Important Medicare Decisions Should Not be Left to Auto-Pilot

Medicare is a complex program—even the savviest among us need help navigating it. Increasingly, artificial intelligence (AI) tools are being used to assist people with their coverage choices—largely by commercial brokers selling Medicare insurance products. Should critical Medicare coverage choices be based on such automation?

Over many years, the Center for Medicare Advocacy has seen Artificial Intelligence (AI) decision-making software used as a means of restricting access to healthcare. A growing number of providers and health plans are using such proprietary software to make Medicare coverage decisions about whether or not, or for how long, services will be covered and provided in certain care settings.  

Too Much Choice Involved

We were contacted about a Medicare beneficiary who was admitted to a skilled nursing facility (SNF) after an inpatient hospitalization. The beneficiary was given an “outcome report” by the SNF, generated by AI software that projected her “success at rehabilitation” and determined her discharge date from the SNF–which was sooner-than expected.

When challenged, the SNF said that it had to comply with the report, and that it was “out of their hands.” Rather than making an individualized assessment of a person’s condition, and determining the ongoing medical necessity of a given service (as required by law), such software uses generalized, more restrictive guidelines than those authorized by Medicare. 

We are now seeing a rise in AI tools being used to help people make decisions about their Medicare coverage and enrollment options, namely among private Medicare Advantage (MA) insurance plans. It’s not surprising that people seek help. In 2021, Medicare beneficiaries have an average of 33 Medicare Advantage (MA) plans and 30 Part D stand-alone prescription drug plans (PDPs) from which to choose. While often touted as the market doing what it does best—providing a wide range of plan options from which to choose based upon the individual’s circumstances—there is a strong argument to be made that this constitutes “too much choice.”  

When it comes to Medicare, however, choices are not merely confined to one set of private health plan options from which to choose, as within Affordable Care Act exchanges. Instead, the most complex choices people have to make about their Medicare coverage options usually must be made when someone is first eligible—including how Medicare might work with any existing coverage they might have, whether someone wants to exercise a (usually) time-limited right to purchase a Medigap plan, or choose a private Medicare Advantage or Part D plan, to supplement their traditional Medicare coverage(or figure out if they even have a choice—e.g., their retiree coverage may not offer options).

‘A given brokerage firm might not contract to sell all of the available products available in a given market.’

People must also decide who they want making their healthcare decisions—their doctor or a private Medicare plan gatekeeper—and what risks they are willing to take. (These might include higher monthly premiums in exchange for better out-of-pocket protections with a Medigap policy, or lower or no premium in exchange for higher costs-sharing when services are used).

And the choices are unequal—for example, while people can get in and out of an MA plan on an annual basis, most people have limited opportunities to purchase a Medigap plan—a fact many people discover too late. Even when it comes to private plans, there are more opportunities to change MA plans than there are stand-alone Part D prescription drug plans, and, in recent years, the government has put its thumb on the scale of promoting private plans choices over traditional Medicare.  

Unbiased Counselors Best

Such decisions about how one wishes to access his or her Medicare coverage—and the discussions leading to such decisions—are best done with the assistance of knowledgeable, unbiased Medicare counselors, such as those available at no cost through the State Health Insurance Assistance Program (SHIP), rather than individuals who have a pecuniary interest in the outcome of the beneficiary’s decision.  

When an agent or brokerage firm employs AI to gather information to help people make decisions, it is questionable whether the necessary complex discussions requiring lots of information for different contingencies, will occur. With agents and brokers, there is always the issue that higher commissions are generally paid for enrollment in MA plans vs. stand-alone Part D plans. Further, a given brokerage firm might not contract to sell all of the available products available in a given market (MA, Part D, Medigap), which can actually limit available options offered to the consumer.

AI might help someone make an optimal choice in a given year concerning, for example, out-of-pocket cost-sharing among the same type of plan (MA or Part D). However, these plans can and do change their coverage, providers and cost-sharing on an annual basis, necessitating an annual selection exercise, from which most people opt out. Medicare coverage choices can be burdensome, and the choices unequal. AI is an insufficient tool for making such a complex, individualized decision. 

Judith Stein is the executive director and David Lipschutz is associate director of the Center for Medicare Advocacy in Washington, DC.