those who are frail, and those with chronic illness. 

Because Medicare Advantage plans do have an infrastructure to coordinate and improve the care for these members, we have a proven track record of making a positive difference in the lives of Medicare beneficiaries. 

Many Medicare beneficiaries do suffer from multiple chronic conditions such as diabetes, heart disease, cancer, asthma, depression. 


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One recent study suggested that over 80 percent of beneficiaries 

have at least one of these chronic conditions. 

Medicare Advantage plans are playing a leadership role in developing strategies and programs to improve patient care for beneficiaries with multiple chronic conditions. We are focused not only 

on ensuring that patients with chronic conditions live longer, but 

we are also helping them live healthier lives with fewer symptoms 

so they can fully participate in the activities they enjoy. 

Our Medicare Advantage members benefit from a variety of programs we have developed over the years to improve their care, including the promotion of prevention and wellness. For example, our 

Connections Health Management program is designed to help our 

Medicare Advantage members by making them more informed 

about their health conditions, assisting them in making difficult 

treatment decisions, helping them and their physicians improve the 

management of chronic conditions, and assisting members, their 

physicians, and their caregivers with the coordination of care. 

Through this program, we use sophisticated predictive modeling 

tools to identify those members who are at highest risk for future 

health events, and identify specific gaps in care and to fill those 

gaps. Specially trained health coaches, typically RNs, are available 

24/7/365. They do telephonic outreach to these members to address 

their care gaps, help them understand their physician’s treatment 

plan, and improve self-management of their chronic conditions. 

The results of this program are very impressive. In 2007, our 

member satisfaction survey showed that 94 percent of members 

were satisfied with their health coach assistance, 90 percent were 

satisfied with their overall program experience, and 94 percent said 

they would recommend the program to other seniors. 

Moreover, 97 percent of members with chronic conditions indicated they were able to follow their health coach’s advice, nearly 

80 percent reported an improved ability to communicate with their 

physician, and nearly 60 percent said that speaking with a health 

coach actually improved the quality of care they received from their 

healthcare provider. 

Medicare Advantage members have also enthusiastically embraced our wellness programs. More than 9,000 seniors are enrolled in fitness programs we have designed to encourage and promote healthy, active lifestyles. Almost 60 percent of these seniors 

complete the program target of 120 visits a year, which is twice the 

rate of non-Medicare members. 

Another problem we implemented for Medicare Advantage members is our physician home visit program. Under this program, a 

physician conducts a proactive home visit to assess members who 

are homebound and then provides follow-up care as needed, and 

also coordinates care with the member’s primary care and specialty 

physicians. This program is designed to improve the control of 

chronic illnesses and reduce the use of emergency services for 

medically frail members. 

We also work on an ongoing basis to provide Medicare Advantage 

members with access to care coordination throughout their healthcare experience. For example, when a member is scheduled for an 

elective admission such as a total knee replacement, we reach out, 

identify their anticipated post-hospital needs, coordinate with their 


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surgeon, begin to make arrangements for post-hospital care such as 

rehabilitation, long before the member ever goes to the hospital. 

This sort of care coordination, like our wellness disease management programs, are not currently available in traditional Medicare, 

and not readily created without considerable planning and investment. In fact, when you consider the array of health infrastructure 

investments and improvements we have implemented over the past 

decade—credentialing a system of quality checks on physicians and 

providers that includes checks on medical records and office adequacy, physician performance monitoring and quality incentives, 

coverage and promotion of preventive medicine, fitness, smoking 

cessation, weight management and related programs, health education, nurse counseling, disease condition management, medication and therapy management, case management, home visits, et 

cetera—you can begin to understand the extent of the planning and 

investment required to bring these kinds of advancements to the 

entire Medicare program. 

Thank you for this opportunity to testify on the Medicare Advantage program. We appreciate the opportunity, and urge the committee to continue to support adequate funding for the system of 

competition, choice, and innovation that is delivering savings and 

value to nearly nine million Medicare Advantage members. 

[The statement of Daniel C. Lyons follows:] 


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f 

Chairman STARK. Thank you. 

Dr. Lyons, were you guys in business in 1997? 

Dr. LYONS. Yes, sir. 

Chairman STARK. You were offering those same services to your 

members in 1997? 

Dr. LYONS. Some. Not all. 


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Chairman STARK. But you offered them? You offered the same 

kind of a program that you just outlined? 

Dr. LYONS. We did not have our comprehensive Connections 

program at that time, Mr. Chairman. No. 

Chairman STARK. How about in 2003? 

Dr. LYONS. It was not as robust as it is today, no. 

Chairman STARK. All right. Let me just run down the line. And 

I know you don’t like to cheer for your competitors, but—and they 

are not really your competitors—but Pilgrim in Boston, Puget 

Sound in Seattle, Kaiser in California, Ford in Michigan, 

Marshfield Clinic in Wisconsin, would you say they are all similar 

to the kind of a plan you just outlined? 

Dr. LYONS. I think they do. They are well-known for their quality, sir. 

Chairman STARK. No. But they have the same general disease 

management and all of these things that—— 

Dr. LYONS. Many of them do. NCQA now certifies these kinds 

of programs and organizations. We all submit data to them. 

Chairman STARK. And they were all chugging along in 1997, fat 

and happy at 95 percent of the AAPCC. And many of them, I am 

aware, operate at less than 100 percent of AAPCC. Why should we 

pay them any more? 

Dr. LYONS. The investments that have been made in systems 

that aren’t tied to delivery systems, systems that are more open or 

substantially more, it is much harder, actually, to engage physicians who aren’t on your payroll, who actually aren’t part of your 

delivery—— 

Chairman STARK. Well, not all of these guys have docs on their 

payroll. Kaiser does; it is a staff model. But not all of them do. 

Many of them operate as managed care plans, and they—well, I 

have trouble. 

Are you familiar with what is referred to as boutique medicine, 

as provided generally by primary care docs? 

Dr. LYONS. Is that where physicians opt out of the Medicare 

system and take—— 

Chairman STARK. Or if they are not in the Medicare system, 

they charge you maybe 1500 bucks and you get 24/7. You get their 

home phone and—— 

Dr. LYONS. You know, that sort of arose a few years ago. I 

haven’t heard a lot of it recently. 

Chairman STARK. Well, it could be done. When I go into Medicare, it will cost you taxpayers nine, ten grand a year. And so for 

15 percent over, I could get a boutique and have a full-time—you 

know, just like the President or somebody else, or a movie star, 

have a full-time physician, basically. And I think that is great. 

I just guess I have trouble figuring out why we would pay for it. 

And I would ask Dr. Thames. United Health Care basically is the 

insurer with whom you contract. Is that correct? 

Dr. THAMES. Yes, sir. 

Chairman STARK. And they sell a Medicare Advantage—they 

provide you the Medicare Advantage policy, and you put your name 

on it. And if I buy a membership, I can get it through you, but it 

is basically operated by United Health Care. Is that—— 


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Dr. THAMES. You get it directly from them. We don’t sell any 

policy. 

Chairman STARK. And they don’t offer the private fee-for-service 

plan, do they? 

Dr. THAMES. That is absolutely correct, sir. It is against our 

policy to support private fee-for-service plans. 

Chairman STARK. And I think that I recall in this conversation 

some time back that Mr. Novelli, your chief executive officer, said 

to me—and I don’t think I am quoting him out of context or incorrectly; if I am, you should let me know and I will set the record 

straight—but that he felt that they should provide these plans at 

no more than 100 percent of fee-for-service costs. 

