Susan Jaffe, Author at ºÚÁϳԹÏÍø News Tue, 17 Mar 2026 20:07:58 +0000 en-US hourly 1 https://wordpress.org/?v=6.8.5 /wp-content/uploads/sites/2/2023/04/kffhealthnews-icon.png?w=32 Susan Jaffe, Author at ºÚÁϳԹÏÍø News 32 32 161476233 Sick of Fighting Insurers, Hospitals Offer Their Own Medicare Advantage Plans /news/article/health-insurance-medicare-advantage-plans-hospitals/ Mon, 26 Jan 2026 10:00:00 +0000 /?post_type=article&p=2145395 Ever since Larry Wilkewitz retired more than 20 years ago from a wood products company, he’s had a commercial Medicare Advantage plan from the insurer Humana.

But two years ago, he heard about Peak Health, a new Advantage plan started by the West Virginia University Health System, where his doctors practice. It was cheaper and offered more personal attention, plus extras such as an allowance for over-the-counter pharmacy items. Those benefits are more important than ever, he said, as he’s treated for cancer.

“I decided to give it a shot,” said Wilkewitz, 79. “If I didn’t like it, I could go back to Humana or whatever after a year.”

He’s sticking with Peak Health. Members of Medicare Advantage plans, a privately run alternative to the government’s Medicare program, can change plans through the end of March.

Now entering its third year, Peak Health has tripled its enrollment since last year, to “north of 10,000,” said Amos Ross, its president. It expanded from 20 counties to 49, he said, and moved into parts of western Pennsylvania for the first time.

Although hospital-owned plans are only a sliver of the Medicare Advantage market, their enrollment continues to grow, reflecting the overall increase in Advantage members. Of the 62.8 million Medicare beneficiaries eligible to join Advantage plans, , according to KFF, the health information nonprofit that includes ºÚÁϳԹÏÍø News. While the number of Advantage plans owned by hospital systems is relatively stable, Mass General Brigham in Boston and others are expanding their service areas and types of plan offerings.

Health systems have dabbled in the insurance business for years, but it’s not for everyone. MedStar Health, serving the greater Washington, D.C., area, said it closed its Medicare Advantage plan at the end of 2018, citing financial losses.

“It’s a ton of work,” said Ross, who spent more than a decade in the commercial health insurance industry.

Like any other health insurer, hospitals entering the business need a back-office infrastructure to enroll patients, sign up providers, fill prescriptions, process claims, hire staff, and — most importantly — assure state regulators they have a reserve of money to pay claims. Once they get a state insurance license, they need approval from the federal Centers for Medicare & Medicaid Services to sell Medicare Advantage policies. Some systems affiliate with or create an insurance subsidiary, and others do most of the job themselves.

Kaiser Permanente, the nation’s largest nonprofit health system by revenue, started an experimental Medicare plan in 1981 and now has nearly 2 million people enrolled in dozens of Advantage plans in eight states and the District of Columbia. The Justice Department announced Jan. 14 that KP had agreed to pay $556 million to settle accusations that its Advantage plans fraudulently billed the government for about $1 billion over a nine-year period.

Last year, UCLA Health introduced two Medicare Advantage plans in Los Angeles County, the most populous county in the United States. Other new hospital-owned plans have cropped up in less profitable rural areas.

“These are communities that have been very hard for insurers to move into,” said Molly Smith, group vice president for public policy at the American Hospital Association.

But Advantage plans offered by hospitals have a familiar, trusted name. They don’t have to move into town, because their owners — the hospitals — never left.

Bad Breakups

Medicare Advantage plans usually restrict their members to a network of doctors, hospitals, and other clinicians that have contracts with the plans to serve them. But if hospitals and plans can’t agree to renew those contracts, or when disputes flare up — often spurred by payment delays, denials, or burdensome prior authorization rules — the health care providers can drop out.

These breakups, plus planned terminations and service area cuts, forced more than 3.7 million Medicare Advantage enrollees to make a tough choice last year: find new insurance for 2026 that their doctors accept or, if possible, keep their plan but find new doctors.

About 1 million of these stranded patients had coverage from UnitedHealthcare, the country’s largest health insurer. In a July earnings update for financial analysts, chief financial officer John Rex blamed the company’s retreat on hospitals, where “most encounters are intensifying in services and costing more.”

The turbulence in the commercial insurance market has upset patients as well as their providers. Sometimes contract disputes have been fought out in the open, with anxious patients in the middle receiving warnings from each side blaming the other for the imminent end to coverage.

When Fred Neary, 88, learned his doctors in the Baylor Scott & White Health system in central and northern Texas would be leaving his Medicare Advantage plan, he was afraid the same thing could happen again if he joined a plan from another commercial insurer. Then he discovered that the 53-hospital system had its own Medicare Advantage plan. He enrolled in 2025 and is keeping the plan this year.

“It was very important to me that I would never have to worry about switching over to another plan because they would not accept my Baylor Scott & White doctors,” he said.

Eugene Rich, a senior fellow at Mathematica, a health policy research group, said hospital systems’ Medicare Advantage plans offer “a lot of stability for patients.”

“You’re not suddenly going to discover that your primary care physician or your cardiologist are no longer in the plan,” he said.

A that Rich co-authored in July found that enrollment in Advantage plans owned by hospital systems grew faster than traditional Medicare enrollment for the first time in 2023, though not as rapidly as the overall rise in sign-ups for all Advantage plans.

The massive UCLA Health system introduced its two Medicare Advantage plans in Los Angeles County in January 2025, even though patients already had a list of more than 70 Advantage plans to choose from. Before rolling out the plan, the University of California Board of Regents discussed its merits at a November 2024 meeting. The offer rare insight into a conversation that private hospital systems would usually hold behind closed doors.

“As increasing numbers of Medicare-enrolled patients turn to new Medicare Advantage plans, UC Health’s experience with these new plans has not been good, either for patients or providers,” the minutes read, summarizing comments by David Rubin, executive vice president of UC Health.

The minutes also describe comments from Jonathon Arrington, CFO of UCLA Health. “Over the years, in order to care for Medicare Advantage patients, UCLA has entered numerous contracts with other payers, and these contracts have generally not worked out well,” the minutes read. “Every two or three years, UCLA has found itself terminating a contract and signing a new one. Patients have remained loyal to UCLA, some going through three iterations of cancelled contracts in order to remain with UCLA Health.”

Costs to Taxpayers

CMS pays Advantage plans a monthly fixed amount to care for each enrollee based on the member’s health condition and location. In 2024, the federal government paid Advantage plans an estimated $494 billion to care for patients, according to the Medicare Payment Advisory Commission, which monitors the program for Congress.

The commission said this month that it projects insurers in 2026 will be paid 14%, or about $76 billion, more than it would have cost government-run Medicare to care for similar patients.

Many Democratic lawmakers have criticized overpayments to Medicare Advantage insurers, though the program has bipartisan congressional support because of its increasing popularity with Medicare beneficiaries, who are often attracted by dental care and other coverage unavailable through traditional Medicare.

Whenever Congress threatens cuts, insurers claim these generous federal payments are essential to keep Medicare Advantage plans afloat. UCLA Health’s Advantage plans will need at least 15,000 members to be financially sustainable, according to the meeting minutes. CMS data indicates that 7,337 patients signed up in 2025.

A study in August compared patients in commercial Medicare Advantage who had major surgery with those covered by Medicare Advantage plans owned by their hospital. The latter group had fewer complications, said co-author Thomas Tsai, an associate professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health.

Smith, of the American Hospital Association, isn’t surprised. When insurers and hospitals are not on opposite sides, she said, care delivery can be smoother. “There’s more flexibility to manage premium dollars to cover services that maybe wouldn’t otherwise be covered,” Smith said.

But Tsai warns seniors that hospital-owned Medicare Advantage plans operate under the same rules as those run by commercial health insurance companies. He said patients should consider whether the extra benefits of Advantage plans “are worth the trade-off of potentially narrow provider networks and more utilization management than they would get from traditional Medicare.”

In Texas, Neary hopes the closer relationship between his doctors and his insurance plan means there’s less of a chance that bills for his medical care will be kicked back.

