TESTIMONY of CALIFORNIA HEALTH ADVOCATES
September 11, 2007
Washington DC 20001
California Health Advocates (CHA) is an independent, non-profit organization dedicated to education and advocacy efforts on behalf of Medicare beneficiaries in California. Separate and apart from the State Health Insurance Program (SHIP), we provide support, including technical assistance and training, to the network of California’s Health Insurance Counseling & Advocacy Programs (HICAPs) which offer SHIP services in California. CHA also provides statewide technical training and support to social and legal services agencies and other professionals helping Californians with questions about Medicare. Our experience with Medicare is based in large part on our close work with the HICAPs and other consumer assistance programs that are on the front line assisting Medicare beneficiaries, as well as CHA’s long-standing participation as a funded consumer representative to the NAIC.
Our written testimony begins with an overview of the landscape currently facing Medicare beneficiaries, including: the vast number of plan options and variables; the difficulty of making informed decisions; a summary of marketing misconduct witnessed since advent of Part D; and both CMS’s and the insurance industry’s response to marketing misconduct. Since CHA has commented extensively on these issues recently in other settings(1), we will focus most of our attention on suggested responses to these problems, including a proposal for greater regulatory oversight by CMS, restoration of state regulatory oversight, and strengthened consumer protections that include standardization and simplification of plans providing coverage of Medicare benefits.
I. LANDSCAPE FACING CONSUMERS
Selecting the appropriate Medicare coverage for an individual’s particular circumstances has become immensely complicated for most Medicare beneficiaries since the enactment of the Medicare Modernization Act of 2003.(2) Whether an individual is just becoming eligible for Medicare or is currently enrolled in a Medicare product, the number of factors that must be considered to choose appropriate coverage has exploded with the establishment and growth of the Medicare Advantage plans, with and without the Part D prescription drug benefit, and freestanding Part D prescription drug plans. Mistakenly enrolling in the wrong plan can result in the loss of employer sponsored retirement plans that coordinate with Medicare, a loss of Medicare supplemental insurance (and the right to get it back), and/or being locked into a plan for the remainder of the calendar year with more expensive cost sharing, a restricted network of providers who will accept the plan, or benefits that do not match an individual’s needs.
The 2006 Medicare Annual Election Period (AEP) presented Medicare beneficiaries with a tsunami of product choices. Each of these choices involved several different types of products, each with complex benefit variations, premium differences, and cost sharing requirements. Beneficiaries in Los Angeles County, for instance, had more than 106 plan options to consider including stand alone drug plans, HMOs, regional and local PPOs, health plans with and without Part D benefits, Private Fee for Service plans, Special Needs Plans, and a Medical Savings Account plan.
Too much choice can negatively impact consumer decision-making. Nobel Prize winning economist Herbert Simon noted that “a wealth of information creates a poverty of attention.” His work showed that most consumers can manage only a very limited amount of information before they reach information overload.(3) Medicare Advantage plan options create an algebraic puzzle that requires consumers to know and understand impossible amounts of complex information to make an appropriate choice of health care benefits. An individual’s out of pocket costs can vary enormously between plans in unfamiliar ways. For instance, one plan might charge an upfront deductible for a hospital stay, an unlimited per day coinsurance in another, or a daily coinsurance for a limited number of days in a third. These variations can be confusing and often hide the potential for out of pocket costs, making it almost impossible for consumers to compare one method of cost sharing with another, or with the cost sharing of Original Medicare.
In addition, some plans carve out certain Part B services such as chemotherapy, radiation, and certain Part B drugs applying a separate coinsurance or copayment that is not credited towards the plan’s annual out of pocket limit. Only people who currently use those services could be expected to know the financial impact of such a carve out if they understand it is part of the plan they are considering.
Side-by-side comparison of any two plans, even of the same type if plan, can be impossible for beneficiaries and their families. Attempts by consumer groups to produce comparison charts to aid consumers in selecting a plan often result in complex spreadsheets that must be explained to each consumer based on their current coverage and needs. Individual counseling sessions often require several hours to give a consumer enough information so that s/he can choose a plan that will best meet their needs.