Dr. THAMES. That is correct, Mr. Chairman. 

Chairman STARK. So I think you are to be commended for that, 

and I am sure that—is Independence Blue Cross going private? Are 

you going to become for-profit? 

Dr. LYONS. No, sir. 

Chairman STARK. No? 

Dr. LYONS. No. We are merging with Highmark Blue Cross. 

Chairman STARK. And are they not-for-profit? 

Dr. LYONS. They are also a hospital charter organization, just 

like we are. 

Chairman STARK. You are going to stay nonprofit? 

Dr. LYONS. Yes, sir. 

Chairman STARK. Good for you. 

Mr. Mattes, in your hospital, how many physicians have privileges there? 

Mr. MATTES. We have 43 on our active medical staff. 

Chairman STARK. Have you got a lot more in the community 

than that? 

Mr. MATTES. No. That is the entire county. 

Chairman STARK. That is kind of interesting. You have got 43 

doctors and 21 plans. 

Mr. MATTES. And only 25 beds in the entire county. 

Chairman STARK. Do you need one plan for every two doctors? 

Mr. MATTES. Well, I was thinking the same thing. Actually, we 

believe there will be more plans. We are aware of some that are 

being sold in addition to the 21 that have actually hit our door. 

Chairman STARK. As I say, does it really offer a lot more choice 

in your what we will refer to as a rural community without demeaning you, I am sure—— 

Mr. MATTES. Well, there is choice in plans but not choice in providers, in reality, because we live in an isolated part of the State 

where they have to travel over a mountain pass. 

Chairman STARK. I understand that. Does every plan let you 

have every doctor? 

Mr. MATTES. Yes. 

Chairman STARK. So if I signed up with any one of the 21 

plans, I wouldn’t be denied the opportunity to see any one of the 

43 doctors? 

Mr. MATTES. Well, I will take that back. One of our plans is a 

PPO plan. So that one has to have members signed up for—participating members in the plan. And I don’t know whether all of them 

are signed up for that one or not. 


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Chairman STARK. I guess I wanted to ask Mr. Lipschutz, in 

California I know that we have attempted over time to deal with 

marketing. And I don’t know what the restrictions on these types 

of policies—I don’t know what you would call them, like AFLAC, 

where you get sick, you get 50 bucks a day. And those are the types 

of plans you are referring to that are sold under the guise of being 

Medigap. Is that—— 

Mr. LIPSCHUTZ. These Medicare Advantage gap plans that we 

learned about are essentially limited benefit plans that are bundled 

together, such as hospital indemnity plans, plans that will pay 

out—— 

Chairman STARK. But just help me here a minute. They don’t 

offer anything but a fixed amount per day, regardless of what triggers it. Otherwise, it would seem to me they would come under the 

Medigap rules. 

Mr. LIPSCHUTZ. Correct. It is our understanding that the current anti-duplication provisions in Federal law apparently allow 

the sale of these types of products—— 

Chairman STARK. Because all they offer is so many dollars a 

day? 

Mr. LIPSCHUTZ. Pay a cash benefit, yes. 

Chairman STARK. Pardon? 

Mr. LIPSCHUTZ. They pay out a cash benefit when people incur 

expenses. 

Chairman STARK. That is it. And then you can then spend the 

money any way you want. They don’t send it right to the doctor or 

the hospital; they just send you a check for X bucks a day. 

Mr. LIPSCHUTZ. Correct. 

Chairman STARK. But I think what your testimony was saying, 

they are thinly disguised or suggested in the marketing approach 

that they are Medigap, as people remember buying it from AARP 

or Blue Cross or whomever. Is that a fair assessment? 

Mr. LIPSCHUTZ. Based on what we have found in advertising, 

it looks like to beneficiaries it is pitched as just limited benefit 

plans that will pay out cash benefits when you need services. But 

to agents selling the plans, it is clearly pitched as a plan meant to 

fill in the gaps of Medicare Advantage and meant to be sold along 

with Medicare Advantage plans in order to fill in those gaps. 

Chairman STARK. You are familiar with the California Insurance Commissioner’s office? 

Mr. LIPSCHUTZ. Yes. 

Chairman STARK. And you have been doing what you have been 

doing under both Republican and Democratic administrations, 

when John Garamendi was insurance commissioner? I don’t know 

who it is now, but—— 

Mr. LIPSCHUTZ. Steve Poizner. 

Chairman STARK [continuing]. Do you find them to be pretty 

even-handed, pretty effective, pretty good at governing insurance 

agents and practices? 

Mr. LIPSCHUTZ. As far as we can tell, yes. However, in the 

Medicare Advantage context—— 

Chairman STARK. Keep going. 

Mr. LIPSCHUTZ. All right. I was going to say—— 


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Chairman STARK. Let me ask the question. It sounded like—I 

have figured it out. But you go ahead. I know what you are—go 

ahead. 

Mr. LIPSCHUTZ. Thank you. In the Medicare Advantage context, the jurisdiction of State departments of insurance is, by and 

large, limited to the regulation of insurance agents selling Medicare Advantage products, and the individual State departments of 

insurance have very little jurisdiction over the actual Medicare Advantage plans themselves and Part D plans. 

Chairman STARK. Let me say it another way because Mr. Pomeroy would say the same thing and I think it is an important distinction here. CMS can regulate the plans, and CMS federally can 

fine Dr. Lyons’ plan or United Health. But CMS can’t—if Dr. Lyons 

company were to employ a broker, an independent agent—I don’t 

know. Do you do that? I would presume—— 

Dr. LYONS. No. We have our own staff. 

Chairman STARK. You sell all direct? 

Dr. LYONS. Our employees—— 

Chairman STARK. You don’t allow insurance brokers to sell? 

Dr. LYONS. Yes. Within our market area, we only have our own 

staff. 

Chairman STARK. Other Blues do, though. Other Blues allow 

brokers. And what I am trying to get at is the Federal Government 

has not ability—they can punish Dr. Lyons’ plan, but they can’t 

punish or regulate the individual independent brokers or agents. 

And it is often the plans who have great intentions, but then 

they pay a commission to any sales person operating under State 

licensure who are very aggressive, probably good at what they do, 

but sometimes they may cut a few corners on explaining benefits 

and selling in the best interests of the consumer. 

And I just wanted to see if you would agree that that would help 

us in California if somehow we could let the State commissioners 

who—at least in California, I think, and I am sure in Pennsylvania 

they do as well—regulate sales practices. And would that—it 

couldn’t affect your plan. Correct? I mean, because you do it directly anyway. 

Would it affect your plan, Dr. Thames, if the States in which you 

operate—— 

Dr. THAMES. Mr. Chairman, it could affect it in Florida. On the 

other hand, we don’t allow all agents of United to sell AARP products. We have special requirements of the agents that sell those 

products. They are required to do outbound follow-up calls after 

sales—— 

Chairman STARK. Would it trouble you if the various State insurance commissioners were—— 

Dr. THAMES. No, sir. It would not trouble us at all. 

Chairman STARK. I guess that is the point I was trying to get 

at—— 

Dr. THAMES. Yes, sir. 

Chairman STARK [continuing]. Is that the companies can have 

the best intentions but can’t often control the independent agents, 

certainly as you do. And that might be an advantage. 

