Archive for November, 2010

What is a Quality Medicare Advantage Health Plan?

It’s open enrollment season again, and Medicare beneficiaries and their families are barraged with mail, TV and radio commercials, and print ads describing the Medicare Advantage and prescription drug plan (PDP) options in their area. This year, Congress and Medicare would like people to consider the quality ratings of plans when making their choice for 2011. Beneficiaries can find quality information about plans on the Medicare Plan Finder tool. Plans are evaluated on a 5-star rating system that looks at medical care as well as customer relations, including complying with CMS rules about marketing and about appeals.

Quality ratings are so important that the new health reform law, the Affordable Care Act, awards quality bonuses, starting in 2012, to all Medicare Advantage plans if they score at least 4 out of 5 stars on the Medicare 5-star rating system. Quality ratings are so important that CMS, the Medicare agency, even moved up the starting date of and expanded eligibility for the quality bonus payments to Medicare Advantage plans. In fact, Medicare has created a demonstration project for 2011 that will give Medicare Advantage plans a bonus payment if they achieve 3 out of 5 stars on the star system.

But what does it mean to be rated “a high-quality Medicare Advantage Health Plan?”

Ask Arcadian Health Plans, a parent company that has been in existence since 1997, and that offers Medicare Advantage plans in 15 states. On November 17th Arcadian sent out press releases to many of the communities in which they offer Medicare Advantage plans to announce that they had been awarded the 2011 Senior Choice Gold Award by HealthMetrix Research “for excellent value among Medicare Advantage plans.” See, e.g., Southeast Community Care’s Medicare Advantage Part D Plan is Rated the #1 Value for Medicare Beneficiaries in the Roanoke Area,; Texas’ Community Care’s Medicare Advantage Part D Plan Is Rated the #1 Value for Medicare Beneficiaries

Yet, two days later, on November 19th, CMS announced it was sanctioning Arcadian Health Plans and two other health plan sponsors and not allowing them to market or enroll new beneficiaries. Arcadian is being sanctioned for violations in marketing the plans they offer to beneficiaries. For example, Arcadian has given beneficiaries incorrect information about whether their doctor is in the plan network or whether their prescription is on the plan’s formulary. Arcadian plan agents may even have enrolled people into health plans who had not consented to, let alone known about, the enrollment. And, according to the letter CMS sent to the plan, CMS has been looking at Arcadian’s marketing activities since 2008.

If CMS is going to suggest that beneficiaries consider enrolling in particular, “highly-rated,” Medicare Advantage plans or PDPs because of the quality of coverage and services they provide, and if these plans are going to get extra bonus payments, we need to be clear about what a high quality plan is – and is not!

Perhaps Arcadian’s press releases are another example of marketing violations that should be investigated by CMS.

November 22, 2010 at 6:15 pm Leave a comment

Our NY Times Letter to the Editor – Improvement Standard Impacts Coverage and Care

The Center for Medicare Advocacy reiterates last week’s New York Times story: the Medicare Improvement Standard is an unjust danger to people in need of care!

November 8, 2010 at 8:17 pm Leave a comment

We Told You So…

The New York Times recently printed an article by Robert Pear entitled “Medicare Standards are Too Strict, 2 Courts Find.”

We’ve been telling people that for years.

The Times article refers to two decisions, Anderson v. Sebelius and Papciak v. Sebelius, both regarding the Medicare “Improvement Standard.”  For anyone not familiar, this is an arbitrary rule of thumb which essentially says that if the beneficiary won’t improve, Medicare won’t cover certain services.

The Improvement Standard has been used for years by Medicare contractors to improperly deny coverage.

However, per these two recent decisions, Medicare must adhere to the law as written, and pay for services if they are needed to maintain a person’s condition or to prevent deterioration of the person’s condition.   The courts stated that Medicare beneficiaries do not have to prove that their condition will improve, as the government generally contends.

The rulings are potentially significant for many people with chronic conditions and disabilities like multiple sclerosis and Alzheimer’s disease; conditions which, by their very nature, simply will not improve. In the words of one judge, patients “need not risk a deterioration of [their] fragile health” to justify continuation of coverage for skilled care.

Center for Medicare Advocacy Director of litigation Gill Deford acted as co-counsel in one of the two cases.  The Center has launched a campaign to end the Improvement Standard, and these decisions represent a significant victory.

November 2, 2010 at 6:14 pm Leave a comment


As if Medicare and your health depend upon it.

November 1, 2010 at 7:07 pm Leave a comment

Health Policy Expertise

We provide effective, innovative opportunities to impact federal Medicare and health care policies and legislation in order to advance fair access to Medicare and quality health care.

Judith A. Stein, Executive Director

Contact us by email
for a free consultation,
Or call at (202) 293-5760.
Se habla español
November 2010


%d bloggers like this: