Rare Enforcements Amid Frequent Complaints on Medicare Advantage Networks

/ KFF Health News

Aging often brings unexpected health hurdles and chronic illnesses, highlighting the comfort found in long-standing doctor-patient relationships. These connections are especially critical in crises, where their absence can be daunting. To safeguard these ties, federal mandates exist to protect those under Medicare Advantage from disruptions when insurers and healthcare providers clash.

Yet, documents from KFF Health News reveal federal oversight barely enforces policies ensuring approximately 35 million users can access their doctors.

Between 2016 and 2022, the Centers for Medicare & Medicaid Services (CMS) sent letters to only five insurers for network inadequacies—issues potentially compromising patient care.

CMS flagged some insurers for insufficient primary or specialized care providers or hospital access. Ignoring these warnings could lead to halts in plan marketing, penalties, or termination.

CMS, however, didn’t elaborate on why only few plans were noted for violations over ten years. According to spokesperson Catherine Howden, such findings stem from targeted reviews rather than full audits.

States plagued by Advantage network issues reported they were left uninformed, including those directing state-funded Medicare assistance programs.

"Finding it hard to accept that only seven plans fell short on network criteria," noted David Lipschutz from the Center for Medicare Advocacy. "Many in rural regions report significant travel just to locate a network provider."

The Landscape of Medicare Advantage

Medicare Advantage rivals traditional Medicare, covering individuals 65 and older and certain disabled persons. Of the eligible Americans, 54% opted for Advantage plans this year, lured by benefits often including vision and dental care, albeit with restricted provider networks. Estimated government payments to these plans reached $494 billion last year.

Unlike traditional Medicare's broad acceptance, Medicare Advantage plans have selective networks, leading to conflicts with healthcare providers. Reports from this year show at least 38 healthcare systems in 23 states have severed ties with 11 plans over disagreements.

Beneficiaries have from March through December 7 to adjust their plans for the following year. Still, healthcare providers can exit plans anytime.

When providers and insurers part ways mid-year, CMS offers a "special enrollment period" (SEP), though the criteria for granting these escape options remain unclear even to seasoned policymakers.

"We Need Your Help"

At a recent conference, CMS encouraged Medicare Advantage insurers to aid in fraud detection. "Act as our alert system," urged Mehmet Oz, encouraging the reporting of observed discrepancies.

CMS's letters to insurers highlighted significant deficits in network adequacy, urging immediate corrective actions. Although deemed initial enforcement steps, the outcomes or penalties post-violation remain undisclosed.

Regulations on Network Adequacy

Federal mandates stipulate that Medicare Advantage networks must offer access to a minimum number of healthcare providers and facilities within set distances. Compliance reviews occur triennially or upon receiving complaints.

Variability exists within networks—even in the same county—since provider minimums align with insurers rather than specific plans. An example: UnitedHealthcare offered multiple plans in Arizona's Maricopa County, boasting varying degrees of physician availability.

Examples of network violations include a 2016 instance in Illinois where Harmony’s network faced sanctions when losing a major clinic, impacting enrollees significantly.

Industry representatives from entities involved in past regulatory actions often declined to comment.