Challenges for Medicare Advantage Members
Facing health issues as we age can be tough, not just because of physical pain but also due to the complex relationships we build with healthcare providers. It’s a bit of a safety net when you have a doctor you trust, especially during health crises. Losing that support can be really scary. This brings us to a less-known federal rule that aims to shield those with private Medicare Advantage plans when providers and insurers have disputes.
However, according to documents acquired by KFF Health News, there’s insufficient oversight of this issue. While Medicare Advantage covers about 35 million individuals, enforcement of a long-standing regulation is lacking, which is meant to help members find doctors more easily.
The Centers for Medicare and Medicaid Services (CMS) responded to a Freedom of Information Act request, revealing that between 2016 and 2022, they only addressed issues with five insurers out of several that didn’t meet network standards. These provider network adequacy requirements can significantly impact the quality of care patients receive.
According to CMS, some plans simply didn’t have enough primary care doctors, specialists, or hospitals. Plans that don’t comply could face caps on marketing, fines, or even termination. The reasons for the low count of network violations were unclear. A CMS representative, Katherine Howden, stated that the findings reflect a targeted review and not a comprehensive audit.
In states where these network issues arose, local officials were not informed by CMS. Some state health insurance programs that help residents navigate Medicare felt kept in the dark. David Lipshutz from the Medicare Advocacy Center expressed skepticism, saying it’s hard to believe there were only seven networks in violation; especially since people frequently report traveling long distances for care.
Medicare Advantage has become increasingly popular among those over 65 and certain individuals with disabilities. This year, 54% of the 63 million eligible individuals chose Advantage plans. They typically offer lower costs and additional benefits, such as vision and dental care, but usually require members to stick to a specific network of providers. Last year, the government spent around $494 billion on these plans.
In contrast, traditional Medicare is accepted by nearly every doctor and hospital across the U.S., which adds a layer of flexibility.
Disputes often pop up between Medicare Advantage plans and their healthcare providers. This year alone, more than 38 hospital systems across 23 states ended partnerships with at least 11 Advantage plans, primarily due to payment conflicts. In the last three years, disputes between Advantage plans and healthcare providers have surged by 66% according to FTI Consulting.
Currently, Medicare Advantage beneficiaries find themselves generally restricted to their existing plans until the annual enrollment period, which ends on December 7, with new coverage starting January 1. Yet, healthcare providers can end their agreements with insurance plans at any moment.
When such splits occur, Advantage members might lose access to longtime doctors and hospitals. In such cases, CMS could provide a little-known option called a “special enrollment period,” allowing members to switch plans or enroll in traditional Medicare mid-year. How CMS determines who qualifies for this special period remains unclear, leaving even those in the know puzzled.
In light of all this, Oregon Senator Ron Wyden and Senator Mark Warner have sought clarification from CMS regarding the SEP process, highlighting its opacity and the potential confusion it causes for beneficiaries.
Urgency for Clarity
On October 15, CMS Administrator Mehmet Oz encouraged Medicare Advantage insurers to help identify fraud in the program. He urged them to report issues they observe to improve the situation. After his address, he was seen interacting with industry leaders, emphasizing collaboration.
CMS has sent violation letters to several insurers detailing inadequate network compliance, which could hinder members’ access to care. Five letters outlined specific deficiencies, and in some cases, plans were notified they could request exceptions but did not. Plans also received warnings to address these issues, with potential penalties looming.
The Medicare Payment Advisory Commission has pointed out that while CMS holds the authority to impose penalties for network violations, they have never acted on it.
A notable case involved California’s Vitality Health Plan, which faced violations for removing multiple hospitals from its network. CMS had informed members of a special enrollment period just prior to notifying Vitality of the violations, indicating a concerning lack of communication about the risks involved.
People in Santa Clara County expressed relief over special enrollment opportunities but weren’t aware of the network violations, leading to potential gaps in their care.
Requirements for Adequate Networks
There are federal mandates that require Medicare Advantage plans to maintain certain numbers of healthcare providers and facilities within an accessible distance for members. These rules vary based on population and density to ensure timely access to care. Generally, CMS checks for compliance every three years, or more often if there are complaints.
Nevertheless, networks can differ greatly even among areas. For instance, in Maricopa County, Arizona, UnitedHealthcare managed numerous plans across different networks, reflecting the variability in access to doctors compared to traditional Medicare beneficiaries.
In a past case involving Harmony, a Medicare Advantage plan, CMS allowed hundreds of employees to leave the program after a significant provider exited. Compliance communication was mishandled, leaving consumers uninformed. This breach of trust is a concern for many advocates who fear that it could lead to poor choices affecting patient health.
Entities like CareSource have made attempts to rectify previous violations, but the overarching issue remains: transparency and effective communication are crucial for ensuring beneficiaries’ trust and access to care.