Thank you for your testimony. Mr. Camp, would you like to inquire? 


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Mr. CAMP. Yes. Thank you. I would agree that Mr. Pomeroy has 

a good point, and I spoke to him informally after he made his comments. 

Dr. Lyons, you were beginning to sort of talk about the costs of 

engaging doctors not on your payroll. Could you just elaborate on 

that a little bit? I don’t know that we got the complete thought 

there. 

*Dr. Lyons. Thank you, sir. In order to set up systems of care, 

particularly systems that monitor quality of care and promote continuity of care, you either have to, A, have physicians who are 

aligned in a system because of contract economic incentives, or B, 

you have to put an infrastructure in yourself. And we have done 

the latter, and that is what many plans have done over the past 

five to six years, put in extensive infrastructures of quality management and care improvement, to act as sort of an overlay to the 

system to promote quality. 

And if I may just briefly continue, there is no question that there 

is good evidence that this does work. We see sequential and statistically significant improvements across a wide variety of care outcomes. There is very limited opportunity to compare our care outcomes with fee-for-service, but when those comparisons have been 

made, for example in the well-cited study by Stephen Jencks in 

2003. There was no question that Medicare Advantage plans in 

general produced better clinical outcomes than were extant in the 

fee-for-service system. 

Mr. CAMP. All right. Thank you. 

Mr. Mattes, you mentioned, I guess in response Mr. Stark’s inquiry, that because there are 21 plans and they cover all your doctors, that they don’t really negotiate much in terms of discounts. 

Yet in your testimony, you said Medicare Advantage carriers will 

use market leverage to force discounts in payment rates. And then 

you go on to say that those are provided to beneficiaries, but that 

hurts small hospitals such as yours. 

But clearly, are they negotiating discounts and leveraging or are 

they not? 

Mr. MATTES. Representative Camp, the comments in my testimony were prospective. We are not negotiating with any of those 

plans other than we have one PPO contract. However, it is my understanding that fee-for-service plans can, when they aggregate 

enough volume, initiate negotiations with providers. And our fear 

is that they will attempt to leverage us in those negotiations. 

Mr. CAMP. So you are concerned that this is in the future. If 

this plan is allowed to continue, they will actually negotiate discounts for their beneficiaries in some fashion. 

Dr. Lyons, can you briefly also explain in a little more detail 

some of the benefits your plan offers that traditional Medicare does 

not, and efforts in terms of coordinating care and wellness? If you 

could just comment on those, I would appreciate it. 

Dr. LYONS. Yes. You are welcome, sir. I would sort of put them 

in three categories. At the front end are prevention and wellness 

services that are not provided to fee-for-service beneficiaries. This 

would be coverage for services that are needed to prevent disease, 

reminders and promotion of those services, and then a fairly broad 

array now of what we would call lifestyle modification programs— 


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smoking cessation, fitness. Probably our most popular benefit is our 

fitness program, free gym membership to seniors; and of course, 

obesity and weight management, currently the biggest epidemic. 

And in the middle is a series of programs that are largely educational in nature, a fairly broad base. But they also allow members who do have specific conditions—we currently have developed 

clinical modules for 21 clinical conditions that actually have very 

intensive education and coaching, more serious events such as 

prostate cancer, breast cancer, and so forth and so on. 

And at the third level, for folks who are actually engaged in a 

chronic illness and are significantly ill or disabled, we have much 

more extensive problems with extensive literature, one-on-one 

coaching, and so forth. 

So that is kind of at the core. More recently, as we have tried 

to work with our delivery system and fill in the holes and gaps that 

we see, particularly around frail, elderly care are our homebound 

physician program. 

Mr. CAMP. Thank you. And I don’t mean to interrupt, but I am 

running out of time. But this comprehensive approach, is that successful in keeping patients healthy and out of the hospital? And if 

so, has that reduced cost? 

Dr. LYONS. Yes. Both. It both improves clinical outcomes—we 

measure them regularly, we report them regularly, and we do have 

data that shows that there have been statistically significant reductions in both in- and outpatient care for the managed population 

compared to the non-managed population in each of the three and 

a half years since we launched our robust programs. 

Mr. CAMP. And is traditional Medicare capable of offering programs like that? 

Dr. LYONS. No. I don’t see how the program could. I am privileged to serve on the Advisory Panel for Medicare Education, and 

I actually have chaired the panel the past two years. So I have a 

wonderful window seat to see all of the wonderful innovations that 

the fee-for-service program is bringing. But to get to that level 

would take substantially more investment, time, and a different 

approach. 

Mr. CAMP. All right. Thank you. Thank you, Mr. Chairman. 

Chairman STARK. Ms. Schwartz, would you like to inquire? 

Ms. SCHWARTZ. Thank you, Mr. Chairman. I appreciate it. And 

I thank all of the panelists. And I did want to start with, I guess, 

my own home-grown—not a constituent, I don’t think, necessarily, 

Dr. Lyons, but—— 

Dr. LYONS. Almost. I am just over the line. 

Ms. SCHWARTZ [continuing]. But I certainly wanted to talk 

about some of the things that you have talked about, and hopefully 

be able to talk a bit more about some of the private fee-for-service 

plans, which I know you are not talking about. 

But I was interested in the fact that—I wonder if you could give 

us more information about some of the successes. I mean, you really talked—and many of us here, the only real statistics we end up 

hearing about the success of more managed programs and more 

prevention are really patient satisfaction, which is a piece. 

That is fine. But really, I think one of the things we ought to be 

really concerned about is actually have we really improved outVerDate Nov 24 2008 14:19 Dec 10, 2010 Jkt 046954 PO 00000 Frm 00152 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\46954.XXX GPO1 PsN: 46954

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comes? Are people—their health status improved, actually? And are 

we doing it in a more cost-efficient way? That would be helpful to 

know. Do you actually have hard data on that and—well, why don’t 

you answer that first. And then I wanted to know how much more 

it costs. 

Dr. LYONS. Yes. Yes, ma’am, we do. We have data about all 

three of those arenas. So when it comes to—do the systems we use 

to promote prevention, do they work? And I would say the two 

major pieces of that are we actually measure and monitor and reward primary care physicians for superior performance in preventive care. So that would be programmatically what we do, number 

one. 

And then number two, we have extensive outreach campaigns 

with members to promote the use. And we use a scientific survey. 

We report the data publicly. And there has been significant improvement from the times that we started the programs. 

Also, if we do plateau, we gather clinicians and just, as an example, some years ago it was very clear that there just wasn’t enough 

interest in the radiology community to provide basic mammography 

any longer. It just wasn’t something they were—so we brought 

them together, brainstormed, and improved some access issues. 

And so, yes, we can show you how that over time—— 

Ms. SCHWARTZ. I would be interested to see some of that hard 

data because otherwise really it’s so much—you are not required, 

though, to give that to CMS or to the government? 

Dr. LYONS. Well, actually, yes. We do report all of our clinical 

outcome studies via NCQA to CMS, and also via annual—including 

utilization data. I know that came up earlier. But we do provide 

utilization. 

Ms. SCHWARTZ. There is a lot of utilization data we don’t actually get. But again, utilization is different than outcomes. And that 

is something that we are really interested in. 

Can you tell us how much more you get paid under the Medicare 

Advantage? 

