Tag: provider networks

When Medicare Advantage Drops Doctors, Some Members Can Switch Plans

By Susan Jaffe  | Kaiser Health News | March 29, 2016 | This KHN story also ran on  nprlogo_112x37

Eliza Catchings has been seeing doctors at the Christie Clinic in central Illinois since 1957. But just after receiving this year’s WellCare Medicare Advantage member card, the insurer told her the clinic was leaving WellCare’s provider network and she would have to choose new doctors.

“I was terrified,” said Catchings, 79, who gets care for diabetes and heart problems. But she was helped by a little-noticed change in federal policy.

Medicare Advantage plans sold by private insurers are an alternative to traditional Medicare, but they cover services only from doctors, hospitals and other providers that are in the insurer’s network. Although providers are allowed to drop out of the plans any time, members can usually change only during the annual sign-up period in the fall. There are exceptions, but until recently losing a provider was not among them.

After insurers dropped hundreds of providers in 2013, the Centers for Medicare and Medicaid Services issued rules giving people a “special enrollment period” to change plans or join regular Medicare if there was a “significant” change in their provider network. The policy took effect in 2015 and applies only to Medicare Advantage members, not to the plans CMS oversees in the health law’s marketplaces. …Yet officials didn’t explain what they considered significant or what would trigger the option.

In the past eight months, Medicare officials have quietly granted the special enrollment periods to more than 15,000 Medicare Advantage members in seven states, the District of Columbia and Puerto Rico based on provider cuts. These decisions offer important details about how members can get permission to follow their doctors who leave their plans. … Medicare doesn’t publicize the option, and few beneficiaries may know about it. Representatives who answered calls earlier in March to Medicare’s toll-free number said nothing could be done.  [Continued on Kaiser Health News or NPR] 

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Medicare Advantage Plans Need Tougher Oversight, GAO Says

By: | Connecticut Health Investigative Team Writer | October 5, 2015
Federal investigators have found that Medicare officials rarely enforce rules for private insurance plans intended to make sure beneficiaries will be able to see a doctor when they need care.
It’s a problem many Connecticut seniors know too well. In 2013, UnitedHealthcare, the nation’s largest health insurance company, dropped hundreds of health care providers from its C-HITConnecticut Medicare Advantage plan, including 1,200 doctors at the Yale Medical Group and Yale-New Haven Hospital. Medicare Advantage beneficiaries scrambled to find new insurance or new doctors while the Fairfield and Hartford counties medical associations went to court to try to stop the terminations.
The report by the Government Accountability Office, the investigative arm of Congress, said that Medicare did not check provider networks to ensure that doctors were available to beneficiaries and cited Connecticut as a “case study” in what can go wrong.
The GAO report shows that Medicare “was not verifying network adequacy. That’s their job and they abdicated that responsibility,” said U.S. Rep. Rosa DeLauro, D-New Haven, who requested the investigation along with other members of the Connecticut congressional delegation. MORE
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Medicare To Offer Help To Some Seniors When Advantage Plans Drop Doctors

By Susan Jaffe  | December 22, 2014 |  Kaiser Health News and also published in

Starting next year, the government will offer some seniors enrolled in private Medicare Advantage insurance an opportunity to leave those plans if they lose their doctors or other health care providers.

Last year, thousands of seniors in at least 10 states were left stranded or assigned new doctors when insurers discontinued contracts with the physicians. Medicare Advantage policies cover 16 million seniors and are an alternative to the government-run Medicare program. Medicare Advantage members can only get care from a network of providers under contract to participate in their plan. They must remain in their plans for the calendar year, with some rare exceptions, but losing their doctor has not been among the permitted reasons. [More from KHN] [More in USA Today]

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Draft Rules Would Help Protect Seniors When Medicare Advantage Plans Drop Doctors

By Susan Jaffe  March 24, 2014  KAISER HEALTH NEWS  in collaboration with wapo

Federal officials are considering new Medicare Advantage rules to help protect seniors when insurers make significant reductions to their networks of doctors and other health care providers. The proposals follow UnitedHealthcare’s decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.

The government’s response is part of the 148-page announcement of proposed rules and payment rates for next year’s Medicare Advantage plans released last month by the U.S. Centers for Medicare & Medicaid Services. Officials say that the terminations only a few weeks before Medicare’s Dec. 7 enrollment deadline may not have given seniors enough time to find new doctors, choose a different plan or rejoin traditional Medicare, which does not restrict beneficiaries to a limited network of providers.

…Although the announcement does not name any insurance companies, officials prefaced the proposals by writing, “Recent significant mid-year changes to MAOs’ [Medicare Advantage organizations’] provider networks have prompted CMS to reexamine its current guidance on these requirements and to consider augmenting such guidance in response to such changes.” [More from KHN] [More from Washington Post]…

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Judge’s Medicare Advantage Order Could Have National Impact

By Susan Jaffe | December 6, 2013 | Kaiser Health News produced in collaboration with  

In a decision that could have national implications, a federal judge in Connecticut temporarily blocked UnitedHealthcare late Thursday from dropping an estimated 2,200 physicians from its Medicare Advantage plan in that state. While the judge’s decision affects only the physicians in Fairfield and Hartford Counties who brought suit, several other medical groups are considering filing similar actions.

“This is very good news from Connecticut,” said Dr. Sam L. Unterricht, president of the Medical Society of the State of New York. “We will definitely seriously consider filing a suit in New York as well.” [Continued in Kaiser Health News and USA Today]

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By Susan Jaffe  | November 29, 2013 |  Kaiser Health News produced in collaboration with 

Dorathy Senay’s doctor had some bad news after her last checkup, but it wasn’t about her serious blood disorder called amyloidosis. Her Medicare Advantage managed care plan from UnitedHealthcare/AARP is terminating the doctor’s contract Feb. 1. She is also losing her oncologist at the prestigious Yale Medical Group — the entire 1,200 physician practice was axed. Senay, 71, of Canterbury, Conn., is among thousands of UnitedHealthcare Medicare members in 10 states whose doctors will be cut from their plan network.

The company is the largest Medicare Advantage insurer in the country, with nearly 3 million members. More than 14 million older or disabled Americans are enrolled in Medicare Advantage plans, an alternative to traditional Medicare that offers medical and usually drug coverage but members have to use the plan’s network of providers.

“I have a rare incurable disease and these doctors have saved my life,” said Senay. “I am in good hands and I will not change doctors.”

…Medicare officials review the private plans every year to make sure they comply with network adequacy and other requirements, but the agency did not approve the reconfigured networks resulting from the new provider cancelations. Spokesman Raymond Thorn said the agency “is currently reviewing UHC and other plans’ provider networks and closely monitoring all areas that have experienced disruptions to ensure that beneficiaries have full, transparent and timely information and access to needed care.” [More from KHN] [More in USA Today]