“I don’t think I would run into a situation where they would not provide coverage if one of their own doctors recommended something,” he said.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 2145395 Cansados de pelear con las aseguradoras, hospitales ofrecen sus propios planes Medicare Advantage /news/article/cansados-de-pelear-con-las-aseguradoras-hospitales-ofrecen-sus-propios-planes-medicare-advantage/ Mon, 26 Jan 2026 09:59:00 +0000 /?post_type=article&p=2147836 Desde que Larry Wilkewitz, de 79 años, se jubiló de una empresa de productos de madera, hace más de 20 años, ha tenido un plan comercial de Medicare Advantage ofrecido por la aseguradora Humana.

Pero hace dos años, escuchó sobre Peak Health, un nuevo plan Advantage creado por el Sistema de Salud de la Universidad de West Virginia, donde atienden sus médicos. Era más económico, ofrecía una atención más personalizada y brindaba beneficios adicionales, por ejemplo, una asignación para productos de farmacia de venta libre.

Esas ventajas son más importantes que nunca, comentó Wilkewitz, quien está recibiendo tratamiento contra el cáncer.

“Decidí probarlo”, dijo. “Si no me gustaba, podía volver a Humana o a cualquier otro plan después de un año”.

Pero ha decidido mantenerse en Peak Health. Consumidores con Medicare Advantage —una alternativa privada al programa Medicare del gobierno— pueden cambiar de plan hasta finales de marzo.

Ahora, al comenzar su tercer año, Peak Health ha triplicado el número de afiliados respecto al año pasado, “superando los 10.000”, dijo su presidente, Amos Ross. La cobertura se amplió de 20 a 49 condados y, por primera vez, llegó a algunas zonas del oeste de Pennsylvania.

Aunque los planes administrados por hospitales representan solo una pequeña porción del mercado de Medicare Advantage, su número de afiliados sigue creciendo, en línea con el aumento general de beneficiarios de ese sistema.

De las 62,8 millones de personas con Medicare que pueden inscribirse en un plan Advantage, , según KFF.

Aunque el número de planes Advantage operados por sistemas hospitalarios se ha mantenido relativamente estable, organizaciones como Mass General Brigham en Boston están ampliando sus áreas de cobertura y creando nuevos tipos de planes.

Los sistemas de salud llevan años incursionando en el negocio de los seguros, pero no es una opción para todos. MedStar Health, que opera en el área metropolitana de Washington D.C., informó que cerró su plan de Medicare Advantage a fines de 2018, alegando pérdidas financieras.

 “Es muchísimo trabajo”, dijo Ross, quien se desempeñó durante más de una década en la industria de seguros de salud comerciales.

Al igual que cualquier otra aseguradora, los hospitales que entran en este negocio necesitan una infraestructura administrativa para inscribir pacientes, contratar proveedores, surtir recetas, procesar reclamos, contratar personal y, lo más importante, demostrar a los reguladores estatales que cuentan con reservas financieras suficientes para pagar los servicios.

Una vez que obtienen una licencia estatal de seguros, deben recibir la aprobación de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés) para vender pólizas Medicare Advantage. Algunos sistemas se asocian con aseguradoras o crean una subsidiaria, mientras que otros gestionan el proceso directamente.

Kaiser Permanente, el sistema de salud sin fines de lucro más grande del país en términos de ingresos, inició un plan experimental de Medicare en 1981 y ahora tiene cerca de 2 millones de afiliados en decenas de planes Advantage en ocho estados y el Distrito de Columbia.

El 14 de enero, el Departamento de Justicia anunció que Kaiser Permanente aceptó pagar $556 millones para cerrar el caso por las acusaciones de haber facturado fraudulentamente al gobierno cerca de $1.000 millones a lo largo de nueve años.

El año pasado, UCLA Health lanzó dos planes Medicare Advantage en el condado de Los Ángeles, el más poblado del país. Otros nuevos planes propiedad de hospitales han surgido en áreas rurales menos rentables.

“Las aseguradoras han tenido muchas dificultades para ingresar a esas comunidades”, dijo Molly Smith, vicepresidenta del área de políticas públicas de la Asociación Americana de Hospitales (American Hospital Association).

Pero los planes Advantage ofrecidos por hospitales tienen un nombre ya conocido, que resulta confiable. No necesitan “llegar” a una comunidad, porque los hospitales —sus propietarios— nunca se fueron.

Separaciones complicadas

Los planes Medicare Advantage generalmente suelen limitar a sus afiliados a una red de doctores, hospitales y otros profesionales de salud con quienes tienen contratos.

Pero si los hospitales y las aseguradoras no logran renovar esos contratos, o surgen disputas —a menudo debido a retrasos en pagos, rechazos de cobertura o reglas engorrosas de autorizaciones previas—, los proveedores pueden abandonar la red.

Estas rupturas, junto con cancelaciones programadas y recortes en las áreas de cobertura, obligaron en 2025 a más de 3,7 millones de afiliados de Medicare Advantage a tomar una decisión difícil: encontrar un nuevo seguro para este año que sus médicos aceptaran o, de ser posible, conservar su plan pero cambiar de proveedores.

Cerca de un millón de estos pacientes afectados estaban cubiertos por United Healthcare, la aseguradora más grande del país. En una actualización financiera en julio, el director financiero John Rex atribuyó el retiro de la empresa a los hospitales, donde “la mayoría de los servicios se están volviendo más complejos y costosos”.

La inestabilidad en el mercado de seguros comerciales ha afectado tanto a pacientes como a proveedores. A veces, las disputas contractuales se ventilan públicamente, con los pacientes angustiados y recibiendo advertencias de ambos lados: cada parte culpa a la otra por la inminente pérdida de cobertura.

Cuando Fred Neary, de 88 años, se enteró de que sus médicos del sistema Baylor Scott & White Health, en el centro y norte de Texas, dejarían de estar en su plan Medicare Advantage, temió que lo mismo pudiera ocurrir si se cambiaba a otra aseguradora comercial. Luego descubrió que ese sistema, que cuenta con 53 hospitales, tenía su propio plan Medicare Advantage. Se inscribió en 2025 y decidió conservarlo este año.

“Para mí era muy importante no tener que preocuparme nunca por cambiarme a otro plan porque no aceptaran a mis médicos de Baylor Scott & White”, dijo.

Eugene Rich, investigador principal de Mathematica, una organización de investigación en políticas de salud, señaló que los planes Medicare Advantage operados por sistemas hospitalarios ofrecen “mucha estabilidad para los pacientes”.

“No vas a descubrir de repente que tu médico de atención primaria o tu cardiólogo ya no están en el plan”, explicó.

Un en julio en la revista Health Affairs del cual Rich fue coautor verificó que, por primera vez en 2023, la afiliación a planes Advantage propiedad de hospitales creció más rápido que la afiliación al Medicare tradicional, aunque no tan rápido como el aumento general de todos los planes Advantage.

El extenso sistema UCLA Health lanzó sus dos planes Advantage en el condado de Los Ángeles en enero de 2025, a pesar de que los pacientes ya contaban con más de 70 planes Advantage disponibles.

Antes de lanzar el plan, la Junta de Regentes de la Universidad de California discutió sus méritos en una reunión de noviembre de 2024. Las ofrecen una visión poco común de un debate que, en sistemas hospitalarios privados, suele ocurrir a puertas cerradas.

“A medida que un número creciente de pacientes de Medicare se vuelca a nuevos planes Medicare Advantage, la experiencia de UC Health con estos planes ha resultado insatisfactoria, tanto para los pacientes como para los proveedores”, señalan las actas, al resumir los comentarios de David Rubin, vicepresidente ejecutivo de UC Health.

Las actas también contienen los aportes de Jonathon Arrington, director financiero de UCLA Health. “A lo largo de los años, para poder atender a pacientes de Medicare Advantage, UCLA ha firmado numerosos contratos con aseguradoras, y estos contratos, en general, no han funcionado bien”, dijo.

Y agregó que “cada dos o tres años, UCLA ha rescindido un contrato y firmado uno nuevo”. Los pacientes, sin embargo, se han mantenido fieles a UCLA, y algunos han atravesado hasta tres rondas de cancelaciones de contratos con tal de seguir atendiéndose en UCLA Health.