Dr. LYONS. Well, I am not an actuary, Congresswoman. But 

what I would say is that—— 

Ms. SCHWARTZ. Well, we know on average that nationally we 

are paying 12 percent more. Are we paying you 12 percent more 

for Medicare Advantage? 

Dr. LYONS. We don’t think so. No, no, we do not think so. Our 

actuaries do not think that the overpayment in our market basket, 

the five counties of Philadelphia, even approaches that much. And 

what we really focus on, because we are a legacy plan who have 

been out there for a long time, is really what happens year over 

year. 

For example, in 2007, our payment increase from CMS was zero. 

It was flat. We got nothing, at a time when healthcare cost inflation in Philadelphia—which as you know is medically rich; it is 

really—— 

Ms. SCHWARTZ. Yes. We have great assets. 

Dr. LYONS. We have great assets and high use of great assets. 

And so our—— 

Ms. SCHWARTZ. But you are saying you don’t know how much 

more you get paid for Medicare Advantage than—— 


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Dr. LYONS. No. As I say, our own studies think that it is a trivial difference, that the difference between Medicare fee-for-service, 

given a lot of the complexities and nuances about our payment 

stream, is very little different from fee-for-service beneficiaries. 

And what we do know is that medical inflation in Philadelphia 

typically runs anywhere from 6 to 8 percent. And when that gap 

intrudes itself, we have nowhere to go with—— 

Ms. SCHWARTZ. Yes. But I am sorry. That is not the question 

I am asking. 

Dr. LYONS. Yes. 

Ms. SCHWARTZ. We actually have a President’s budget that is 

not acknowledging any medical inflation at all. So inflation, medical costs, they are either flat funding or cuts. So that is really 

barely on the table. I mean, we are actually raising that as to 

whether that is reasonable. 

But my real question is that you are providing these additional 

services—well, you actually didn’t really say they were—well, some 

of them are services. But how much more does that cost you to do 

that? You can’t tell us that, or you don’t know it? 

Dr. LYONS. I know what our administrative costs are. I do know 

that. As to the question of how our payment rates relate to the feefor-service system, I don’t have a specific answer. But I could certainly find out. 

Ms. SCHWARTZ. One of the things we are obviously concerned 

about and interested in is that if we are paying—the public taxpayer is paying more money to get services to Medicare beneficiaries, to just some, about 20 percent of our beneficiaries, we 

want to make sure that we are using those dollars well—right? 

Dr. LYONS. Very reasonable. 

Ms. SCHWARTZ. And if in fact it is really very wonderful and 

working, then why doesn’t everybody get advantage of this? And 

most of the Medicare managed plans—I am assuming you have 

said yours as well—is that you can do more for the same amount 

of money by managing it better, by being smarter, by being more 

efficient, by doing prevention. Right? And then they come back and 

say, we still need more money. 

So it is kind of inconsistent. We are trying to figure out if there 

is a way to actually say if you really are saving lives and keeping 

people healthier, having better outcomes, then you are saving some 

dollars. So why do we actually have to pay you extra for that? 

Dr. LYONS. I think, again, these are complicated questions. 

There are no simple answers to them. But my own perspective is 

that the system itself is very badly flawed. In other words, the 

overall healthcare delivery system—we are just a part of it. 

But we operate with a much larger system, with all sorts of incentives that are not particularly well aligned with quality and accountability, all of which is very well documented in Institute of 

Medicine and other reports. So we are a bit swimming upstream 

doing the best we can. 

Ms. SCHWARTZ. Well, I understand. Actually, I think you are 

being incredibly modest. For those who don’t know, Independence 

Blue Cross has a huge percent of the marketplace in southeastern 

Pennsylvania and is a very big player in potentially making big differences in the creating incentives and the way we do things. So 


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I appreciate your modesty, but I’m not sure that it isn’t true that 

you actually have a very big player in the field here and could actually be very much of a participant. 

Just one other question. You really talked a lot about prevention. 

You know, we have been trying to incentivize through Medicare, 

traditional Medicare, more prevention, more primary care, and creating those same kind of incentives. We have actually had a real 

push-back from the administration about that and from the other 

side of the aisle as potentially not being a useful thing to do. 

Would any of you think that that is not a smart thing, to actually 

be putting greater emphasis, more resources, on prevention and 

primary care? 

Dr. LYONS. Congresswoman, I would put on my advisory panel 

hat for just a moment. I don’t know, candidly, the administration’s 

posture. I know at the panel meetings, we panelists have regularly 

heard from CMS staff about all the things they are doing to promote prevention, including systems that would actually somewhat 

mirror what we do, which is getting out at least reminders and so 

forth to folks, allowing you to set up sort of web-based personal 

health registries and so forth. 

So I think they are making progress. It isn’t anything such as 

what we have and are developing, but still I think important steps 

are being made. 

Ms. SCHWARTZ. All right. I have many other questions, but I 

think my time is up. And I yield back. 

Chairman STARK. Mr. Becerra, would you like to inquire? 

Mr. BECERRA. Thank you, Mr. Chairman. And thank you to the 

witnesses for your patience and indulgence. We appreciate your 

being here. 

Let me begin with Dr. Thames. It is Thames? 

Dr. THAMES. Thames, yes. 

Mr. BECERRA. Dr. Thames, thank you for being here. Private 

fee-for-service plans, I think you have heard a little bit of discussion about the private fee-for-service plans. I know there is a great 

amount of concern about the private fee-for-service plans, not only 

because of a lack of oversight, but because they seem to be providing a lot of offers but less in actual services and value for service. 

And so I am wondering if you can—and if you have already answered this, I apologize—but does the AARP’s plan that it uses 

with some of its private insurance company providers work with 

them to provide a private fee-for-service plan to its AARP members? 

Dr. THAMES. Absolutely not. We have a policy, AARP presently 

and for a number of years, which is not expected to change, that 

says we do not support private fee-for-service plans. And we don’t 

plan with our present provider to offer any such plans under Medicare Advantage or otherwise. 

Mr. BECERRA. Now, and if you can do this briefly, give me an 

explanation. Because I think most seniors who are listening who 

may understand the difference between a fee-for-service traditional 

Medicare program, which they are accustomed to if they have been 

on it for a while, as opposed to a health insurance company product, Medicare Advantage, called private fee-for-service, they might 


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think they are getting the best of both worlds. They are getting feefor-service but in a private setting. 

And can you give a brief explanation of why you avoid using private fee-for-service plans? 

Dr. THAMES. Yes, sir. I will try to keep it very brief. First, they 

are the highest paid of the policies, and again, our policy is for equity in payment, as MedPAC and others have recommended. So 

that is the first thing that would not qualify them. 

Mr. BECERRA. And when you say paid, meaning government 

payments through Medicare for the insurance carrier? 

Dr. THAMES. Eighteen percent more than they do for traditional 

Medicare. Secondly, they are not required to belong to quality improvement organizations, and we believe that that should be part— 

as it is for the other Medicare Advantage programs—a requirement. 

Third, they are not required to do coordinated care, and we feel 

that is very important both in better medicine and lowering costs 

for medicine as a whole. And last—or perhaps one of the other reasons, at least; it may not be last—but at least one of the other ones 

is from what we have seen, most of the complaints that come in 

that we have looked at come from problems that are with private 

fee-for-service plans. 

And again, another reason is we don’t believe in balanced billing 

for people on Medicare programs. 

