Lack of data reporting means there are unanswered questions around how supplemental benefits are utilized.
Supplemental benefits are a significant differentiator between Medicare Advantage (MA) and traditional Medicare, with enrollees often opting for the private program because of its coverage for services like dental and vision.
However, how beneficiaries actually use these benefits continues to be a mystery because MA insurers do not report that data, leaving gaps that limit necessary assessment of the private program.
Analysis by Kaiser Family Foundation (KFF) found that most enrollees in individual MA plans have access to eye exams and/or glasses (more than 99%), hearing exams and/or aids (98%), a fitness benefit (98%), telehealth services (98%), and dental care (96%). A report from the Government Accountability Office (GAO) examined plan benefit data for 3,893 MA plans and found that all but one plan offered at least one supplemental benefit not covered under traditional Medicare, with vision and hearing being the most common at 98% and 94%, respectively.
As MA has dramatically grown in recent years, more and more money is going to MA insurers for these supplemental benefits. In the last five years, these payments have more than doubled, increasing from $1,140 per enrollee in 2018 to $2,350 per enrollee in 2023, according to KFF.
How this money is being used by payers is also difficult to understand without the aforementioned data on enrollee spending on supplemental benefits. But why is that data not available?
Though MA plans are required to submit encounter data, which includes supplemental benefits, to CMS, GAO's report uncovered that the information is limited for two reasons.
First and foremost, CMS guidance on encounter data does not specifically mention data for supplemental benefits. GAO said that according to interviewed CMS officials, the inclusion of supplemental benefits is clear. Officials from three MA organizations, on the other hand, told GAO they are not required to submit encounter data on supplemental benefits.
Additionally, CMS officials and two MA organizations told GAO there are challenges, such as there being no procedure codes for some supplemental benefits, in collecting and submitting encounter data.
HHS concurred with GAO's recommendations to clarify guidance on what encounter data submissions must include in relation to supplemental benefits and to address challenges in submitting encounter data for supplemental benefits. Until the reporting of data on supplemental benefits is fully required and enforced though, MA plans will continue operating without necessary oversight.
"Basic descriptive data could also be used to assess whether supplemental benefits are helping to address health disparities by filling specific social or medical needs, such as transportation, and whether the benefits are being targeted to those with the greatest needs," KFF wrote.
Jay Asser is the contributing editor for strategy at HealthLeaders.
Nearly all Medicare Advantage members are in plans that offer access to supplemental benefits like vision, hearing, and dental.
Yet how those services are used by enrollees isn't reported by Medicare Advantage insurers because of lack of guidance on what encounter data is necessary to submit to CMS.
Without encounter data on supplemental benefits, it's challenging to properly assess Medicare Advantage plans and understand how supplemental benefits can improve equity.