Costos para los contribuyentes

Los CMS pagan una cantidad fija mensual a los planes Advantage por cada afiliado, según su condición de salud y ubicación.

En 2024, el gobierno federal destinó a estos planes un estimado de $494.000 millones para la atención de los pacientes, según la Comisión Asesora de Pago de Medicare (Medicare Payment Advisory Commission), que supervisa el programa para el Congreso.

La comisión indicó que proyecta que en 2026 las aseguradoras recibirán un 14% más —unos $76.000 millones— de lo que le habría costado a Medicare tradicional atender a los mismos pacientes.

Muchos legisladores demócratas han criticado estos pagos excesivos a aseguradoras de Medicare Advantage, aunque el programa cuenta con el apoyo de demócratas y republicanos en el Congreso debido a su creciente popularidad entre los beneficiarios de Medicare, quienes a menudo se sienten atraídos por servicios como atención dental y otros no incluidos en el Medicare tradicional.

Cada vez que el Congreso plantea posibles recortes, las aseguradoras insisten en que estos generosos pagos federales son esenciales para mantener a flote los planes Advantage. Según las actas de la junta, los planes Advantage de UCLA Health necesitarán al menos 15.000 afiliados para ser financieramente sostenibles. Pero los datos de los CMS indican que en 2025 se inscribieron en ellos 7.337 personas.

Un de agosto comparó a los pacientes de Medicare Advantage comercial que se sometieron a cirugías mayores con los afiliados a planes Advantage propiedad de hospitales. Este último grupo tuvo menos complicaciones, indicó el coautor Thomas Tsai, profesor asociado del Departamento de Políticas y Gestión de Salud en la Escuela de Salud Pública T.H. Chan de Harvard.

Smith, de la Asociación Americana de Hospitales, no se sorprende. Cuando aseguradoras y hospitales no están en lados opuestos, la atención médica puede ser más fluida, dijo. “Hay más flexibilidad para administrar el dinero de las primas y cubrir servicios que tal vez de otra forma no se cubrirían”, agregó.

Pero Tsai advierte a los adultos mayores que los planes Medicare Advantage propiedad de hospitales funcionan bajo las mismas reglas que los administrados por aseguradoras privadas. Señala que los pacientes deberían evaluar si los beneficios adicionales de estos planes “valen la pena frente al costo de tener redes de proveedores potencialmente más limitadas y un mayor control del uso de servicios que el que ofrece Medicare tradicional”.

En Texas, Neary espera que la relación más cercana entre sus médicos y su plan reduzca la posibilidad de que le nieguen pagos por su atención médica.

“No creo que enfrente una situación en la que no me brinden cobertura si uno de sus propios profesionales lo recomienda”, dijo.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 2147836 Las quejas sobre deficiencias en Medicare Advantage son comunes, pero la supervisión federal es rara /news/article/las-quejas-sobre-deficiencias-en-medicare-advantage-son-comunes-pero-la-supervision-federal-es-rara/ Fri, 21 Nov 2025 14:40:48 +0000 /?post_type=article&p=2122780 Además de los dolores ocasionales, envejecer puede traer sorpresas desagradables y enfermedades graves. Las relaciones de largo plazo con doctores de confianza suelen hacer que incluso las malas noticias sean más llevaderas.

Perder ese respaldo —especialmente en medio de una crisis de salud— puede ser aterrador. Por eso, existen requisitos federales poco conocidos que, se supone, protegen a las personas con cobertura de Medicare Advantage, operada por aseguradoras privadas, cuando las disputas contractuales hacen que los proveedores de salud y las aseguradoras se separen.

Pero documentos gubernamentales obtenidos por ºÚÁϳԹÏÍø News muestran que la agencia que supervisa Medicare Advantage no se esfuerza por hacer cumplir normas vigentes desde hace tiempo para garantizar que unos 35 millones de afiliados puedan, primero que nada, acceder a sus médicos.

En respuesta a una solicitud de información pública (Freedom of Information Act) que cubre la última década, los Centros de Servicios de Medicare y Medicaid (CMS) entregaron cartas enviadas a solo cinco aseguradoras entre 2016 y 2022, después de que siete de sus planes no cumplieran . Estas fallas podrían, en algunos casos, afectar la atención de los pacientes.

Según las cartas, los funcionarios de la agencia señalaron que algunos planes no contaban con suficientes médicos de atención primaria, especialistas u hospitales. Y advirtieron que el incumplimiento de esos requisitos podría resultar en la suspensión de la promoción e inscripción de nuevos afiliados, multas o incluso el cierre del plan.

Los CMS no explicaron por qué encontraron tan pocos planes con infracciones en la red durante esos 10 años. “El número de infracciones identificadas refleja los resultados de revisiones específicas, no de una auditoría completa de todos los planes en todos los años”, dijo Catherine Howden, vocera de los CMS.

Funcionarios en estados con infracciones de la red en planes Advantage afirman que los CMS no los notificaron, incluidos los directores del Programa Estatal de Asistencia de Seguros de Salud (SHIP), que ayuda a las personas a navegar Medicare y que cuenta con financiación gubernamental.

“Me cuesta creer que solo siete planes de Medicare Advantage hayan violado las reglas de la red”, dijo David Lipschutz, codirector del Centro de Defensa de Medicare (Center for Medicare Advocacy), una organización sin fines de lucro. “Frecuentemente escuchamos de personas —sobre todo en zonas rurales— que deben recorrer largas distancias para encontrar proveedores contratados”.

Medicare Advantage es una alternativa cada vez más popular al programa de Medicare tradicional, administrado por el gobierno, que cubre a personas mayores de 65 años y algunas personas con discapacidades. De los 63 millones de estadounidenses elegibles para unirse a planes Advantage en lugar de Medicare tradicional, el 54% lo hizo este año.

Estos planes usualmente ofrecen costos más bajos de bolsillo y beneficios adicionales, como cobertura para la vista, servicios dentales y auditivos, pero por lo general requieren que sus afiliados utilicen redes específicas de doctores, hospitales y otros proveedores. El año pasado, el gobierno federal pagó unos $494.000 millones a los planes Advantage por la atención a sus afiliados.

En comparación, Medicare tradicional no tiene red y es aceptado por casi todos los doctores y hospitales del país.

Es habitual que haya conflictos entre planes de Medicare Advantage y los doctores, hospitales y otros proveedores que atienden a sus afiliados. Solo este año, al menos 38 sistemas hospitalarios en 23 estados dejaron de trabajar con unos 11 planes Advantage, al no llegar a un acuerdo sobre pagos y otros temas, según una revisión de comunicados de prensa y reportes periodísticos. En los últimos tres años, las rupturas entre planes Advantage y sistemas de salud aumentaron un 66%, según FTI Consulting, una consultora que monitorea estos conflictos.

Después de marzo, los afiliados de Medicare Advantage por lo general hasta el próximo período de inscripción abierta, que está en curso y se extiende hasta el 7 de diciembre, para cobertura que comienza a partir del 1 de enero. Pero los hospitales, doctores, farmacias y otros proveedores de salud pueden salir de los planes en cualquier momento.

Cuando se produce una separación entre proveedores y aseguradoras, los afiliados pueden perder el acceso a sus doctores de confianza o a sus hospitales preferidos a mitad de año. En respuesta, los CMS a veces ofrecen a los afiliados de Advantage una opción poco conocida: un “período especial de inscripción” (SEP), para cambiar de plan o pasar a Medicare tradicional a mitad de año.

Cómo deciden los CMS quién califica para un SEP es un misterio incluso para reguladores estatales experimentados y senadores que supervisan los programas federales de salud. El senador Ron Wyden, demócrata de Oregon y miembro del Comité de Finanzas del Senado, y el senador Mark Warner, demócrata de Virginia, citaron reportes previos de ºÚÁϳԹÏÍø News sobre Medicare Advantage en una carta del 30 de octubre donde solicitaron una explicación a Mehmet Oz, el administrador de los CMS.

“A pesar del impacto significativo de los SEP sobre los afiliados y el mercado, el proceso para determinar quién califica es opaco, dejando a los afiliados y a los reguladores estatales en la oscuridad”, escribieron.

“Los adultos mayores merecen saber que su plan de Medicare no los va a abandonar a mitad de año”, dijo Wyden a ºÚÁϳԹÏÍø News.