Mr. BECERRA. So I thank you for outlining the Medicare Advantage problems with their private fee-for-service plans. Let me 

ask you this: As a doctor, if I needed to get a hearing aid, what 

is the average cost or what am I looking at in terms of a cost for 

a hearing aid? 

Dr. THAMES. Well, you are looking at—and it is of interest that 

we are looking at hearing aids because so many of our people want 

those—you are looking at from something like Miracle Ear or something along that line for just a couple of hundred dollars to the best 

digital hearing aids that may cost you $2500 an ear for those, so 

that that is definitely a very high cost item. 

Mr. BECERRA. And so we are hearing more and more about 

some of these Medicare Advantage plans that are offering these 

wraparound packages or saying that they are offering a great deal 

of benefits if these seniors were to switch over from regular, traditional fee-for-service to the Medicare Advantage program. 

And I have information here about a program in Michigan, a 

Medicare Advantage plan in Michigan, that lists for those who are 

thinking of switching over to their plan that it provides dental, 

hearing, and vision benefits in their plan. They say that in their 

plan summary, that they provide those benefits in dental, hearing, 

and vision, and that there are no co-payments. 

Obviously, any senior hearing that—no co-payments; I go in, I 

don’t have to fork over any money for going in for that visit or for 

that particular product. But then at the end of the explanation of 

benefits, at the very end, you read the following: ‘‘Dental, vision, 

and hearing benefits are part of the basket benefit. The basket benefit is capped at $700 annually for all of these services.’’ 

And so in essence, what they are saying is that we offer you 

these benefits. You don’t have to pay anything up front. But if you 


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don’t finish reading this whole paragraph or this whole page, you 

won’t notice that you only get $700 worth of this. And so if you try 

to get a couple of hearing aids, you get the cheapest ones, you have 

already used up $500 of your $700 benefit. Forget about vision and 

contact lenses and dental, that who knows how much it will cost. 

But is that the way that you allow any of the Medicare Advantage plans that you work with to market to your seniors? 

Dr. THAMES. No, sir. As I indicated a little earlier, we have— 

the only agents for United who can offer our products are people 

who have had special training on selling those products and being 

completely honest, and fully disclosing to them, and have to take 

tests and pass those. 

Secondly, they have to sign a code of ethics. And last, we do secret shoppers from AARP—not from our carrier, but from us—to 

ask our people and listen in to the sales pitch and see if they are 

really doing what they say they are supposed to do and what they 

have signed up to do. 

And then, as I indicated earlier, after the calls, we have the outbound follow-up calls that we also require. So we have a limited 

number of agents within that company who do that, and we hope 

that we are going to have the highest quality standards in the 

business. 

Mr. BECERRA. Mr. Chairman, I know my time is expired. If I 

could just ask Mr. Lipschutz one question, and that is: You have 

heard what Dr. Thames from AARP has said, that they undertake 

to do some oversight of these Medicare Advantage plans. Do all 

Medicare Advantage plans do that type of oversight? 

Mr. LIPSCHUTZ. It is my understanding that no, most of them 

don’t. And looking at the United Health plan that AARP has lent 

or sold its name to, other products under that umbrella have been 

a source of significant complaints in the field of marketing. For example, Secure Horizons products in California, they do sell private 

fee-for-service plans, and they are targeting dual eligibles in some 

areas that has resulted in significant harm to beneficiaries. 

Mr. BECERRA. I appreciate it. Thank you, Mr. Chairman. 

Chairman STARK. Welcome. I acknowledge the presence of our 

distinguished gentleman from Texas, Mr. Johnson. Would you like 

to add some wisdom to this, Mr. Johnson? 

Mr. JOHNSON. Thank you, Mr. Chairman. I appreciate that. I 

don’t know about the wisdom part. 

Dr. Lyons, Independence Blue Cross provides physicians with information that compares their practice’s ability to manage chronic 

disease against performance of their peers. Do you find that information useful, and do you believe other physicians can learn from 

those comparisons? 

Dr. LYONS. Yes. Yes, sir, I absolutely do. We developed those reports with their input, and so we try to make sure at the front end, 

sir, that this is going to be useful information, that it won’t be inflammatory, that it will be helpful to them, and actually help them 

give better care. 

I don’t practice any more. I did for many years. I practiced in a 

very rural community. And candidly, I would have loved to have 

gotten more information about care gaps so that I would have 


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known better exactly who was getting what and what they needed 

at the time of their care. 

Mr. JOHNSON. Yes. That is good. Thank you very much. I am 

going to yield to Mr. Camp, if I may, some of my time. 

Chairman STARK. Without objection. 

Mr. CAMP. Thank you. Thank you very much. 

Dr. Thames, do you have information that you can make available to this committee about any concerns you have received from 

Medicare beneficiaries on any marketing and sales tactics used by 

AARP’s Medicare Advantage plans? Have you got that information? 

Dr. THAMES. I don’t personally have it, Mr. Camp. I will certainly—and my staff people are here from AARP—go back and see, 

since we only began to have these programs since January. But I 

will be happy to provide any material that we have to the committee. 

Mr. CAMP. And also, to help us evaluate the effectiveness of 

these plans and the satisfaction people have with these plans—— 

Dr. THAMES. Yes, sir. 

Mr. CAMP [continuing]. If you have those sorts of complaints or 

any concerns about people that are in AARP’s Medicare Advantage 

plan that maybe didn’t realize they were in it or any of that nature. I think we are very interested in sort of the sales and marketing side of this as well. 

Dr. THAMES. Yes, sir. 

Mr. CAMP. And I think that is something we want to try to 

move forward with together. 

I guess I would just say I appreciate all of your testimony. Thank 

you very much. Thank you, Mr. Chairman. 

Mr. JOHNSON. Thank you, Mr. Chairman. 

Chairman STARK. Well, I want to thank you. I wanted to explain to the witnesses that for a variety of procedural reasons, the 

House has finished, perhaps an hour ago, its deliberations, formal 

deliberations, for today, I guess for the rest of the week. And so 

many of our colleagues headed home to escape this wonderful 

weather. And I want to suggest to you that your testimony is appreciated. The efforts in getting here and your patience is appreciated. 

And I hope, although each of you have some different approaches, that just to summarize, I think we could say to Dr. Lyons 

that all of us appreciate the many advantages that are possible 

under a coordinated, multi-discipline practice. And we appreciate 

groups that have the huge resources like AARP, as well as rural 

communities that wish they had more resources, and through modern technology and digital imaging may get the advantages of 

group practice over the internet and in other manners. 

And then the consumer advocates like Mr. Lipschutz, who just 

offer tremendous help to congressional offices, who often hear these 

complaints or hear the bewilderment of seniors wondering what 

they now have and why they can’t see the doctor they saw before, 

or why Kaiser is raising their rates so much. I don’t suppose that 

Blue Cross does that, but you hear it. 

And so what we are trying to do is figure out—on the one hand, 

we are hearing the clarion call that Medicare is going to go broke. 

And we have got to figure out how best to reimburse all the profesVerDate Nov 24 2008 14:19 Dec 10, 2010 Jkt 046954 PO 00000 Frm 00158 Fmt 6633 Sfmt 6602 I:\WAYS\OUT\46954.XXX GPO1 PsN: 46954

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sionals who work hard to get the best quality we can. And your 

contributions to enlightening us in that direction are very much appreciated. I want to thank each of you for taking the trouble to be 

here and helping us. 

And with that, the hearing is adjourned. 

