Today, nearly 50% of Medicare-eligible people choose to receive their Medicare benefits through Medicare Advantage plans, which number in the thousands nationally. For the enrollment period open from October to December 2022, the typical enrollee has a choice of 43 Medicare Advantage plans.¹ Navigating this large number of options makes for complex decision-making.

So how do enrollees weigh all the cost and coverage features of, on average, 43 plans? 

Choice is important, but it is only valuable if enrollees can understand the meaningful differences across plan options. The current tools available to enrollees to evaluate Medicare plans fall short.

While the federal government allows plans to vary their most critical features, the government-provided tool—Medicare.gov’s Plan Finder—does not let enrollees evaluate plans on some of their most important features. This is a huge problem for the more than 28 million Americans currently enrolled in a Medicare Advantage plan or standalone Part D drug plan who can change their coverage for 2023.2

Limitations of Plan Finder’s provider search

As network-based insurance plans, Medicare.gov notes that with a Medicare Advantage plan, “...you can only use doctors and other providers who are in the plan’s network and service area…” Understandably, the first question enrollees raise when initially considering a Medicare Advantage plan or looking to switch their plan is, “are my current health care providers in the plan’s network?”

Unfortunately, the Plan Finder tool does not include an integrated provider directory that identifies which plans a provider (doctor, hospital, lab, etc.) participates in. Enrollees do not have the ability to enter their doctors and then receive a ranking of plans based on their chosen providers’ in-network or out-of-network status.

Instead, a person must leave Plan Finder and visit each plan’s website to see if the provider is in-network. For example, if someone has four doctors and wants to search six plans, such a search would require looking up those physicians 24 times! Given the number of plans in each geographic location, it’s practically impossible to search the networks for every plan.

Someone might also limit their searches to only the largest plans to make the number of options more manageable. That could inadvertently produce search results that do not optimally meet individual health care and financial situations. We recommend enrollees avoid defaulting their searches purely based on plan size.

Plan Finder limits when comparing prescription drug coverage

While Plan Finder does provide information on the cost and coverage of prescription drugs by a plan, the plan’s utilization management requirements or drug restrictions are not prominently featured on the tool. Common drug utilization management restrictions include:

• Quantity limits
• Prior authorization (defined by HealthCare.gov as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan)
• Step therapy, which requires that plan enrollees try and fail with a cheaper drugs regimen before the plan will approve the use of the more expensive prescription.

It’s important for enrollees to understand the methods the plan will use to manage its costs because this determines whether an enrollee would be able to access prescribed drugs in a timely way that meets the enrollee’s health needs.

To locate the restrictions on a drug, users must click on a link entitled “View more drug coverage” on the plan detail page. While knowing the restrictions a plan places on the drugs is an important point of comparison when choosing among plans, Plan Finder currently does not display any drug restriction information on the plan comparison page.       

Additional benefits: Easy to find, difficult to compare

Medicare Advantage plans typically offer several additional benefits. In 2022, more than nine in 10 Medicare Advantage plans provided some type of additional benefit.¹ Examples include coverage for hearing, dental, or vision services, along with allowances for transportation, over-the-counter medications, fitness memberships, acupuncture, and grocery or meal credits.

However, the scope and amount of a given benefit varies tremendously across plans available in the same ZIP code. For example:

• Dental: Some plans may include coverage for only $500 in annual dental services,³ while other options in the same area may cover an annual amount up to four times greater.⁴
• Hearing aids: Some plans may cover a limited allowance of $1,400 every three years,⁵ while other plans may cover up to $3,000 each year!⁶  

The good news is that Medicare.gov’s Plan Finder allows searching for plans based on the type of benefit.

But the bad news is Plan Finder does not allow enrollees to compare plans based on the degree or kind of coverage for each benefit. Enrollees can only filter to identify plans that have any benefits of a given type (dental benefits, for example). The website fails to provide details on the level of benefits and possible limits for them. Such limitations may require enrollees to prove they’re eligible for benefits by proving that they have a chronic medical condition. Also, the enrollee may not be told whether benefits are only available in certain states or geographic areas.

This missing information and functionality are critically important. Consider someone who needs coverage for comprehensive dental services, not just a semi-annual check-up; or a someone who needs robust hearing aid coverage.

