A crackdown on ‘misleading’ Medicare Advantage ads

Apr 06, 2023

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By Daniel Payne and Krista Mahr

Presented by

With help from Carmen Paun

Driving the Day

A page from the 2019 U.S. Medicare Handbook.

CMS issued regulations that prohibit insurers from advertising Medicare Advantage plans in ways that confuse, mislead or misrepresent the plan to consumers. | Pablo Martinez Monsivais/AP Photo

ADVERTISEMENT ADVERSARIES — The Biden administration looks to prohibit insurers from advertising their Medicare Advantage plans in misleading ways, POLITICO’s David Lim reports.

HHS Secretary Xavier Becerra told reporters the policy, part of a final CMS rule announced Wednesday, was important because some older adults are persuaded by the advertisements and then make decisions “to their detriment.”

The administration plans to eliminate “overly general” ads that could confuse people about their eligibility and the plans’ details.

And there’s more to the rule than advertising requirements. It also touches on prior authorization, health equity, clinical psychology coverage and Inflation Reduction Act implementation.

The finalized rule:

— Clarified that MA plans must comply with existing coverage requirements included in traditional Medicare. An insurer offering an MA plan will also be mandated to create a committee tasked with annually reviewing whether its policies are consistent with Medicare requirements.

— Detailed appointment wait-time standards for behavioral health care and aims to boost MA provider availability by making clinical psychologists and licensed clinical social workers eligible for a 10 percentage point telehealth credit.

— Added a health equality index to its 2027 Medicare Star Ratings program to reward Medicare Part D and Medicare Advantage plans that provide care to underserved communities.

— Expanded the full Medicare Part D low-income subsidy benefit to people who have incomes up to 150 percent of the federal poverty level starting in 2024, an increase for those who previously qualified for a partial subsidy.

WELCOME TO THURSDAY PULSE, where we’re following the uproar over whether Chipotle’s salsa is too spicy (leading The Wall Street Journal to send samples to a lab for analysis).

What hot news should we be following? Drop us a line at dpayne@politico.com and kmahr@politico.com.

TODAY ON OUR PULSE CHECK PODCAST, host Ruth Reader talks with Katherine Ellen Foley, who attended the World Vaccine Congress this week, about the transition drugmakers will need to make to sell their Covid vaccines in the commercial market as well as the world of next-gen vaccines.

Listen to today’s Pulse Check podcast

A message from PhRMA:

What’s a pharmacy benefit manager (PBM)? They decide if medicines get covered and what people pay for them, regardless of what your doctor prescribes. These middlemen are putting their profits before your medicines. And getting between you and your doctor. You need to see what’s going on.

Global Health

A raccoon dog sits on grass.

Chinese researchers have rejected the hypothesis that Covid was spread by raccoon dogs. | Atsushi Tomura/Getty Images

CHINA UPDATES COVID-ORIGIN STUDY — Researchers from the Chinese Center for Disease Control and Prevention published an updated report in Nature on Wednesday about the animals sold at the Huanan Seafood Market in Wuhan at the beginning of the pandemic, leading to more controversy among scientists about what the data means, Carmen reports.

In a nutshell: The researchers wrote that existing evidence is insufficient to conclude that raccoon dogs sold at the market were the intermediate host animal for the virus or the virus spilled over from animals to people at the market, as an international study suggested last year.

China CDC researchers said they didn’t identify any animal infected with the virus among their samples. And even if that were the case, it’s possible that people infected the animals instead of the other way around.

What this means: We’re still not sure whether the pandemic started in the Wuhan market, where many wild animals were sold.

Why this study created controversy: The raw data underpinning this study was published recently on the international virus database GISAID, leading a group of mostly Western scientists to release an analysis linking raccoon dogs with the virus’ emergence. GISAID briefly revoked the scientists’ access to the database, claiming they had broken the rules of use by publishing their analysis before the Chinese scientists had the chance to do so.

Now, the Western scientists accuse the Chinese scientists of misinterpreting data, such as identifying animals like pandas not sold at the Huanan market and confusing dogs with raccoon dogs. They also said the methods Chinese experts used to analyze the data aren’t reproducible and their conclusions are flawed.