Many Medicare beneficiaries have limited or low functional literacy and a significant portion are cognitively impaired, both of which can impact informed decision-making. Many others have limited English proficiency adding another layer of complexity to choosing appropriate coverage. For those beneficiaries who seek more information and/or help in their decision-making about their options through Medicare, roughly half of beneficiaries rely on family and friends, many of whom are usually in the same situation of having to compare plan options. The second-most used source of advice about Medicare coverage options comes from insurance agents and the private Medicare plans themselves.(4)
Information from Medicare private plans and their contracting agents is often inadequate in scope and availability, and ultimately self-serving since it is motivated by maximizing profit. Beneficiary confusion surrounding the multi-faceted and Byzantine Medicare plan options and benefits can be – and has been – easily exploited by both plans and agents, particularly when meeting with beneficiaries in person, often in their own home.
Consumer advocates, state insurance regulators, the media, and Congress have all found appalling abuses surrounding the sale of Medicare Advantage and Part D plans over the last year and a half, resulting in real harm to Medicare beneficiaries. This misconduct has been well documented by all of these sources, including CHA.(5)
Misconduct surrounding the sale of MA plans has ranged from outright fraudulent sales practices to misleading sales due to agent ignorance and inadequate plan oversight. Examples of abuses include: Medicare beneficiaries signed up for plans without their consent or knowledge; prospective MA enrollees told outright lies in order to entice them to join plans; high pressure in-home sales following unsolicited (and prohibited) door-to-door marketing; behavior by agents meant to intimidate consumers; mass enrollments at senior and/or disabled housing facilities following sales presentations, and agents who misunderstood the plan benefits they were selling and enrolled their clients in inappropriate plans.
Despite CMS and industry response, discussed below, marketing abuses are not subsiding. For example, California’s Department of Insurance, which earlier this year reported few consumer complaints, recently issued a warning about aggressive Medicare marketing schemes (July 25th, 2007). In addition, CHA continues to receive reports of marketing misconduct occurring in California and elsewhere.
Industry & CMS Response
Facing mounting pressure from media stories and Congressional hearings, CMS and the insurance industry took several measures in response to reports of marketing abuses. As we have outlined elsewhere, though, these steps do not go far enough to fix the entire range of marketing misconduct surrounding the sale of MA plans.(6) The inadequacies of industry and regulatory response include the following: corrective action plans already imposed on sponsoring companies have not stemmed abusive conduct surrounding the sale of their plans; CMS’ new marketing guidance for PFFS plans, while helpful, does little to monitor and prevent ongoing abusive conduct, and has not been required of other, non-PFFS MA plans; the “voluntary” PFFS suspension of sales announced in June is already over for most plans, with questionable time and effort to correct deficiencies; and plans are still not held accountable for the actions of agents selling their products. So long as the number and complexity of plans continue to grow, consumers cannot easily choose appropriate coverage, and the economic incentives to sell one plan over another continues, marketing misconduct will continue as well.
Due, in part, to the design of Medicare’s regulatory structure, CMS as the federal regulator has allowed Part D and Medicare Advantage plans to police their own marketing activity. Federal law preempts traditional state authority over plans and their actions. Allowing plans and their agents maximum flexibility to sell products has come at the expense of adequate protection for consumers, including the ability of consumers to make apples to apples comparisons between plans they are considering. We argue that CMS should not be concerned with the “balance” between the interests of insurance companies profiting from the Medicare program and people who depend on those Medicare benefits. Instead, the federal government’s role as a federal regulator should be to protect consumers by setting and enforcing standards that create a healthy marketplace with an even playing field for all commercial participants.
Medigap Regulation: Past is Prologue
The complexity and number of permutations of Medicare Advantage plans mimics the number and complexity of Medigap policies before Congress limited the number and benefit designs of those products through federal legislation.(7) The marketing abuses surrounding the sale of MA and Part D plans is also with precedent: as the NAIC recently noted in a June letter to Senators Baucus and Grassley, the “rampant abuses” in the Medigap market leading to passage of OBRA ’90 “bear a striking similarity to the problems we are seeing today with Medicare Advantage and Medicare Part D prescription drug plans.”