[Whereupon, at 1:04 p.m., the subcommittee was adjourned.] 

[Submissions for Record follow:] 

Statement of Association for Community Affiliated Plans 

Chairman Stark, Ranking Member Camp, and Members of the Subcommittee, the 

Association for Community Affiliated Plans is pleased to submit a statement for the 

record to the Subcommittee on Health of the House Ways and Means Committee 

as you examine the cost and value of Medicare Advantage plans. 

ACAP is a national trade organization representing 37 non-profit safety net 

health plans that serve more than 4.5 million Americans in Medicare, Medicaid, and 

other public health programs. Nineteen of our ACAP plans operate Special Needs 

Plans (SNPs) as an integral part of their mission. SNPs can assure continuity of 

care to dual eligibles who may be served by the plan through a Medicaid contract 

with the State or who were enrolled with the plan immediately prior to their Medicare eligibility. 

We have watched as your committee addresses the very compelling issues of cost, 

benefits and marketing practices within the Medicare Advantage program. We wish 

to call your attention to a report, Medicare Advantage Special Needs Plans/Six 

Plans’ Experience with Targeted Care Models to Improve Dual Eligible Beneficiaries’ Health and Outcomes commissioned by Association for Community Affiliated Plans and prepared by Avalere Health. 

The executive summary is attached to this testimony 

Avalere studied six not-for-profit Medicare managed care health plans across the 

country that entered the SNP insurance market over the last two years. The report 

consists of case studies of six not-for-profit, community-based SNPs and documents 

the variety of ways in which these plans use highly tailored strategies and focused 

care models to provide benefits that go beyond traditional models of insurance for 

dual eligible beneficiaries. SNPs in the study include Affinity Health Plan, 

CareOregon, Community Health Plan of Washington, Denver Medical Health Plan, 

Mercy Care, and Neighborhood Health Plan of Rhode Island. 

Some of the innovative services provided by these health plans include: 

• Assignment of patient navigators who are dedicated to helping coordinate the 

complexities of Medicare and Medicaid benefits, 

• Deployment of intensive, high-touch medical case management programs for 

those at highest clinical risk, 

• Links to community services that address homelessness, hunger, and other nonmedical stressors that can often lead to poor health outcomes and increased 

healthcare costs if left unaddressed, and 

• Enhanced benefit designs that help cover dental care or other services that neither Medicaid nor Medicare cover but can contribute to decreased health. 

The report demonstrates that the SNP designation served as a catalyst for these 

non-profit, Medicaid-focused plans to develop coordinated benefit models for dual eligible beneficiaries already served by Community Affiliated Plans for their Medicaid 

benefits. These plans are uniquely situated to integrate care under the Medicare 

and Medicaid programs. 

You have heard from people appearing before your committee that what works for 

enrollees is when the right plan with the right incentives is available. We believe 

that mission focused plans with strong experience in serving low income beneficiaries can be that ‘‘right plan’’. 

We would be happy to answer any of your questions about how we serve Medicare 

dual eligibles or have a member plan present to the committee. 

ACAP Member Plans with Special Needs Plans 

Affinity Health Plan (NY) 

Alameda Alliance (CA) 

CalOptima (CA) 

CareOregon (OR) 

Care Source (OH) 

Colorado Access (CO) 


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Commonwealth Care Alliance (MA) 

Community Health Plan (WA) 

Contra Costa Health Plan (CA) 

Denver Health Medical Plan (CO) 

Health Plan of San Mateo (CA) 

Horizon NJ Health (NJ) 

LA Care (CA) 

Neighborhood Health Plan of Rhode Island (RI) 

Santa Clara Family Health Plan (CA) 

Virginia Premier (VA) 

University Family Care (AZ) 

UPMC For You (PA) 

Executive Summary 

Congress authorized Special Needs Plans (SNPs) through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) to encourage health 

plans to develop targeted programs to more effectively care for high-risk beneficiaries. Plans have the statutory authority to limit enrollment to one of three special needs populations: beneficiaries dually eligible for Medicare and Medicaid, institutional beneficiaries, and those suffering from severe or disabling chronic conditions. Since the program’s inception, the number of SNP plans and the aggregate 

SNP enrollment has grown dramatically, to over 477 plans with more than 1 million 

enrollees. This growth has attracted the attention of policymakers and raises questions about the value of the program and the ability of these plans to design and 

deliver programs that meet the unique needs of special needs individuals. 

SNPs serving beneficiaries eligible for both Medicare and Medicaid (dual eligibles) 

have attracted particular attention, as these plans make up the majority of SNPs 

and have the highest aggregate enrollment. The characteristics of this population 

demonstrate that it is a population with special needs. Compared to the non-dual 

Medicare population, dual eligible beneficiaries are sicker, report lower health status, have lower functional status, and are more likely to be disabled. Medicare 

spending on a per capita basis is considerably higher for dual eligible beneficiaries 

($10,884) than Medicare spending for non-dual eligible beneficiaries ($5,975). 

This report focuses on how six not-for-profit, Medicaid managed care health plans 

are using the SNP authorization to serve dual eligible members through focused 

programs that are tailored to meet their needs. The case study plans are diverse 

and vary by geography, plan size, and relationship to Medicaid programs. Despite 

this variation, all of the plans invest across four key dimensions that they deem as 

critical to serving this population, including: 

• Coordination of the Medicare and Medicaid Benefit. All plans coordinate the 

Medicare and Medicaid benefit and have staff dedicated to helping members 

navigate Medicare, Medicaid, social services, and the health system. These plan 

staff, often called patient navigators or Medicare advocates, serve as a single 

point of contact for members and assist with Medicare and Medicaid eligibility, 

Medicaid waiver eligibility and applications, obtaining medical appointments, 

securing transportation, and other member needs. While not all plans are in 

states that have dual eligibles enrolled in Medicaid managed care, all plans perform this coordination function, relying on their Medicaid plan experiences and 

relationships to do so. 

• Intensive medical case management programs. Both the composition of the care 

teams and the method of interaction with members are tailored towards the 

special needs of this population. Case managers and/or care teams may include 

social workers, pharmacists, and other disciplines as well as registered nurses 

(RNs). The health plans rely on a high-touch model, which provides frequent 

contact between plan staff and members to educate patients on their condition, 

address member concerns, monitor health status, and identify healthcare needs. 

• Links to Community Social Services. The six case study plans also link members to key community and social resources to address the non-medical stressors 

caused by poverty that often lead to poor health outcomes and increased 

healthcare costs if left unaddressed. Plans believe that linking members with 

essential social service supports that address needs such as homelessness, hunger, and lack of heating is critical to members’ ability to participate in their own 

healthcare. The plans leverage their experiences with low-income populations 

and community social service providers to understand member needs and connect them with appropriate social service networks. 

• Benefit Design Plans use their Medicare supplemental dollars to fund enhanced 

care coordination services to help members navigate the healthcare system. In 


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addition, they use these supplemental dollars to eliminate coverage gaps, such 

as dental care, that neither Medicaid nor Medicare may cover. 

The six health SNPs profiled in this report are employing new models of care to 

better identify, treat, and manage the healthcare needs of persons dually eligible for 

both Medicare and Medicaid. As Congress and the Centers for Medicare & Medicaid 

Services (CMS) look to promote innovative models to serve high-risk populations 

such as dual eligibles, these case studies suggest that SNPs that have programs to 

meet the social and healthcare needs of the population hold promise of improved 

access, quality, and reduced costs. 

