Study utilization management in Medicare Advantage

MA provides healthcare coverage through private managed care plans for hospital and physician services as an alternative to traditional Medicare FFS. Enrollment in MA has continued to grow over the years and now accounts for more than 50 percent of Medicare enrollees. As enrollment continues to increase in the MA program, it’s critical for policymakers and regulators to fully understand any key differences in ability to access care between MA and traditional Medicare FFS, including the ability to access care for MH/SUDs.

Unlike Medicare FFS, MA plans employ utilization management tools, such as cost-sharing and prior authorization requirements, that may impact how beneficiaries are able to access treatments and services. MA plans  may also provide additional services and benefits that are not covered by traditional Medicare FFS (e.g., dental and vision benefits).

Presently, the Mental Health Parity and Addiction Equity Act of 2008 does not apply to any part of Medicare. Thus, it is critical  to understand whether and how MA plans may be restricting access to MH/SUD care. While some information is known about the differences between the two programs [2], a clearer and more comprehensive assessment is needed. Congress should require the GAO to conduct a study that seeks to understand the differences in enrollee cost-sharing and utilization management with the goal of ensuring that MA plans are not restricting access to MH/SUD, particularly as compared to Medicare FFS.[1]