Why it matters: This debate adds to the confusion about how the pandemic started — reminder: we don’t know — and may embolden other experts and U.S. lawmakers who believe the virus most likely spilled over from a virology lab in Wuhan to continue emphasizing that theory.

IT’S OVER? Germany’s health minister, Karl Lauterbach, announced Wednesday that the pandemic is over in his country, POLITICO’s Gabriel Rinaldi reports.

After reviewing data on variants, vaccination rates and hospital cases, Lauterbach said he made the assessment that Germany had “successfully overcome the pandemic.”

The epidemiologist was known for cautious Covid policies early in the pandemic, but his tone has changed recently.

On Tuesday, the government’s Covid-19 expert council met for the last time. After Friday, all protective government measures against the pandemic will come to an end, including remaining mask requirements such as those for hospital visitors.

The U.S. is headed in a similar direction, with many pandemic-era policies scheduled to end next month.

A message from PhRMA:

In Congress

MEDICARE PAYMENT TIED TO INFLATION? A bipartisan bill expected to be announced today would increase the physician payment rate by connecting annual updates to inflation.

Rep. Raul Ruiz (D-Calif.) will introduce the bill with several lawmakers who are doctors involved in physician reimbursement discussions: Reps. Larry Buschon (R-Ind.), Ami Bera (D-Calif.) and Mariannette Miller-Meeks (R-Iowa).

The big picture: The amount of money Medicare reimburses doctors is one of the largest — and most predictable — battles in health policy.

It was a key issue addressed in year-end omnibus debates in Congress and will likely again be center stage in the next spending bill.

Though lobbyists have told Pulse they’re often skeptical about the payment system changing, they’ve shown interest in any tweaks that may be possible.

EYES ON SAMHSA — Republicans on the House Energy and Commerce Committee are pressing the Substance Abuse and Mental Health Services Administration for details about Covid spending, the suicide hotline rollout, mental health treatments and the new Office of Recovery.

In a letter sent to administration leaders, GOP committee members requested more information about how money was spent and how administrative authority was used.

The letter points to the significant number of mental illness diagnoses in the U.S. and asks about SAMHSA’s impact after getting extra money through the pandemic.

GO INSIDE THE 2023 MILKEN INSTITUTE GLOBAL CONFERENCE: POLITICO is proud to partner with the Milken Institute to produce a special edition "Global Insider" newsletter featuring exclusive coverage, insider nuggets and unparalleled insights from the 2023 Global Conference, which will convene leaders in health, finance, politics, philanthropy and entertainment from April 30-May 3. This year’s theme, Advancing a Thriving World, will challenge and inspire attendees to lean into building an optimistic coalition capable of tackling the issues and inequities we collectively face. Don’t miss a thing — subscribe today for a front row seat.

Names in the News

Rachel Portman is now a policy adviser at DLA Piper. She previously was deputy health policy director for the Senate HELP Committee for former Sen. Richard Burr (R-N.C.).

Rich Buckley has been named managing director at Rational 360, following his roles as vice president of global corporate affairs at AstraZeneca.

A message from PhRMA:

Insurers and their PBMs don’t want you to see that you could be paying more than they are for your medicines. Rebates and discounts can significantly lower what insurers and PBMs pay for medicines. These savings can reduce the cost of some brand medicines by 50% or more. But insurers and PBMs aren’t required to share those savings with you at the pharmacy counter.

They don’t want you to see that they use deductibles, coinsurance and other tactics to shift more costs on to you. Or that the three largest PBMs control 80% of the prescription drug market. Or that last year they blocked access to more than 1,150 medicines, including medicines that could have lowered costs for you at the pharmacy. 

PBMs and insurance practices are shrouded in secrecy,  they need to be held accountable.  

What We're Reading

The Financial Times reports on the fight over the meaning of the word pandemic as countries race to agree to a pandemic treaty.

CNN reports on an effort to transform Alzheimer’s with a $300 million research data platform.

STAT reports on longstanding cancer drug shortages in the U.S.

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