Some Medicare Managed Care Plans Restrict Mammograms

Some Medicare managed care organizations (MCOs) are telling beneficiaries that they need to get a referral from one of the plan physicians before they can get a mammogram. But that is not what the law says. A woman can get an annual, routine mammogram without any referral. William Scanlon, director of health financing and public health for the General Accounting Office (GAO), says that a study the GAO just did of 16 MCOs found that five of them erroneously stated the mammogram benefit.

And that wasn’t the only problem the GAO found after it combed through the plan documents and contracts for these MCOs. There were problems with the prescription drug benefit, too. Managed care organizations offer outpatient drugs—which are not available as part of Medicare fee-for-service—as an enticement to get people into managed care plans. Scanlon says that one plan stated in its contract with Medicare that it would pay the first $1,200 a year in name brand prescription expenses for each Medicare beneficiary. However, the literature given to potential members by the MCO stated that only the first $600 in name brand prescription expenses would be covered.

Those revelations came out at hearings held by the Senate Special Committee on Aging. Sen. Charles Grassley (R-Iowa), chairman of the committee, says inaccurate information given to beneficiaries by MCOs leads to appeals when benefit claims are then denied.