Healthcare Business News

Consumers can opt out if Medicare Advantage networks drop their docs: CMS

By Andis Robeznieks
Posted: April 8, 2014 - 5:45 pm ET

Lost in Monday's announcement by the CMS of 2015 Medicare Advantage rates was another significant decision it issued to allow consumers an opt-out option when their health plans narrow their MA networks.

The agency “is establishing a policy to allow enrollees to switch plans when they are affected by significant mid-year provider network terminations initiated by their Medicare Advantage Organization without cause,” according to a CMS fact sheet. This action was being taken “in response to comments from beneficiary advocates and some professional associations,” according to the fact sheet.

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The CMS now will require plans to give 90 days' advance notice of “any significant changes to their provider networks in order to ensure help compliance with provider access requirements.” Previously, only a 60-day notice was required. The agency also established best practices to guide plans making significant changes to their networks.

Health plans, particularly UnitedHealth Group, had responded to expectations for lower rates by terminating providers from their networks—much to the surprise of doctors in Connecticut, Florida, Indiana, New Jersey, New York and Rhode Island in particular.

In October, plans said the terminations were being made in anticipation of rate cuts. Jack Larsen, CEO of UnitedHealthcare Medicare & Retirement, said at the time that the network narrowing would improve the long-term outlook for the Medicare Advantage program. “This turmoil we're in is heading for a better place,” he said. “That's my forecast.”

State medical societies protested the terminations, which were made just before the MA open enrollment period. The timing resulted in some cases where the names of physicians who had been given advance notice that they were being axed from the network were still appearing on health plan rosters as patients were deciding which plan to pick.

However, Matt Katz, the executive vice president and CEO of the Connecticut State Medical Society, was not impressed with the latest CMS move.

“They seem to be addressing the symptom and not the condition,” Katz said, explaining that the issue remains insurance companies' ability to restrict access to care. “They can no longer eliminate patients, but they can still cherry pick patients by eliminating their doctors,” he said.

The CMS move was cheered by Rep. Rosa DeLauro (D-Conn.), who said 32,000 Connecticut Medicare Advantage enrollees were affected when 2,000 doctors were dropped from UnitedHealthcare's MA network last year.

“Businesses have a right to make business decisions, but as an alternative to the federally administered Medicare program, they also have the responsibility to provide quality, accessible care,” DeLauro said in a news release. “CMS is taking a step in the right direction with these new rules to ensure Medicare Advantage plans are serving the needs of seniors.”

Katz half-heartedly agreed. He was particularly concerned that, when insurance plans trim doctors from networks, the CMS only issued best practice guidelines they could follow rather than requirements they must adhere to.

“It's a step, but it's really a baby step that plans can disregard,” he said.

Follow Andis Robeznieks on Twitter: @MHARobeznieks

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