“Ayúdennos”

Oz habló ante representantes de aseguradoras de Medicare Advantage el 15 de octubre en una conferencia organizada por Better Medicare Alliance, un grupo del sector privado, y las animó a ayudar a los CMS a combatir el fraude en el programa.

“Sean nuestro sistema de alerta temprana”, les dijo. “Dígannos qué problemas están viendo. Ayúdennos a encontrar mejores formas de abordarlos”.

Al terminar, se sentó junto a Mary Beth Donahue, presidenta y directora ejecutiva del grupo, y posó para fotos.

En seis cartas obtenidas por ºÚÁϳԹÏÍø News, funcionarios de CMS informaron a cinco aseguradoras que las violaciones en el desempeño de sus redes podrían afectar el acceso de los afiliados a la atención médica. Cinco cartas enumeraban la cantidad o los tipos de especialistas o centros médicos ausentes en sus redes. En tres casos, los CMS señalaron que los planes podrían haber solicitado excepciones a las normas, pero no lo hicieron. En una carta, los CMS solicitaron que se permitiera a los afiliados recibir atención fuera de la red sin costo adicional. Cuatro cartas exigían pasos concretos para resolver las deficiencias, como presentar evidencia de que se habían agregado más médicos a las redes.

Tres cartas requerían un “plan de acción correctiva”, establecían plazos para solucionar los problemas y advertían que no cumplir podría resultar en la suspensión de inscripciones y promoción, multas o cierre del plan. Las otras tres cartas eran “avisos de incumplimiento”, que instaban a las aseguradoras a cumplir con los requisitos legales.

Aunque los CMS consideran estas cartas como el primer paso en su proceso de supervisión, la agencia no ofreció información sobre si las infracciones se resolvieron ni si derivaron en sanciones.

La Comisión Asesora de Pagos de Medicare (Medicare Payment Advisory Commission), un grupo creado por el Congreso para supervisar el programa, señaló en un que “CMS tiene la autoridad para imponer sanciones intermedias o multas por incumplimiento de los estándares del desempeño adecuado de la red, pero nunca lo ha hecho”.

Una de las cartas sobre estas infracciones se envió en noviembre de 2020 a Vitality Health Plan of California. Eso ocurrió después de que cinco hospitales y 13 residencias de adultos mayores en un condado y cuatro hospitales en otro condado salieran de su red, según la carta firmada por Timothy Roe, entonces director de la División de Cumplimiento, Supervisión y Promoción de los CMS. Dos meses antes de enviar esa carta, los CMS concedieron a los afiliados del plan Vitality un período especial de inscripción.

Los beneficiarios agradecieron esa oportunidad, según Marcelo Espiritu, director del Programa de Asesoría y Defensa del Seguro de Salud en el condado de Santa Clara, California. Pero Espiritu no sabía en ese momento que la escasa red de Vitality violaba los requisitos de CMS, que, según Roe, “ponía en riesgo la salud de los beneficiarios de Vitality”.

“Al no tener suficientes proveedores en la red, es muy probable que los beneficiarios no reciban los servicios necesarios de forma oportuna, o que no los reciban en absoluto”, escribió Roe.

Esa es información que los pacientes necesitan saber, dijo Espiritu.

“La gente no recibiría los beneficios prometidos, habría demoras en la atención y mucha frustración al tratar de encontrar un nuevo plan”, señaló. “Sin duda que alertaríamos a las personas sobre ese plan y lo eliminaríamos de nuestro material”.

Representantes de Commonwealth Care Alliance, que adquirió Vitality en 2022, no respondieron a solicitudes de comentarios.

Mínimos de la red

La ley federal exige que los planes de Medicare Advantage incluyan en sus redes un mínimo de 29 tipos de proveedores de salud y 14 tipos de centros médicos, que los beneficiarios puedan visitar dentro de ciertas distancias y tiempos de traslado. Las normas, que varían según la población y densidad de cada condado, también establecen cuánto tiempo debe esperar un paciente para una cita médica. La agencia revisa el cumplimiento cada tres años, o más seguido si recibe quejas.

Las redes pueden variar considerablemente incluso dentro de un mismo condado, porque los requisitos mínimos se aplican a la aseguradora, no a cada plan que ofrece, según un . Una aseguradora puede ofrecer la misma red a afiliados de varios planes en uno o más condados, o crear una red distinta para cada plan.

En el condado de Maricopa, Arizona, investigadores de KFF encontraron que, en 2022, UnitedHealthcare ofrecía 12 planes con 12 redes diferentes. Según el plan, los clientes de la aseguradora tenían acceso a entre el 37% y el 61% de los médicos disponibles para los afiliados de Medicare tradicional en esa zona.

A principios de 2016, los CMS permitieron que 900 personas afiliadas a un plan Advantage en Illinois, operado por Harmony —una subsidiaria de WellCare en ese momento— se salieran del plan después de que Christie Clinic, un gran centro médico, dejara la red. El plan de WellCare siguió funcionando sin la clínica. Pero en junio de 2016, los CMS informaron al plan, en una de las cartas obtenidas por ºÚÁϳԹÏÍø News, que la pérdida de Christie Clinic implicaba que la red restante ya no cumplía con los requisitos federales.

Fue “un cambio significativo en la red con un impacto considerable para los beneficiarios”, decía la carta.

Claudia Lennhoff dijo que su grupo no supo de la carta en ese momento. Lennhoff es directora ejecutiva de , un servicio gubernamental de asesoría sobre Medicare que ayudó a los afiliados de WellCare.

“No divulgar esa información es una traición a la confianza”, dijo Lennhoff. “Podría llevar a alguien a tomar una decisión que le perjudique o de la que luego se arrepienta profundamente”.

Centene Corp. compró WellCare en 2020, y representantes de la empresa, con sede en St. Louis, declinaron comentar sobre hechos ocurridos antes de esa adquisición.

Los CMS enviaron dos cartas por infracciones a Provider Partners Health Plan de Ohio, en 2019 y 2022. El Departamento de Seguros de Ohio no estaba al tanto, según su vocero Todd Walker quien dijo que tampoco se notificó al Programa de Información sobre Seguros de Salud para Personas Mayores del estado, un servicio gratuito de asesoría.

En 2021, los CMS también enviaron una carta de infracción a Liberty Advantage, de Carolina del Norte. Pero no informó sobre esta carta al del estado, dijo su directora, Melinda Munden.

Representantes de Liberty no respondieron a solicitudes de comentarios.

Los CMS enviaron una carta en 2016 a CareSource sobre deficiencias en la red de algunos de sus planes Advantage vendidos en Kentucky e Indiana. La agencia pidió a la empresa corregir los problemas, incluyendo reembolsar a cualquier afiliado que hubiera recibido facturas por servicios de doctores fuera de la red.

“En respuesta a las infracciones de 2016, implementamos de inmediato un Plan de Acción Correctiva, que incluyó una revisión exhaustiva de nuestra red de proveedores para asegurar que se cumplieran los estándares de desempeño adecuado”, dijo Vicki McDonald, vocera de CareSource. “Los CMS aprobaron nuestro plan y no fue necesaria ninguna otra acción”.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 2122780 Complaints About Gaps in Medicare Advantage Networks Are Common. Federal Enforcement Is Rare. /news/article/medicare-advantage-insurance-network-adequacy-standards-cms-federal-enforcement/ Thu, 20 Nov 2025 10:00:00 +0000 /?post_type=article&p=2119255 Along with the occasional aches and pains, growing older can bring surprise setbacks and serious diseases. Longtime relationships with doctors people trust often make even bad news more tolerable. Losing that support — especially during a health crisis — can be terrifying. That’s why little-known federal requirements are supposed to protect people with privately run Medicare Advantage coverage when contract disputes lead their health care providers and insurers to part ways.

But government documents obtained by ºÚÁϳԹÏÍø News show the agency overseeing Medicare Advantage does little to enforce long-standing rules intended to ensure about 35 million plan members can see doctors in the first place.

In response to a Freedom of Information Act request covering the past decade, the Centers for Medicare & Medicaid Services produced letters it sent to only five insurers from 2016 to 2022 after seven of their plans failed to meet — lapses that could, in some cases, harm patient care.

