At the annual Medicarians conference in Las Vegas on Monday, an analyst on Medicare Advantage policy research sounded the alarm about how there’s a fundamental shift in attitude towards MA at the federal level. It’s a combination of several factors: deep concerns over overpayment and fraud, resulting in legislative and political scrutiny on insurers; 3 million seniors losing their MA coverage in 2026 because health insurers pulled out of their counties; and large and small public insurance companies faring badly at the stock market.
Especially at the Centers for Medicare and Medicaid Services, overpayments have become a sticking point.
“CMS has begun shifting to, I think a more adversarial posture when it comes to how they view Medicare Advantage,” said Tom Kornfield, founder and CEO of MAST Health Policy Solutions. “And that’s before we even get into what happens under an election season, which is when the rhetoric gets turned up to 11, to quote Spinal Tap.”
The Medicarians conference brings together healthcare and life insurance brokers, agents, owners of brokerages as well as independent marketing organizations and field marketing organizations that serve as a liaison between an insurance carrier and an agent. The attendees are united by the single goal of understanding the needs of seniors and fulfilling those needs by selling insurance products — whether health or financial — to them. The conference also draws agents and companies involved in the Affordable Care Act marketplace.
Kornfield said that CMS’s scrutiny is also falling on Chronic Care Special Needs Plans.
“The concern about them from CMS is that they are bypassing some of the requirements for the Dual Eligible Special Needs Plan,” he declared. “So I think we could see some activity on that front.”
He added that, depending on the outcome of the midterms — especially if Democrats win — he expects to see a lot of activity in terms of regulation and legislative changes affecting MA.
While more seniors are enrolled in MA plans today compared with traditional Medicare, enrollment in MA plans is slowing across the board, except in Special Needs Plans or SNPs. In 2021, MA enrollment was at 11%; in 2026 it was 3%.
Whether CMS and other federal agencies are zeroing in on fraud or controlling overpayment, a lot of the negative headlines about MA stem from the fact that year after year, costs keep going up. The latest MedPAC report shows that MA payments were $76 billion above what spending would have been if those same seniors were enrolled in traditional Medicare instead.
And that is especially hard to stomach given that when Medicare Advantage was conceived legislatively, it was not only to provide more choice to seniors but also to hold down healthcare costs that are funded by taxpayer dollars.
But the scrutiny is not only about the cost of MA.
“So there are the MedPAC numbers that I mentioned, and there’s also been increased scrutiny by the administration of what they think is waste going on within the Medicare Advantage plans or fraud even with risk adjustment, data validation audits, which is where they go in, review medical records, see if that diagnosis is supported by the medical record,” Kornfield pointed out.
Other than ballooning costs, the national souring on MA also has to do with activity of health insurance marketing organizations, even though Kornfield was careful not to castigate his audience members, the overwhelming majority of whom were agents and brokers.
“During Covid, unfortunately, not trying to assign blame, but because of the probably call center-related [issues], there were plenty of complaints about marketing and that got the attention of people on the Hill and that’s a real problem.,” he said. “And that may not be as big of a problem now, but I think there’s still a hangover from that.”
All in all, the MA market is in the middle of a fundamental shift.
“Medicare Advantage is really at an inflection point,” Kornfield declared. “So this isn’t really a rough patch. It’s not a cycle. It’s really a reset.”
Will this dynamic shift depend on the outcome of midterms? Will it be better for brokers, insurers and the MA industry if Democrats sweep the midterms or Republicans are able to hold the line?
“I would think that the Democratic Congress would be much more active in bringing the health plans up there,” Kornfield said. “There is concern about the size of these large-scale companies, these insurers, UnitedHealthcare. There’s been a lot of negative publicity about the health insurers.”
But the host of the compliance track where Kornfield was speaking saw it differently. He saw equal concern from both sides of the aisle.
“They want to see the cost to the taxpayer of Medicare Advantage as a program go down, and this is Democrats and Republicans, guys don’t get confused,” Steve Kaplan, chief legal, compliance, and privacy officer, at HealthPlanOne, told the audience. “And so they’re like, ‘How can agents and brokers help?’”
Source: sesame, Getty Images