Currently, Congress and other policymakers are examining the SNP program, and 

they are considering additional requirements to ensure these plans are truly meeting the needs of special needs individuals. Stronger requirements and criteria may 

contribute to greater consensus around the role of SNPs in providing tailored services to these populations. The SNP designation provides an administrative vehicle 

for policymakers to set and expect high standards for plans serving special needs 

individuals. Such standards can also serve to inform the current CMS and National 

Committee for Quality Assurance initiative to develop quality measures for SNPs 

that reflect the population and measure plans’ success at improving access and quality and reducing costs. 

f 

Statement of Cathy Roberts 

My name is Cathy Roberts and I am a senior paralegal here at Empire Justice, 

a statewide non-profit law firm focusing on poverty law issues. I work in our Medicare Part D (prescription drug) advocacy project, which provides backup training 

and support on Part D and related issues to advocates assisting dual eligible Medicare beneficiaries in upstate New York and on Long Island, including local SHIP 

(State health insurance program) counselors and legal services offices. We have been 

conducting an ongoing assessment of available services and unmet needs on Part 

D issues in communities throughout New York State. 

Our message to the Committee is that that Medicare Advantage plans are particularly problematic for our dual eligible population in New York State. We will 

focus on two specific areas of special concern—marketing abuses and cost-sharing 

for dual eligibles. 

Marketing abuses 

One issue that keeps coming up among our advocacy network is continued marketing abuses of Medicare Advantage (MA) plans, especially among Private Fee For 

Service (PFFS) plans. Despite heightened enforcement and outreach on the Federal 

and State levels, as well as an aggressive public education campaign by State and 

local government agencies, illegal MA marketing practices continue to victimize seniors in New York State. 

For example, our SHIP in Broome County has worked with dozens of seniors in 

Binghamton and surrounding areas who received ‘‘cold call’’ visits from an insurance 

agent selling MA PFFS plans during the fall of 2006 and early 2007. 

Many of these seniors were pressured into purchasing MA PFFS policies because 

of misleading sales tactics on the part of the insurance agent. The SHIP filed a series of complaints with the State Insurance Department and in January 2008, the 

Insurance Department revoked this agent’s license. The Insurance Department also 

issued a press release warning seniors to be particularly cautious of high-pressure 

or misleading sales practices during the MA open enrollment period. 

We were hopeful that this publicity would have halted or significantly reduced the 

incidences of improper MA PFFS marketing practices in Broome County. Unfortunately, the local SHIP has continued to receive a steady stream of calls from seniors 

who have been misled by other insurance agents into purchasing MA PFFS plans. 

During the most recent influx of calls, the SHIP learned that seniors signed up for 

MA PFFS plans after being erroneously told by an insurance agent that ‘‘if you have 

Parts A, B & D of Medicare, but not Part C, you don’t have a complete Medicare 

package.’’ The agent(s) had not made clear that enrolling in Part C meant losing 

their original Medicare coverage under Parts A & B. Once the seniors understood 

the full implications of enrolling in the MA plan, they wanted to disenroll. The 

Broome County SHIP office has been helping these folks disenroll and get back into 

original Medicare. 

During discussions with the Broome County SHIP, the SHIP stressed that while 

there are many MA plans who provide good customer service and strive to abide 

by CMS’ marketing rules, the damage done by the ‘‘bad apples’’—agents/brokers 


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conducting improper home visits to market MA PFFS plans—is considerable. Seniors on limited incomes are pressured into obtaining MA coverage they don’t want 

or need; the coerced MA enrollment results in a disruption of medical care or payment for services (because many times seniors learn after the fact that their doctors 

do not participate in the MA PFFS plan); and it takes significant time and energy 

to help these seniors straighten things out. 

Unfortunately, improper MA marketing practices are not limited to Broome County. We have learned of these practices occurring throughout upstate New York—including Jefferson and Niagara counties—and in New York City, and some of the victims have been dual eligibles. Dual eligibles are particularly vulnerable to MA marketing abuses since their Low Income Subsidy status allows them to enroll in, drop 

or switch MA plans on a monthly basis, not just during the annual open enrollment 

period. 

While the steps taken by CMS to crack down on MA PFFS marketing abuses have 

been helpful, the problem is so pervasive that a more sweeping solution is needed. 

Cost-sharing issues for dual eligibles 

Some dual eligibles enrolled in MA plans are being improperly charged for co-pays 

that should be picked up by their Medicare Savings Program or by Medicaid. We 

have only recently started to hear about this problem, probably because more dual 

eligibles are enrolling in MA plans. It is an extremely complicated and time-consuming issue to address on an individual case basis there are different cost-sharing 

responsibilities among the various categories of dual eligibles. So for an individual 

beneficiary you must: 

• figure out the beneficiary’s dual eligible status (are they QMB, SLIMB, QI–1? 

Do they also have Medicaid?) ; • assess the State’s cost-sharing liability using the CMS cost-sharing matrix; • if the State is responsible, go back to the plan and the person’s medical providers and advocate to get them to follow the proper billing procedures, which 

may require the filing of an appeal or grievance on the client’s behalf and/or 

require CMS intervention. 

These are steps that require fairly extensive knowledge of Medicare and Medicaid 

as well as considerable advocacy skills. How do we expect our disabled and elderly 

beneficiaries to be able to navigate through all this? 

The dual eligibles with the lowest income—QMBs (with or without Medicaid)— 

are not supposed to have any cost-sharing liability in Medicare Advantage plans. 

However, the reality is that some of the poorest dual eligibles are being charged for 

services provided through an MA plan when they shouldn’t be—at the same time 

that the MA plan is being reimbursed at a higher rate than original Medicare. 

Conclusion 

Medicare Advantage participation poses unique challenges for our dual eligibles, 

and the improper marketing abuses of MA PFFS plans and the inappropriate billing 

of dual eligibles cause significant harm to this very vulnerable population. 

f 

Statement of Representative Kathy Castor 

I would like to thank Chairman Stark and members of the Ways and Means Subcommittee on Health for the opportunity to submit my testimony on Medicare Advantage for the record. It is no secret that Medicare Advantage marketing abuses 

have affected many seniors both in my district and the country as a whole. Reports 

from the Government Accountability Office highlighting the failure of the Bush Administration to adequately audit Medicare Advantage providers show that the time 

has come for legislative action. New standardized regulations are required or these 

forms of abuse will continue. 

Too often we find that Medicare beneficiaries choose to participate in private 

Medicare Advantage plans without fully understanding their choice and its potential 

consequences. Often, beneficiaries are not made aware that the decision to choose 

Medicare Advantage is a decision to give up traditional Medicare. We have heard 

of instances when beneficiaries continue to send in their Medicare supplement premium for several months after they’ve signed up for a Medicare Advantage plan, 

never having been told that they are no longer responsible for that payment. 

Seniors also transition to Medicare Advantage without warning that they may no 

longer have access to their current doctor. It is common for patients to inadvertently 

sign up for private Medicare Advantage plans that cost more in out-of-pocket expenses after being mislead about which doctors accept the plans. In many cases, 


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there may be just a few if any doctors that accept such plans. Other stories include 

signing up seniors with dementia or using scare tactics such as ‘‘Medicare is going 

private,’’ and they will lose Medicare or Medicaid if they do not sign up. 