Agency officials said some plans lacked enough primary care clinicians, specialists, or hospitals, according to the letters. And they warned that failure to meet the requirements could result in a freeze on marketing and enrollment, fines, or closure of the plan.

CMS declined to detail why it found so few plans with network violations over the 10 years. “The number of identified violations reflects the outcomes of targeted reviews, not a comprehensive audit of all plans in all years,” said Catherine Howden, a CMS spokesperson.

Officials in states with Advantage network violations say CMS didn’t notify them, including directors of the government-funded , which helps people navigate Medicare.

“It’s hard for me to believe that only seven Medicare Advantage plans violated network rules,” said David Lipschutz, a co-director of the Center for Medicare Advocacy, a nonprofit group. “We often hear from folks — particularly in more rural areas — who have to travel significant distances in order to find contracted providers.”

Medicare Advantage is an increasingly popular alternative to the government-run Medicare program, which covers adults 65 and older and some people with disabilities. Of the 63 million Americans who were eligible to join Advantage plans instead of traditional Medicare, 54% did so for this year. The plans usually offer lower out-of-pocket costs and extra benefits, like coverage for vision, dental, and hearing care, but typically require their members to stick to select networks of doctors, hospitals, and other providers. Last year, the federal government paid Advantage plans an estimated $494 billion to care for patients.

Traditional Medicare, by comparison, has no network and is accepted by nearly all doctors and hospitals in the nation.

Conflicts between Medicare Advantage plans and the doctors, hospitals, and other providers that serve their members are common. Just this year, at least 38 hospital systems serving all or parts of 23 states have cut ties with at least 11 Advantage plans after failing to agree on payment and other issues, according to a review of news releases and press reports. Over the past three years, separations between Advantage plans and health systems have increased 66%, said FTI Consulting, which tracks reports of the disputes.

After March, Medicare Advantage beneficiaries are their plans for the year until the annual open enrollment period happening now through Dec. 7, for coverage beginning Jan. 1. But hospitals, doctors, pharmacies, and other health providers can leave plans anytime.

When providers and insurers separate, Advantage members can lose access to longtime doctors or preferred hospitals in the middle of the year. In response, CMS sometimes gives Advantage customers a little-known escape hatch called a “special enrollment period” to change plans or enroll in traditional Medicare midyear.

How CMS decides who gets an SEP is a mystery even to well-versed state insurance regulators and U.S. senators who oversee federal health programs. Oregon Sen. Ron Wyden, the senior Democrat on the Senate Finance Committee, and Sen. Mark Warner (D-Va.) cited previous ºÚÁϳԹÏÍø News reporting on Medicare Advantage in an Oct. 30 letter asking CMS Administrator Mehmet Oz for an explanation.

“Despite the serious impacts of SEPs on enrollees and the market, the process of SEP determinations is opaque, leaving enrollees and state regulators in the dark,” they wrote.

“Seniors deserve to know their Medicare plan isn’t going to pull the rug out from under them halfway through the year,” Wyden told ºÚÁϳԹÏÍø News.

‘Help Us’

Oz spoke to Medicare Advantage insurers Oct. 15 at a conference organized by the Better Medicare Alliance, a trade group, and encouraged them to help CMS police fraud in the program.

“Be our early-warning system,” he told them. “Tell us about problems you’re witnessing. Help us figure out better ways of addressing it.”

When he finished speaking, he took a seat in the audience next to the president and chief executive of the group, Mary Beth Donahue, and smiled for photos.

In six letters ºÚÁϳԹÏÍø News obtained, CMS officials told five insurers that their network adequacy violations could affect Advantage members’ access to care. Five letters listed the number or types of medical specialists or facilities missing from the networks. In three cases, CMS noted that plans could request exceptions to the rules but didn’t. In one letter, CMS requested the plan allow members to receive out-of-network care at no additional cost. Four letters required specific steps to address deficiencies, including submitting evidence that more clinicians were added to networks.

Three letters required a “corrective action plan,” set deadlines for fixing problems, and warned that failure to comply with the rules could result in enrollment and marketing suspensions, fines, or forced plan closure. The other three letters were a “notice of non-compliance,” which urged insurers to comply with legal requirements.

Although CMS regards the letters as the first step in its enforcement process, the agency did not provide information about whether these violations were resolved or if they resulted in penalties.

The Medicare Payment Advisory Commission, a group created by Congress to monitor the program, said in a that “CMS has the authority to impose intermediate sanctions or civil monetary penalties for noncompliance with network adequacy standards, but it has never done so.”

One of the network adequacy violation letters went to Vitality Health Plan of California in November 2020. That came after five hospitals and 13 nursing homes in one county and four hospitals in another all left the insurer’s network, according to the letter from Timothy Roe, then-director of CMS’ Division of Compliance, Surveillance, and Marketing. Two months before sending its letter, CMS granted Vitality plan members a special enrollment period.

Beneficiaries welcomed the opportunity, said Marcelo Espiritu, program manager of the Santa Clara County office of California’s Health Insurance Counseling & Advocacy Program. But Espiritu didn’t know at the time that Vitality’s depleted network violated CMS requirements, which Roe said put “the health of Vitality’s beneficiaries at risk.”

“By not having enough network providers, beneficiaries may not be able to receive necessary services timely, or at all,” Roe wrote.

That’s information patients need to know, Espiritu said.

“People would not be able to receive promised benefits and there would be delays in care and a lot of frustration in trying to find a new plan,” he said. “We would certainly warn people about the plan and remove it from our materials.”

A spokesperson for Commonwealth Care Alliance, which acquired Vitality in 2022, declined to comment on issues that predate the ownership change.

Network Minimums

Federal law requires Medicare Advantage plans to include in their networks a minimum of 29 types of health care providers and 14 kinds of facilities that members can access within certain distances and travel times. The rules, which vary depending on a county’s population and density, also limit how long patients should wait for appointments. The agency checks compliance every three years, or more often if it receives complaints.

Networks can vary widely even within a county because the provider minimums apply to the insurer, not each plan it sells, according to a , a health information nonprofit that includes ºÚÁϳԹÏÍø News. The company can offer the same network to members of multiple plans in one or more counties or create a separate network for each plan.

In Arizona’s Maricopa County, KFF researchers found, UnitedHealthcare offered 12 plans with 12 different networks in 2022. Depending on the plan, the company’s customers had access to 37% to 61% of the physicians in the area available to traditional Medicare enrollees.

In early 2016, CMS allowed 900 people in an Advantage plan in Illinois run by Harmony, then a WellCare subsidiary, to leave after the Christie Clinic, a large medical practice, left its provider network. The WellCare plan continued to operate without the clinic. But in June 2016, CMS told the plan in one of the letters ºÚÁϳԹÏÍø News obtained that losing the Christie Clinic meant the remaining provider network violated federal requirements.

It was “a significant network change with substantial enrollee impact,” the letter said.

Claudia Lennhoff, executive director at , a government-funded Medicare counseling service that helped the WellCare members, said her group didn’t know about the letter at the time.

“Not disclosing such information is a violation of trust,” Lennhoff said. “It could lead someone to make a decision that will be harmful to them, or that they will deeply regret.”

Centene Corp. bought WellCare in 2020, and representatives for the St. Louis-based company declined to comment on events that occurred before the acquisition.

Two violation letters ºÚÁϳԹÏÍø News obtained from CMS went to Provider Partners Health Plan of Ohio in 2019 and 2022. The Ohio Department of Insurance was unaware of the violations, spokesperson Todd Walker said. He said CMS also did not notify the Ohio Senior Health Insurance Information Program, the state’s free counseling service.

Rick Grindrod, CEO and president of Provider Partners Health Plans, which is based in Maryland, said that after CMS reviewed its 2019 network, “we proactively reduced our service area and deferred enrollment in the plan until 2021.”

But Grindrod said the plan enrolled only a small number of members in one county in 2021 and decided to withdraw from the Ohio market entirely at the end of that year.

After Provider Partners withdrew from Ohio, CMS sent it another letter in March 2022 saying its network in 2021 had gaps in four counties for four types of providers and facilities. CMS asked the plan to comply with network rules by adding more providers.