Prior to the Omnibus Budget Reconciliation Act of 1990 (OBRA ’90) Medigap policies had proliferated in number, each with different riders, benefit variations, deductibles, and cost sharing requirements making it nearly impossible for consumers to compare one policy with another. As a veteran of the policy debate surrounding Medigap standardization noted at the time, consumers faced many challenges in the pre-standardized Medigap market: “Polices are purposely incomprehensible in their language and construction. They defy side-by-side comparison, and even singly are impossible for consumers to understand.”(8)
The same factors that existed in the Medigap marketplace before OBRA ‘90 exist today in Part D and Medicare Advantage plans; consumers cannot compare benefits and costs and therefore must depend on what agents and plans tell them to choose appropriate coverage. In hindsight, the variations in pre-standard Medicare supplement policies pale by comparison. In addition, unlike Medigap plans, Medicare Advantage plans can change their benefits – and participation in Medicare – annually, giving Medicare beneficiaries far less stability than they enjoy through Medigap coverage and disrupting their continuity of care.
Many of the current Medicare Advantage and Part D marketing abuses result from an unfettered market in which agents and companies are able to put their own economic interests first. Insurance companies and CMS – the agency tasked to regulate them – have placed the blame for misconduct squarely on the shoulders of “rouge” agents, acting without authority from the plans whose products they are selling. Congress heard the same refrain during hearings in the late 1980’s on Medigap abuses until a district attorney in Santa Cruz, California brought a civil case against an insurance agency for those practices and provided Congressional investigators with exhibits from the case which included vivid examples of systemic marketing misconduct in the Medigap marketplace.
In the Medigap context, after hearing numerous complaints that consumers were unable to make informed decisions about their health care coverage in a market with too many complex choices, Congress acted to establish mandatory federal benefit standards, consumer protections, and loss ratios requirements to ensure that consumers received fair value for the products they purchased. During the last 15 years consumers have benefited enormously from the simplicity of choosing a Medigap plan, and many have asked why other insurance purchases can’t be similarly simplified. Below, we offer both broad and specific recommendations concerning the Medicare Advantage and Part D programs aimed towards providing consumers with greater protection.
II. RECOMMENDATIONS for STRENGTHENING CONSUMER PROTECTIONS
We are convinced that much of the marketing abuse prevalent in the Medicare Advantage marketplace stems from several factors, including: the flow of money – both paid to Medicare Advantage sponsors by the Medicare program, and to agents selling these plans through commissions; the inability of consumers to compare plans and make informed choices on their own; and the preemption of traditional state authority over products sold in their state. Below, we make a number of recommendations to address marketing abuses in the Medicare Advantage marketplace. These recommendations range from broad suggestions that would require fundamental changes to the Medicare program, to more specific recommendations that NAIC, on behalf of state regulators, and CMS, as the federal regulator, can implement.
1) Apply the standardization and simplification requirements of the NAIC Medigap Model Act and Regulation to all Medicare Advantage and Part D plans
We strongly endorse NAIC’s request to Congress to consider the current regulation of Medigap insurance as a regulatory model for Medicare Advantage and Part D plans. As noted in a recent letter drafted by NAIC, the “regulation of Medigap insurance provides a good model for enforcement, as states have the ability to take action against both the agents and the companies themselves.”
Standardization and simplification requirements should include:
- Loss ratio standards to limit administrative costs and ensure adequate funds for medical care;
- Guaranteed renewability requirements to ensure stability of benefits;
- Suitability requirements to ensure the right set of benefits is sold to meet individuals’ needs;
- Required disclosures that include notice of availability of SHIP counseling;
- 30 day “free look” to allow time to examine plan documents and seek counseling;
- Replacement disclosure documents and standards to ensure that people understand differences between current benefits and replacement coverage and restrictions.
2) Create standard benefit packages for Medicare Advantage and Part D Plans
The proposal to standardize Medicare Advantage (previously Medicare+Choice) plan benefits is not a new one.(9) We believe it is time for Congress to delegate to the NAIC a charge to standardize and simplify Medicare Advantage and Part D plans. The NAIC’s original and continuing work on Medigap polices offers a structure and format for convening a similar group of interested parties to produce a limited number of benefit packages and simplify products that promise to provide Medicare covered services. There can be little argument that this is a necessary step given the striking parallels to the inability to make an informed choice of a Medigap policy prior to 1990, and the almost instant reforms benefiting consumers that resulted from standardizing those products.
While the nature of Medicare supplement insurance and Medicare Advantage products are very different, important lessons can be learned from the federal standards established in OBRA 90. Following OBRA 90, it was easier for consumers to compare products and prices and to choose the health benefits they needed at a known cost. In addition, complaints about carriers and agents were reduced.(10) There are no hidden out of pocket costs in these products and there are no changes to their benefits once enrolled. Over the years, choosing a Medicare supplement policy has become one of the easiest insurance decisions older Americans are required to make, although cost remains an issue for many low-income beneficiaries. Consumers often ask why other insurance products couldn’t be made as easy to compare. It’s a good question and one that can and should be applied to Medicare Advantage and Part D plans.