Today, those enrollees are not able to use Plan Finder to identify plans that meet these criteria, or easily compare the specific benefits for which they may be eligible. They’re left to scroll through 100+ page plan documents. This activity is presumably the type of manual, error-prone work that Plan Finder is designed to prevent.

Limitations on updating Plan Finder data

Passed in August 2022, the Inflation Reduction Act (IRA) capped monthly copays for covered insulin at $35 and eliminated cost-sharing for certain Part D vaccines, like Shingles, beginning in January 2023. Plan Finder is not currently updated to reflect the $35 insulin copay cap or the $0 cost sharing on Part D-covered vaccines because the IRA was passed too late in the calendar year.

While CMS has placed notes on Plan Finder to raise awareness, the inaccurate costs will remain a point of confusion for enrollees throughout the 2023 enrollment period. Plan Finder’s inability to update plan information will require a legislative or policy solution.

The price the shopper sees on Plan Finder does not reflect these changes, which has caused much confusion. The Centers for Medicare and Medicaid Services (CMS) has attempted to work within the current rules and has put helpful enrollee information on the insulin cap, for instance, where they can on Plan Finder. Once the shopper adds a covered insulin to the drug list, CMS has ensured that a notice then pops up advising the enrollee to get help with comparing plans.

The path forward: Improving Plan Finder

CMS notes that it is “committed to providing comprehensive and easily accessible information to support people with Medicare in their decision making.”⁷

In addition to continued usability and design improvements, we urge CMS to focus on improving the quality and detail of the information that CMS provides to enrollees, both directly and via partners. Medicare selection is complex, and we encourage CMS to work more closely with other public, private, and social sector partners who can support efforts to manage the software and data complexity to best serve enrollees.

Losing access to a trusted provider because they are not in the plan’s network or learning that prescription drugs are not covered by a new plan can have negative health consequences. In this complex, frequently changing market, CMS should also test the Plan Finder tool regularly, collaborate with stakeholder groups in designing enrollee surveys in a transparent process, and share results and findings online. 

Fortunately, CMS already receives and processes quarterly data from carriers that detail the amount and scope of each additional benefit (CMS publishes this data here). CMS should act swiftly to incorporate this more comprehensive data into Plan Finder.

While strong design is critical, it cannot compensate for material omissions or inaccuracies with respect to some of the most fundamental features of Medicare Advantage plans. Using available data, working with stakeholders, and strengthening the user experience on Plan Finder will go a long way to making sure that enrollees are making the best choice for their health and financial security.

Sources

1. Meredith Freed, Jeannie Fuglesten Biniek, Anthony Dameco, and Tricia Neuman. Medicare Advantage 2023 Spotlight: First Look. Kaiser Family Foundation. Nov. 10, 2022. Found on the internet at https://www.kff.org/medicare/issue-brief/medicare-advantage-2023-spotlight-first-look/

2. Meredith Freed, Jeannie Fuglesten Biniek, Anthony Dameco, and Tricia Neuman. Medicare Advantage in 2022: Enrollment Update and Key Trends. Kaiser Family Foundation. Aug. 25, 2022. Found on the internet at https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2022-enrollment-update-and-key-trends/

3. Cigna. Evidence of Coverage. January 1-December 31, 2023. Found on the internet at https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2023/eoc-h4513-068-001.pdf

4. Aetna Medicare Solutions. 2023 Summary of Benefits. Aetna Medicare Premier Plus Plan. Found on the internet at https://www.aetnamedicare.com/documents/individual/2023/summaryofbenefits/Y0001_H5521_321_PR04_SB23_M.pdf

5. Cigna. 2023 Summary of Benefits. Cigna Preferred Savings Medicare (HMO). Found on the internet at https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2023/sb-h4513-068-001.pdf

6. Amerigroup. Summary of Benefits. Medicare Advantage and Part D. Plan Year: January 2-December 31, 2023. Tennessee. Amerivantage Balance Plus (HMO). Found on the internet at https://file.anthem.com/MED2023/Y0114_23_3002534_U_M_0248.pdf

7. CMS.gov. CMS Unveils More User-Friendly Medicare Website. May 18, 2022. Found on the internet at https://www.cms.gov/newsroom/press-releases/cms-unveils-more-user-friendly-medicare-website