“We believe CMS’ network adequacy standards are generally clear and appropriate for ensuring beneficiary access,” Grindrod said. “While the standards are not difficult to understand, as a provider-sponsored plan with a small footprint, we sometimes face challenges securing contracts with large systems that prioritize larger Medicare Advantage plans.”

In 2021, CMS also sent a violation letter to North Carolina’s Liberty Advantage. CMS didn’t tell the state’s free counseling service, the , about the letter, said its director, Melinda Munden.

Liberty representatives did not respond to requests for comment.

CMS sent a letter in 2016 to CareSource about network deficiencies in some of its Medicare Advantage plans sold in Kentucky and Indiana. The agency asked the company to fix the problems, including by reimbursing any members billed for services from doctors who were not in the plans’ networks.

“In response to the 2016 violations, we promptly implemented a Corrective Action Plan, which included a thorough review of our provider network to ensure adequacy standards were met,” said Vicki McDonald, a CareSource spokesperson. “CMS approved our plan, and no further action was required.”

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 2119255 When Hospitals Ditch Medicare Advantage Plans, Thousands of Members Get To Leave, Too /news/article/hospitals-abandon-medicare-advantage-plans-members-quit-too/ Mon, 28 Apr 2025 09:00:00 +0000 /?post_type=article&p=2017341 For several years, Fred Neary had been seeing five doctors at the Baylor Scott & White Health system, whose 52 hospitals serve central and northern Texas, including Neary’s home in Dallas. But in October, his Humana Medicare Advantage plan — an alternative to government-run Medicare — warned that Baylor and the insurer were fighting over a new contract. If they couldn’t reach an agreement, he’d have to find new doctors or new health insurance.

“All my medical information is with Baylor Scott & White,” said Neary, 87, who retired from a career in financial services. His doctors are a five-minute drive from his house. “After so many years, starting over with that many new doctor relationships didn’t feel like an option.”

After several anxious weeks, Neary learned Humana and Baylor were parting ways as of this year, and he was forced to choose between the two. Because the breakup happened during the annual fall enrollment period for Medicare Advantage, he was able to pick a new Advantage plan with coverage starting Jan. 1, a day after his Humana plan ended.

Other Advantage members who lose providers are not as lucky. Although disputes between health systems and insurers happen all the time, members are usually locked into their plans for the year and restricted to a network of providers, even if that network shrinks. Unless members qualify for what’s called a , switching plans or returning to traditional Medicare is allowed only at year’s end, with new coverage starting in January.

But in the past 15 months, the Centers for Medicare & Medicaid Services, which oversees the Medicare Advantage program, has quietly offered roughly three-month special enrollment periods allowing thousands of Advantage members in at least 13 states to change plans. They were also allowed to leave Advantage plans entirely and choose traditional Medicare coverage without penalty, regardless of when they lost their providers. But even when CMS lets Advantage members leave a plan that lost a key provider, insurers can still enroll new members without telling them the network has shrunk.

At least 41 hospital systems have dropped out of 62 Advantage plans serving all or parts of 25 states since July, according to Becker’s Hospital Review. Over the past two years, separations between Advantage plans and health systems have tripled, said FTI Consulting, which tracks reports of the disputes.

CMS spokesperson Catherine Howden said it is “a routine occurrence” for the agency to determine that provider network changes trigger a special enrollment period for their members. “It has happened many times in the past, though we have seen an uptick in recent years.”

Still, CMS would not identify plans whose members were allowed to disenroll after losing health providers. The agency also would not say whether the plans intended to ensure that Medicare Advantage members have sufficient providers within certain distances and travel times.

The secrecy around when and how Advantage members can escape plans after their doctors and hospitals drop out worries Sen. Ron Wyden of Oregon, the senior Democrat on the Senate Finance Committee, which oversees CMS.

“Seniors enrolled in Medicare Advantage plans deserve to know they can change their plan when their local doctor or hospital exits the plan due to profit-driven business practices,” Wyden said.

The increase in insurer-provider breakups isn’t surprising, given the growing popularity of Medicare Advantage. The plans attracted about who had both Medicare Parts A and B and were eligible to sign up for Medicare Advantage in 2024, according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

The plans can offer unavailable from traditional Medicare because the federal government pays insurers about 20% more per member than traditional Medicare per-member costs, according to the Medicare Payment Advisory Commission, which advises Congress. The extra spending, which some lawmakers call wasteful, will total about $84 billion in 2025, MedPAC estimates. While traditional Medicare does not offer the additional benefits Advantage plans advertise, it does not limit beneficiaries’ choice of providers. They can go to any doctor or hospital that accepts Medicare, as nearly all do.

Sanford Health, the largest rural health system in the U.S., serving parts of seven states from South Dakota to Michigan, decided to leave a Humana Medicare Advantage plan last year that covered 15,000 of its patients. “It’s not so much about the finances or administrative burden, although those are real concerns,” said Nick Olson, Sanford Health’s chief financial officer. “The most important thing for us is the fact that coverage denials and prior authorization delays impact the care a patient receives, and that’s unacceptable.”

The National Association of Insurance Commissioners, representing insurance regulators from every state, Puerto Rico, and the District of Columbia, has appealed to CMS to help Advantage members.

“State regulators in several states are seeing hospitals and crucial provider groups making decisions to no longer contract with any MA plans, which can leave enrollees without ready access to care,” the group . “Lack of CMS guidance could result in unnecessary financial or medical injury to America’s seniors.”

The commissioners to Health and Human Services Secretary Robert F. Kennedy Jr. “Significant network changes trigger important rights for beneficiaries, and they should receive clear notice of their rights and have access to counseling to help them make appropriate choices,” they wrote.

The insurance commissioners asked CMS to consider offering a special enrollment period for all Advantage members who lose the same major provider, instead of placing the burden on individuals to find help on their own. No matter what time of year, members would be able to change plans or enroll in government-run Medicare.

Advantage members granted this special enrollment period who choose traditional Medicare get a bonus: If they want to purchase a Medigap policy — supplemental insurance that helps cover Medicare’s considerable out-of-pocket costs — insurers can’t turn them away or charge them more because of preexisting health conditions.

Those potential extra costs have long been a deterrent for people who want to leave Medicare Advantage for traditional Medicare.

“People are being trapped in Medicare Advantage because they can’t get a Medigap plan,” said Bonnie Burns, a training and policy specialist at , a nonprofit watchdog that helps seniors navigate Medicare.

Guaranteed access to Medigap coverage is especially important when providers drop out of all Advantage plans. Only — Connecticut, Massachusetts, Maine, and New York — offer that guarantee to anyone who wants to reenroll in Medicare.

But some hospital systems, including Great Plains Health in North Platte, Nebraska, are so frustrated by Advantage plans that they won’t participate in any of them.

It had the same problems with delays and denials of coverage as other providers, but one incident stands out for CEO Ivan Mitchell: A patient too sick to go home had to stay in the hospital an extra six weeks because her plan wouldn’t cover care in a rehabilitation facility.

With traditional Medicare the only option this year for Great Plains Health patients, Nebraska insurance commissioner Eric Dunning asked for a special enrollment period with guaranteed Medigap access for some 1,200 beneficiaries. After six months, CMS agreed.

Once Delaware’s insurance commissioner contacted CMS about the Bayhealth medical system dropping out of a Cigna Advantage plan, a special enrollment period starting in January.

Maine’s congressional delegation for nearly 4,000 patients of Northern Light Health after the 10-hospital system dropped out of a Humana Advantage plan last year.

“Our constituents have told us that they are anticipating serious challenges, ranging from worries about substantial changes to cost-sharing rates to concerns about maintaining care with current providers,” the delegation told CMS.

CMS granted the request to ensure “that MA enrollees have access to medically necessary care,” then-CMS Administrator Chiquita Brooks-LaSure wrote to Sen. Angus King (I-Maine).

Minnesota insurance officials appealed to CMS on behalf of some 75,000 members of Aetna, Humana, and UnitedHealthcare Advantage plans after six health systems announced last year they would leave the plans in 2025. So many provider changes caused “tremendous problems,” said Kelli Jo Greiner, director of the Minnesota State Health Insurance Assistance Program, known as a SHIP, at the Minnesota Board on Aging. SHIP counselors across the country provide Medicare beneficiaries free help choosing and using Medicare drug and Advantage plans.