We believe that MA and Part D plans should be standardized and simplified so that Medicare beneficiaries can make meaningful comparisons, and plans can be held accountable for providing adequate benefits. We believe that standardization should include the following elements:
- Limits on annual out-of-pocket spending;
- Requirement that MA plans charge no more cost-sharing for services than what is charged under Original Medicare (e.g. inpatient and SNF stays, home health services, Part B drugs, DME, etc.) and a limitation on the number of permissible cost sharing methods;
- Development of more comprehensive disclosure documents to ensure that people with Medicare will understand the changes they are making to the way they get their Medicare benefits and any effect on their Medicaid benefits. For instance, MA marketing materials should clearly disclose – in plain language – that purchase of this product may change how the individual receives Medicare-covered services. Managed care products should clearly warn potential members that enrollment may limit which doctors and other providers they can see. Such important changes in coverage should not be buried in fine print;
- Requirement that all MA and Part D product names clearly specify what they are. Instead of “value”, “reward”, “gold”, “silver” etc., there should be clear descriptive terms in the name of each product, such as “HMO” or “PDP” and a proscribed disclosure developed by CMS to alert people with Medicare to any changes they are making to their health care delivery system.
While MA and Part D plans vary considerably by plan type and benefit design there are elements of each that could be standardized to make it easier for consumers to differentiate one plan from another and to readily identify costs associated with each plan. For instance, for CMS could:
- Limit companies to two plans for each type of plan and eliminate unnecessary duplication and confusion;
- Limit the variables between plans such as deductibles and other cost sharing and eliminate some of the complexity of comparing plans;
- Prohibit cost sharing for specific medical services and end a discriminatory practice against people with critical or chronic medical conditions;
- Require a standardized format for displaying benefits and cost sharing to achieve the goal of side-by-side comparisons.
3) Rescind the statutory preemption that prevents states from enforcing state laws on consumer protections and the marketing of insurance products.
The primary obligation of state insurance departments is to protect the buying public who purchase the promise of immediate or future insurance benefits by the payment of premiums to insurance companies. States license, monitor and enforce state law for insurance companies that make insurance products available for sale in their state and the agents authorized to sell those insurance products. However, states have been stripped of their authority to apply and enforce state law in regard to companies selling products related to the federal Medicare program under the Medicare Modernization Act (MMA).(11) Federal preemption limits a state’s authority to the issuance of a state license to companies under contract to the federal government, unless the Centers for Medicare and Medicaid (CMS) issues a waiver allowing a company to escape this requirement. State insurance departments must be able to exercise their authority to enforce state law and regulate companies and the products sold in their state. The federal preemption of state authority should be repealed.
We strongly support NAIC’s request to Congress to restore state insurance regulatory authority over Medicare Advantage and all Part D plans (see NAIC’s 6/19/07 letter to Senators Baucus and Grassley). States should have the authority, when a pattern of marketing misconduct by a Medicare Advantage or Part D plan is demonstrated, to order plans to “cease and desist” from enrollment, to levy financial penalties and to revoke the licensure of state plans. States should have the authority to require plans to appoint their independent agents and brokers and hold the plans accountable for the actions of these plan representatives. In addition, state insurance appointment laws should be applied towards Medicare Advantage and Part D plans; as noted by NAIC, “state insurance regulators’ already limited ability to hold companies responsible for the acts of their agents has been eroded even further by CMS’ interpretation that state insurance appointment laws, which help create an agency relationship between plans and their agent/brokers, are pre-empted and unenforceable” (NAIC letter to Sens. Baucus and Grassley, 6/19/07). Unless there is enforcement by state regulators that penalizes plans – instead of just agents – abuses will continue. States should have similar authority to that which they have in the Model Act and Regulation for Medigap policies
4) Prohibit plans from offering differential commissions based on what type of plan is selected by the enrollee.