Many seniors are also not aware of their rights or ability to leave Medicare Advantage. Those who are aware and make the decision to return to traditional Medicare are forced to enter a complicated lengthy process that can adversely affect the 

delivery of health services and leave them without Part D coverage. 

My home State of Florida has a large population of seniors. The marketing practices and abuses by private Medicare Advantage insurers are acute in Florida. Individuals in my own district have suffered marketing abuses under Medicare Advantage. Charleen Edge was enrolled in a private HMO that she neither requested nor 

desired. She tried in vain several times to switch back to regular Medicare. After 

breaking her pelvis last April neither Medicare nor the HMO would pay her bills. 

As a result, she is burdened with $30,000 in debt. William DiPietrantonio, 73, of 

Tarpon Springs, signed up for the Universal Health Care plan called, ‘Any, Any, 

Any’ with the belief he would be able to see any doctor or go to hospital he wanted. 

When he learned that he could not, he attempted to switch back to traditional Medicare. An entire month passed before he was finally reenrolled in traditional Medicare. During this month, he accumulated $15,000 in hospital bills for his chemotherapy treatments for lymphoma. 

Without regulation, seniors will continue to suffer. My recently introduced legislation, H.R. 4790, the Accountability and Transparency in Medicare Marketing Act of 

2007, will hold Medicare Advantage providers liable for their abuses and will make 

such abuses publicly known. This legislation requires the National Association of Insurance Commissioners (NAIC) to develop standardized marketing practices. It prohibits certain activities such as cross-selling of products. Under this legislation, the 

NAIC must establish a committee to study and make recommendations to the Secretary of HHS and Congress on the establishment of standardized benefit packages 

and their regulation. As CMS has largely abdicated its oversight responsibility, it 

is now imperative for Congress to protect America’s seniors. 

I would like to again thank Chairman Stark for this opportunity. I commend the 

Committee on Ways and Means and the Subcommittee on Health for holding hearings on Medicare Advantage. It is with great anticipation that I look forward to future hearings and opportunities to address this vital issue. 

f 

On behalf of the approximately 1.2 million members of The Senior Citizens 

League (TSCL), a proud affiliate of The Retired Enlisted Association (TREA), thank 

you for the opportunity to submit a statement regarding the need for accountability 

and oversight of marketing and sales by Medicare private plans. TSCL consists of 

active senior citizens, many of whom are low income, concerned about the protection 

of their Social Security, Medicare, and veteran or military retiree benefits. 

While TSCL fully understands the need to address the looming Medicare Trust 

Fund exhaustion, we are also concerned with the complexity and plethora of private 

Medicare plans. It has been widely reported that many seniors have been misled 

and in some cases fraudulently signed up for a plan by insurance representatives. 

TSCL has been encouraged that the 2009 Budget proposal by the President’s Administration included improved program integrity that could strengthen the Medicare entitlement program. 

Unfortunately, TSCL has received a number of emails and comments from many 

seniors who have wound up in private health plans only to belatedly discover unexpectedly high costs. Often, they did not understand that they were leaving the traditional Medicare when they signed up. 

Senate investigators have learned that insurance agents in at least 39 States used 

illegal or unethical tactics to sell private Medicare health plans, known as Medicare 

Advantage plans. Some insurers signed up unwitting consumers by using ‘‘bait and 

switch’’ tactics, forging signatures, using personal information stolen from Federal 

records, and even by submitting applications for deceased individuals. The New York 

Times reported that Albuquerque cancer specialist, Dr. Barbara L. McAney, said 

that many of her patients who signed up for such plans ‘‘suddenly found that they 

had huge new co-payments $1,250 every three weeks for a combination of five intravenous chemotherapy drugs.’’ 

Agents of the private plans have worked out of booths in discount stores or tables 

set up in front of grocery or drug stores. Seniors might have thought they were signing up to get drug coverage or just more information. Then, if they required hospitalization or other costly services later, they might learn that there were higher 

co-payments than normally would be charged under traditional Medicare. 


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Enrollment in Medicare Advantage plans has exploded in the past year with one 

out of five Medicare beneficiaries enrolled. According to the Medicare Payment Advisory Commission, however, the government pays the private plans 12% to 19% more 

than it would cost Medicare to serve the same people. The non-partisan Congressional Budget Office estimates that the cost for these extra payments will amount 

to $65 billion over the next five years. These extra payments are passed on to the 

nearly 80% of Medicare beneficiaries not enrolled in a Medicare Advantage plan in 

the form of higher Part B premiums and who receive none of the promised additional benefits provided by the plans. 

Also many advocates are worried that the plans tend to siphon off younger and 

healthier seniors. TSCL’s Medicare policy analyst found that this appears to be true 

based on the plans she evaluated during last November/December’s Open Enrollment. Those plans were set up in a way that would have most benefited those who 

were young and healthy, and would have been cost-prohibitive for older seniors who 

might need a prolonged hospital stay. Because the plans receive higher payments 

than traditional Medicare and the young and healthy individuals are less likely to 

need to use many services under their plans, it contributes to raising the cost of 

Part B for everyone. 

The Medicare Rights Center (MRC) has reported that there are common problems 

people have in Medicare Advantage plans. Unfortunately, many people discover 

these flaws after they have joined the plan and cannot switch until the following 

year. Problems can include: 

• Care that costs more than it would under traditional Medicare. 

• Difficulties in getting emergency or urgent care and care away from home. 

• Choice of doctor, hospital and other providers is restricted. 

• Promised extra benefits can be very limited. 

TSCL is also highly concerned that the Centers for Medicare and Medicaid Services (CMS) have not been providing strong oversight of the private plans as required 

by law. Last fall, the Government Accountability Office (GAO) said that private insurance companies participating in Medicare have kept millions of dollars in Federal subsidies that should have gone to seniors to help lower premiums and co-insurance costs. The GAO also reported that CMS did not properly audit the companies or try to recover the money. Under Federal law, Medicare officials are supposed 

to audit the financial records of at least one-third of private Medicare Advantage 

insurers annually. The GAO said that CMS had never met the ‘‘statutory requirement.’’ 

At the same time, however, CMS was vigorously pursuing money that it says was 

owed to insurance companies by Medicare beneficiaries. In most cases, the premiums were supposed to have been withheld from monthly Social Security checks, 

but the government withheld the wrong amounts or nothing at all. 

Conclusion 

Although we are pleased that Congress is addressing the growing problem of private plan marketing abuse and while we do not have a perfect solution, there are 

some simple actions that could be taken in the meantime. 

Tougher enforcement and increased transparency will save Medicare billions of 

dollars annually. A significant portion of expenditures comes from fraud and 

abuse that hurts the solvency of important entitlement programs like Medicare for current and even future retirees. When Medicare has had the investigative staff and tools required to combat fraud, about ten dollars for every one dollar invested has been saved in the past. 

TSCL also supports lowering payments to the Medicare Advantage plans thereby 

making them equal to traditional Medicare plans. Preventing door-to-door sales of 

Medicare Advantage plans, stopping marketing abuses, and encouraging all Medicare participants to seek assistance from an unbiased, Medicare benefits counselor 

are seemingly simple steps that can be taken to protect beneficiaries and the future 

of Medicare. 

Regardless of which solution Members of Congress believe is best, The Senior Citizens League sincerely hopes that the Medicare and Social Security Trust Funds are 

protected and strengthened for future generations. 

Thank you. 

Æ 


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