Providers serving about 15,000 of Minnesota’s Advantage members ultimately agreed to stay in the insurers’ networks. CMS decided 14,000 Humana members qualified for a network-change special enrollment period.

The remaining 46,000 people — Aetna and UnitedHealthcare Advantage members — who lost access to four health systems were not eligible for the special enrollment period. CMS decided their plans still had enough other providers to care for them.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 2017341 Beneficiarios de Medicare gastarán menos en medicamentos en 2025 /news/article/beneficiarios-de-medicare-gastaran-menos-en-medicamentos-en-2025/ Mon, 21 Oct 2024 12:40:41 +0000 /?post_type=article&p=1932442 Cuando Pam McClure se enteró que el próximo año ahorraría casi $4,000 en sus medicamentos recetados dijo: “parece demasiado bueno para ser verdad”.

Para finales de 2024, habrá gastado casi $6,000 en estos fármacos, incluido uno para controlar su diabetes.

McClure, de 70 años, es una de las con un plan de medicamentos recetados de Medicare cuyos costos de bolsillo se limitarán a $2,000 en 2025 gracias a la Ley de Reducción de la Inflación (IRA, por sus siglas en inglés) de 2022 promulgada por la administración Biden, según un estudio de Avalere/AARP.

La IRA, una ley de atención médica y clima que el presidente Joe Biden y la vicepresidenta Kamala Harris promueven en la campaña como uno de los mayores logros de su administración, rediseñó radicalmente el beneficio de medicamentos de Medicare, conocido como Parte D, que sirve a unas 53 millones de personas de 65 años o más, o que viven con ciertas discapacidades.

Gracias a este nuevo límite en el gasto de bolsillo y otros cambios importantes, pero menos conocidos, la administración estima que alrededor de 18.7 millones de personas ahorrarán aproximadamente $7.4 mil millones solo el próximo año.

El período de inscripción anual para que los beneficiarios de Medicare de medicamentos, o elijan un plan Medicare Advantage, comenzó el 15 de octubre y se extiende hasta el 7 de diciembre. Medicare Advantage es la alternativa comercial al Medicare tradicional administrado por el gobierno y cubre atención médica y, a menudo, medicamentos recetados.

Los planes de medicamentos independientes de Medicare, que cubren medicamentos que normalmente se toman en casa, también son administrados por compañías de seguros privadas.

“Siempre alentamos a los beneficiarios a que realmente revisen los planes y elijan la mejor opción para ellos”, dijo Chiquita Brooks-LaSure, quien dirige los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), a ºÚÁϳԹÏÍø News. “Y este año, en particular, es importante hacerlo porque el beneficio ha cambiado mucho”.

Las mejoras a la cobertura de medicamentos de Medicare requeridas por la IRA son los cambios más importantes desde que el Congreso agregó el beneficio en 2003, pero la mayoría de los votantes no los conocen, según , una organización sin fines de lucro de información sobre salud que incluye a ºÚÁϳԹÏÍø News. Y algunos beneficiarios pueden sorprenderse por un inconveniente: algunos planes aumentarán sus primas.

El 27 de septiembre, los CMS dijeron que, a nivel nacional, la prima promedio de los planes de medicamentos de Medicare disminuyó alrededor de $1.63 al mes —aproximadamente un 4%— respecto al año pasado.

“Las personas inscritas en un plan de la Parte D de Medicare seguirán viendo primas estables y tendrán amplias opciones de planes asequibles”, dijeron los CMS en un comunicado.

Sin embargo, encontró que “muchas aseguradoras están aumentando las primas” y que grandes aseguradoras como UnitedHealthcare y Aetna también redujeron la cantidad de planes que ofrecen.

Las propuestas iniciales de primas de muchas aseguradoras de la Parte D para 2025 . Para amortiguar el impacto del precio, la administración Biden creó lo que llama un programa de demostración para pagar a las aseguradoras $15 adicionales al mes por beneficiario si aceptaban limitar los aumentos de primas a no más de $35.

“En ausencia de esta demostración, los aumentos de primas ciertamente habrían sido mayores”, escribió Juliette Cubanski, subdirectora del Programa de Políticas de Medicare en KFF, en su análisis del 3 de octubre.

Casi todas las aseguradoras de la Parte D aceptaron el acuerdo. Los republicanos lo han criticado, para hacer los pagos adicionales y llamándolos una maniobra política en un año electoral.

Sea cual sea la razón, las primas están subiendo dramáticamente para algunos planes.

En el estado de Nueva York, por ejemplo, la prima del popular plan Value Script de Wellcare pasó de $3.70 mensuales a $38.70 el próximo año, un aumento de $35, más de diez veces que el costo actual.

Cubanski identificó ocho planes en California que aumentaron sus primas exactamente $35 al mes. ºÚÁϳԹÏÍø News encontró que las primas aumentaron en al menos el 70% de los planes de medicamentos ofrecidos en California, Texas y Nueva York, y en alrededor de la mitad de los planes en Florida y Pennsylvania, los cinco estados con más beneficiarios de Medicare.

Voceros de Wellcare y de su empresa matriz, Centene Corp., no respondieron a las solicitudes de comentarios. En una declaración este mes, la vicepresidenta senior de servicios clínicos y especializados de Centene, Sarah Baiocchi, dijo que Wellcare ofrecería el plan Value Script .

Además del límite de $2,000 en el gasto de medicamentos, la IRA limita los copagos de Medicare para la mayoría de los productos de insulina a no más de $35 al mes y permite que Medicare negocie directamente los precios de algunos de los medicamentos más caros directamente con las farmacéuticas.

También eliminará una de las características más frustrantes del beneficio de medicamentos, una brecha conocida como el “agujero de dona (doughnut hole)” que suspende la cobertura justo cuando las personas enfrentan crecientes costos de medicamentos, obligándolas a pagar el precio completo de las drogas de su plan de su bolsillo hasta que alcancen un umbral de gasto que cambia de un año a otro.

La ley también amplía la elegibilidad para los subsidios de “ayuda adicional” para aproximadamente 17 millones de personas de bajos ingresos en los planes de medicamentos de Medicare y aumenta el monto del subsidio. Las farmacéuticas deberán contribuir para ayudar a pagarlo.

A partir del 1 de enero, el beneficio de medicamentos rediseñado funcionará más como otras pólizas de seguro privado. La cobertura comienza después que los pacientes paguen un deducible, que no será mayor de $590 el próximo año. Algunos planes ofrecen un deducible menor o ninguno, o excluyen ciertos medicamentos, generalmente genéricos baratos, del deducible.

Después que los beneficiarios gasten $2,000 en deducibles y copagos, el resto de sus medicamentos de la Parte D serán gratuitos.

Eso se debe a que la IRA aumenta la parte de la factura asumida por las aseguradoras y las compañías farmacéuticas. La ley también intenta frenar futuros aumentos de precios de medicamentos al limitar los aumentos a la tasa de inflación al consumidor, que fue del . Si los precios suben más rápido que la inflación, las farmacéuticas deben pagar a Medicare la diferencia.

“Antes del rediseño, la Parte D incentivaba los aumentos de precios de los medicamentos”, dijo Gina Upchurch, farmacéutica y directora ejecutiva de Senior PharmAssist, una organización sin fines de lucro en Durham, Carolina del Norte, que asesora a beneficiarios de Medicare. “La forma en que está diseñada ahora coloca más obligaciones financieras en los planes y los fabricantes, presionándolos para que ayuden a controlar los precios”.

Otra disposición de la ley permite a los beneficiarios pagar los medicamentos en un plan de pago a plazos, en lugar de tener que pagar una factura abultada en un corto período de tiempo.

Las aseguradoras deben hacer los cálculos y enviar una factura mensual a los titulares de pólizas, que se ajustará si se agregan o eliminan medicamentos.

Junto con los grandes cambios introducidos por la IRA, los beneficiarios de Medicare deben prepararse para las sorpresas inevitables que surgen cuando las aseguradoras revisan sus planes para un nuevo año. Además de aumentar las primas, las aseguradoras pueden eliminar medicamentos cubiertos y eliminar farmacias, médicos u otros servicios de las redes de proveedores que los beneficiarios deben usar.