The current commission structure employed by plan sponsors creates an incentive to sell certain MA plans over PDP plans, regardless of whether it is the best option for an individual. Basing higher commissions on the amount of time necessary to explain a plan option serves as a convenient rationale for allowing plans to reward agents that sell plans that generate more revenue, whether or not the plan is suitable for the consumer. Agents should receive compensation based not solely on initial enrollment into a plan, but also based on continued enrollment. This would ensure stability in plan enrollment and encourage agents to sell appropriate coverage and is the compensation system used for most insurance products.
High commissions, sales contests and other devices are far more likely to attract agents who have little interest in the industry as a profession and have far more interest in a quick buck. These agents are more likely than career agents to be responsible for continued marketing abuses. Some career agents are unwilling to be associated with a product that creates such bad press for the profession. Unless payment to Medicare Advantage is on par with the Original Medicare program, and commissions are more uniform, financial incentives will continue to contribute to abusive sales of these products.
5) Repeal lock-in and allow people with Medicare to change MA plans and prescription drug plans during the course of the year.
Instead of restricting most beneficiaries to making plan choices to certain times of the year, we believe that all Medicare beneficiaries should be allowed to change plans on a monthly basis. Coupled with recommendations concerning suitability standards and replacement commissions, this would allow enrollees to undo bad choices more easily. Excessive movement out of a plan would be clear cut evidence that enrollees were not sold appropriate coverage.
6) Offer the Part D prescription drug benefit through Original Medicare.
Give people with Medicare the choice of a drug coverage option under the Original, Medicare program. If people with Medicare do not want to deal with private plans and their marketing agents, they won’t have to.
7) Eliminate the overpayments to Medicare Advantage plans and put payments on par with local costs under Original Medicare.
Pegging Medicare Advantage payment benchmarks to Original Medicare costs will encourage plans to devote their resources to improving efficiency and adding value to their products and eliminate the windfall profits that are driving aggressive marketing strategies and paying for commissions and bonuses to unscrupulous agents. OBRA 90, which stemmed abusive marketing of Medigap supplemental plans, was successful in part because it tempered the profitability of Medigap plans by establishing minimum medical loss ratios — minimum percentages of premium income that must be spent on medical benefits — and thus the financial incentives for aggressive marketing. Putting Medicare Advantage payments on par with Original Medicare costs should likewise dampen incentives for aggressive marketing.
8) Standardize and streamline the process through which plan enrollment and disenrollment disputes are handled, including Special Enrollment Periods (SEPs) and retroactive disenrollment requests.
Absent a meaningful, standardized appeals process designed for these issues, resolution of beneficiary problems will remain inconsistent and incomplete.
9) Public disclosure of corrective actions
When advocates file complaints with Medicare about plan conduct, the results of these complaints, if any, are rarely made available. In an effort to encourage Medicare beneficiaries to report bad plan conduct – and to deter plans from engaging in such conduct – CMS should make sanctions and other corrective plans/efforts it imposes on plans publicly available and easily accessible, including through their website.
In addition, MA and Part D plans should be required to report all complaints about their agents to CMS and to the appropriate state regulatory agency. CMS should keep records of the agents reported to them and work with the appropriate state agency to resolve those complaints. Agents fired by one company selling Medicare products should not be allowed to sell another company’s Medicare products. CMS should provide technical training to state insurance departments to help them understand how the purchase or replacement of coverage is related to a state’s rules for inappropriate or abusive sales.
10) Hold sponsoring companies accountable for the actions of agents selling their insurance products.
When an agent engages in misconduct while selling a plan’s product, the plan should be forced to take corrective measures, including the imposition of monetary sanctions against the sponsors and agents. People with Medicare harmed by these practices should be held harmless and any debt they have incurred should be the responsibility of the sponsoring company.
