It’s Medicare Open Enrollment Time: Beware of Plan Restrictions That Limit Access to Sight-Saving Care

As millions of Americans review their health insurance options during Medicare open enrollment, the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) are urging consumers to be aware of insurance policies that can limit their access to sight-saving procedures and treatments.

Medicare’s fall open enrollment period will end on December 7. Open enrollment is an opportunity for beneficiaries to make changes related to Medicare Advantage plans or prescription drug coverage, allowing them to choose a different Medicare Advantage plan offered through a private insurer or return to original Medicare.

Medicare Advantage plans, the private plan alternative to original Medicare, have become a significant part of the health insurance landscape over the last decade. A recent report from the Kaiser Family Foundation (KFF) shows enrollment in Medicare Advantage more than doubled to 26 million people and accounts for 42 percent of the entire Medicare population.

Unfortunately, some Medicare Advantage plans include frustrating restrictions – often buried deep in the fine print – that limit access to critical procedures and treatments. But most people don’t find out about them until it’s too late. More than 70 percent of Medicare beneficiaries do not compare plans, according to additional KFF analysis.  As insurers have moved to increase the use of prior authorization, it is more critical than ever for consumers to carefully review the details and inquire with plan representatives about care obstacles they may encounter.

For example, Aetna recently began requiring prior authorization for all cataract surgeries across its health plans – including Medicare Advantage. Prior authorization is the process that requires physicians to get advance approval from the patient’s health plan before the insurer will agree to cover a medical service or a medication.

Requiring prior authorization for certain treatments or conditions is a growing trend in the health care insurance industry, one with devastating consequences for patients and physicians. According to an American Medical Association survey, 94 percent of physicians say prior authorization causes care delays, and 30 percent say prior authorization has led to a serious adverse event for a patient in their care.

As a result of Aetna’s new prior authorization policy for cataract surgery, tens of thousands of Americans covered by Aetna have had their sight-restoring surgeries delayed or denied, while insurance company representatives decide who gets to see better – and who must wait for their cataract to get worse before insurance will cover surgery.

“Aetna’s new prior authorization policy for cataract surgery is a troubling example of a health plan restriction that has made it more difficult for Medicare Advantage enrollees to access sight-saving care,” said David Glasser, MD, secretary for Federal Affairs for the AAO. “As the nation’s ophthalmologists continue to fight these care delays and denials on behalf of our patients, we also want consumers to be aware of the restrictions some insurers are imposing so they can choose Medicare Advantage plans accordingly.”

In addition to prior authorization, seniors should closely review Medicare Advantage plans’ Part B drug formularies for restrictions and limitations. One of these restrictions, called step therapy or “fail first,” requires beneficiaries to try and “fail” on an insurer-preferred medication before the insurer will cover the therapy prescribed by their health care provider.

“Medicare beneficiaries receiving Part B covered drugs include some of the most vulnerable patients in the program – those with cancer, progressive blinding eye diseases, rheumatic diseases, multiple sclerosis and compromised immune systems, among others,” said George Williams, MD, a retina specialist and spokesperson for the AAO. “Requiring these beneficiaries to step through a plan-selected drug regimen before accessing treatment recommended by their trusted health care provider can have devastating consequences for patients with vision disorders, including the risk of irreversible blindness.”

Medicare beneficiaries are frustrated by insurance company restrictions like prior authorization and step therapy. The AAO, ASCRS, and the Regulatory Relief Coalition (RRC), of which the AAO is a founding member, are all working with champions in Congress to protect patients from abusive insurer practices. We are advocating for the Improving Seniors’ Timely Access to Care Act (HR 3173/S 3018), which would put guardrails around prior authorization in Medicare Advantage plans.

 

“The RRC is proud to have been on the ground floor as the bill was created and advanced,” said Peggy Tighe, Legislative Counsel to RRC.  “As seniors face the prospect of an often-confusing open enrollment period, we again call for passage of this legislation – to help seniors make fully informed decisions about which health care plan is right for them.” 

 

The majority bipartisan bill now has 239 co-sponsors in the House and was recently introduced in the Senate. In addition, AAO and ASCRS are asking the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs Medicare, to permanently ban step therapy in the Part B program.

 

“Consumers have an opportunity right now to protect themselves from undesirable insurance policies that don’t serve their best interests,” said Richard S. Hoffman, MD, president of the ASCRS. “It can be arduous to review health plans and wade through the convoluted language – but in this case, it’s about good medicine and healthy lives. It’s worth the time.”

 

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About the Academy

The American Academy of Ophthalmology is the world’s largest association of eye physicians and surgeons. A global community of 32,000 medical doctors, we protect sight and empower lives by setting the standards for ophthalmic education and advocating for our patients and the public. We innovate to advance our profession and to ensure the delivery of the highest-quality eye care. Our EyeSmart^® program provides the public with the most trusted information about eye health. For more information, visit aao.org.

About the ASCRS

Founded in 1974, ASCRS has been at the forefront of anterior segment surgery and has established itself as a trusted resource for cataract, refractive, cornea, and glaucoma surgeons. For more than 40 years, ASCRS has been committed to advancing the art and science of ophthalmic surgery as a primary source for the latest clinical information, published research, and regulatory updates affecting anterior segment surgeons and the patients they serve. For more information, visit ascrs.org.

About the Regulatory Relief Coalition

The Regulatory Relief Coalition (RRC) is a group of national physician specialty organizations advocating for regulatory burden reduction in Medicare so that physicians can spend more time treating patients. For more information, visit www.regrelief.org