11) Agent-specific recommendations
Agent activity should be further regulated to include:
- Prohibition against agents cross-selling unrelated products (e.g., annuities and life insurance) during a Medicare product solicitation or sales session. We share NAIC’s concern about these high-pressure sales tactics, and we call for a prohibition of these activities;
- Prohibition against cold calling;
- Mandatory agent training – CMS should require all MA plans (and PFFS sponsors in particular) to provide a standard curriculum with accompanying testing by an outside 3rd party. Minimum training should include an overview of Medicare and all types of products (MA, PDP, Medigap) and how Medicare interacts with other coverage such as Medicaid, retiree coverage, VA, etc., and should highlight that individuals with certain kinds of insurance are in danger of losing it if they enroll in an MA or PDP. Training scripts should include clear, unbiased explanations of the coverage options available, including Original Medicare, Medigap supplemental plans, Medicare Advantage, Medicaid and Medicare Savings Programs, as well as marketing guidelines. Training should not be limited to company product lines. In addition, agents should be required to provide information to each prospective enrollee about how to reach their local SHIP program. Ultimately, the training should enable agents to help beneficiaries make the most appropriate choice among their coverage options;
- Sales reporting requirements –CMS should ban sales in senior or disabled housing facilities, and implement reporting requirements that enable plans and CMS to identify and prevent unsolicited door-to-door sales. All in-home enrollments should be flagged and agents should be able to document how an invitation for an in-home presentation was secured. Mass enrollments at sale presentations should also trigger increased plan efforts to verify suitability of their product for the new enrollee and should be discouraged or barred in the commission structure for agents. Mass enrollments indicate an absence of individualized attention on the part of the agent necessary to ensure the product sold is appropriate to an individual’s needs. Similarly, plans should monitor monthly enrollment figures for individual agents in order to ensure that high production does not indicate a failure to adequately explain suitable coverage options to consumers.
Standardization of Medicare supplemental policies came only after years of complaints of bad sales practices and confounding benefit structures. Medicare Advantage and Part D plans, though, provide the sole access to one or more of Medicare’s benefits and have a much more profound impact on the health care status of beneficiaries. In addition, once a choice is made beneficiaries have few options to make any changes during the current year. Given the central role MA and Part D plans play in the Medicare arena, it is unreasonable to delay action that would make it easier for consumers to choose coverage, make benefits and costs more transparent, and allow consumers to realistically determine their ability to absorb the costs of the plan they choose.
Thank you for the opportunity to provide these comments. Respectfully submitted by:
Training & Policy Specialist
California Health Advocates
California Health Advocates
- See, e.g., CHA reports drafted with Medicare Rights Center entitled “After the Gold Rush” (January 2007). “The Reluctant Regulator” (July 2007); also see CHA testimony before the House Ways & Means Health Subcommittee (May 22, 2007); and CHA testimony before House Energy & Commerce Oversight Subcommittee (June 26, 2007).
- Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub.L. 108-173, 117 Stat. 2066
- Simon, H. 1979. Information processing models of cognition. Annual Review of Psychology, 30:363-396.
- MedPAC Report to Congress: Increasing the Value of Medicare re: choosing a plan: 49% of beneficiaries cited using family members or friends as resources as they made decisions. Other sources of assistance used by beneficiaries were insurance agents (17%), Part D plans (8%), pharmacists (3%), doctors (1%), counselors (6%), nursing home/senior housing (3%), and employer/union (2%). (MedPAC, June 2006); http://www.medpac.gov/….pdf.
- For an analysis of the factors contributing to marketing abuses, as well as example misconduct, see, e.g., CHA reports drafted with Medicare Rights Center entitled “After the Gold Rush” (January 2007), and “The Reluctant Regulator” (July 2007); also see CHA testimony before the House Ways & Means Health Subcommittee (May 22, 2007); and CHA testimony before House Energy & Commerce Oversight Subcommittee (June 26, 2007).
- See, e.g., CHA report drafted with the Medicare Rights Center entitled “The Reluctant Regulator: The Center for Medicare and Medicaid Services’ Response to Marketing Misconduct by Medicare Advantage Plans” (July 2007).
- Omnibus Budget Reconciliation Act of 1990 (P.L. 101-508, OBRA 90) and the Social Security Act Amendments of 1994 (P.L. 103-432, SSAA 94).
- Bonnie Burns, Hearing testimony on Medicare Supplement Policies, Subcommittee on Health of the Committee on Ways and Means House of Representatives, March 13, 1990
- See, e.g., Fox, Peter, Snyder, Rani, Dallek, Geraldine, Rice, Thomas, “Should Medicare HMO Benefits be Standardized?” Commonwealth Fund (February 1999); Dallek, Geraldine, Edwards, Claire, “Restoring Choice to Medicare+Choice: The Importance of Standardizing Health Plan Benefit Packages” Commonwealth Fund (October 2001).
- Hahn, Jim; Standardized Choices: Medigap Lessons for Medicare Part D, CSR Report for Congress, (Received through the CRS Web) March 8, 2006 (Order Code RL33300)
- See Section 232(a) of 42 USC 1395w-26(b), which expands federal preemption of Medicare Advantage and PDP plan regulation by states.