Perder la oportunidad de cambiar de plan significa que la cobertura se renovará automáticamente, incluso si cuesta más o ya no cubre los medicamentos que el afiliado necesito o sus farmacias preferidas.

La mayoría de los beneficiarios no pueden realizar ningún cambio en sus planes, o pasar a otros por fuera del período de inscripción annual, a menos que los CMS les otorgue un “”.

Sin embargo, muchos no se toman el tiempo para comparar docenas de planes que pueden cubrir diferentes medicamentos a diferentes precios en diferentes farmacias, incluso cuando el esfuerzo podría ahorrarles dinero.

En 2021, solo el 18% de los inscritos en planes de medicamentos de Medicare Advantage y el 31% de los miembros de planes de medicamentos independientes de su plan con los de los competidores, según encontraron investigadores de KFF.

Para obtener ayuda gratuita e imparcial para elegir un plan de medicamentos, los beneficiarios pueden comunicarse con el Programa de Asistencia Estatal de Seguros de Salud (SHIP) de su estado en o en la línea de ayuda 1-877-839-2675.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 1932442 Medicare Drug Plans Are Getting Better Next Year. Some Will Also Cost More. /news/article/medicare-part-d-drug-plans-premiums-caps/ Mon, 21 Oct 2024 09:00:00 +0000 /?post_type=article&p=1931706 When Pam McClure learned she’d save nearly $4,000 on her prescription drugs next year, she said, “it sounded too good to be true.” She and her husband are both retired and live on a “very strict” budget in central North Dakota.

By the end of this year, she will have spent almost $6,000 for her medications, including a drug to control her diabetes.

McClure, 70, is one of with Medicare prescription drug insurance whose out-of-pocket medication costs will be capped at $2,000 in 2025 because of the Biden administration’s 2022 Inflation Reduction Act, according to an Avalere/AARP study.

“It’s wonderful — oh my gosh. We would actually be able to live,” McClure said. “I might be able to afford fresh fruit in the wintertime.”

The IRA, a climate and health care law that President Joe Biden and Vice President Kamala Harris promote on the campaign trail as one of their administration’s greatest accomplishments, radically redesigned Medicare’s drug benefit, called Part D, which serves about 53 million people 65 and older or with disabilities. The administration estimates that about 18.7 million people will save about $7.4 billion next year alone due to the cap on out-of-pocket spending and less publicized changes.

The annual enrollment period for Medicare beneficiaries to or to choose a Medicare Advantage plan began Oct. 15 and runs through Dec. 7. Medicare Advantage is the commercial alternative to traditional government-run Medicare and covers medical care and often prescription drugs. Medicare’s stand-alone drug plans, which cover medicines typically taken at home, are also administered by private insurance companies.

“We always encourage beneficiaries to really look at the plans and choose the best option for them,” Chiquita Brooks-LaSure, who heads the Centers for Medicare & Medicaid Services, told ºÚÁϳԹÏÍø News. “And this year in particular it’s important to do that because the benefit has changed so much.”

Improvements to Medicare drug coverage required by the IRA are the most sweeping changes since Congress added the benefit in 2003, but most voters don’t know about them, . And some beneficiaries may be surprised by a downside: premium increases for some plans.

CMS said Sept. 27 that nationwide the average Medicare drug plan premium fell about $1.63 a month — about 4% — from last year. “People enrolled in a Medicare Part D plan will continue to see stable premiums and will have ample choices of affordable Part D plans,” CMS said in a statement.

However, , a health information nonprofit that includes ºÚÁϳԹÏÍø News, found that “many insurers are increasing premiums” and that large insurers including UnitedHealthcare and Aetna also reduced the number of plans they offer.

Many Part D insurers’ initial 2025 premium proposals . To cushion the price shock, the Biden administration created what it calls a demonstration program to pay insurers $15 extra a month per beneficiary if they agreed to limit premium increases to no more than $35.

“In the absence of this demonstration, premium increases would certainly have been larger,” Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, wrote in her Oct. 3 analysis.

Nearly every Part D insurer agreed to the arrangement. Republicans have criticized it, to make the extra payments and calling them a political ploy in an election year. CMS officials say the government has taken similar measures when implementing other Medicare changes, including under President George W. Bush, a Republican.

In California, for example, Wellcare’s popular Value Script plan went from 40 cents a month to $17.40. The Value Script plan in New York went from $3.70 a month to $38.70, a more than tenfold hike — and precisely a $35 increase.

Cubanski identified eight plans in California that raised their premiums exactly $35 a month. ºÚÁϳԹÏÍø News found that premiums went up for at least 70% of drug plans offered in California, Texas, and New York and for about half of plans in Florida and Pennsylvania — the five states with the most Medicare beneficiaries.

Spokespeople for Wellcare and its parent company, Centene Corp., did not respond to requests for comment. In a statement this month, Centene’s senior vice president of clinical and specialty services, Sarah Baiocchi, said Wellcare would offer the Value Script plan in 43 states.

In addition to the $2,000 drug spending limit, the IRA caps Medicare copayments for most insulin products at no more than $35 a month and allows Medicare to negotiate prices of some of the most expensive drugs directly with pharmaceutical companies.

It will also eliminate one of the drug benefit’s most frustrating features, a gap known as the “donut hole,” which suspends coverage just as people face growing drug costs, forcing them to pay the plan’s full price for drugs out-of-pocket until they reach a spending threshold that changes from year to year.

The law also expands eligibility for “extra help” subsidies for about 17 million low-income people in Medicare drug plans and increases the amount of the subsidy. Drug companies will be required to chip in to help pay for it.

Starting Jan. 1, the redesigned drug benefit will operate more like other private insurance policies. Coverage begins after patients pay a deductible, which will be no more than $590 next year. Some plans offer a smaller or no deductible, or exclude certain drugs, usually inexpensive generics, from the deductible.

After beneficiaries spend $2,000 on deductibles and copayments, the rest of their Part D drugs are free.

That’s because the IRA raises the share of the bill picked up by insurers and pharmaceutical companies. The law also attempts to tamp down future drug price hikes by limiting increases to the consumer price inflation rate, which was . If prices rise faster than inflation, drugmakers have to pay Medicare the difference.

“Before the redesign, Part D incentivized drug price increases,” said Gina Upchurch, a pharmacist and the executive director of Senior PharmAssist, a Durham, North Carolina, nonprofit that counsels Medicare beneficiaries. “The way it is designed now places more financial obligations on the plans and manufacturers, pressuring them to help control prices.”

Another provision of the law allows beneficiaries to pay for drugs on an installment plan, instead of having to pay a hefty bill over a short period of time. Insurers are supposed to do the math and send policyholders a monthly bill, which will be adjusted if drugs are added or dropped.

Along with big changes brought by the IRA, Medicare beneficiaries should prepare for the inevitable surprises that come when insurers revise their plans for a new year. In addition to raising premiums, insurers can drop covered drugs and eliminate pharmacies, doctors, or other services from the provider networks beneficiaries must use.

Missing the opportunity to switch plans means coverage will renew automatically, even if it costs more or no longer covers needed drugs or preferred pharmacies. Most beneficiaries are locked into Medicare drug and Advantage plans for the year unless CMS gives them a “.”

“We do have a system that is run through private health plans,” CMS chief Brooks-LaSure said. But she noted that beneficiaries “have the ability to change their plans.”

But many don’t take the time to compare dozens of plans that can cover different drugs at different prices from different pharmacies — even when the effort could save them money. In 2021, only 18% of Medicare Advantage drug plan enrollees and 31% of stand-alone drug plan members against competitors’, KFF researchers found.

For free, unbiased help selecting drug coverage, contact the State Health Insurance Assistance Program at or 1-877-839-2675.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 1931706 Biden Plan To Save Medicare Patients Money on Drugs Risks Empty Shelves, Pharmacists Say /news/article/biden-medicare-dir-fees-reform-pharmacy-cash-flow/ Tue, 11 Jun 2024 09:00:00 +0000 /?post_type=article&p=1864843 Months into a new Biden administration policy intended to lower drug costs for Medicare patients, independent pharmacists say they’re struggling to afford to keep some prescription drugs in stock.

“It would not matter if the governor himself walked in and said, ‘I need to get this prescription filled,’” said Clint Hopkins, a pharmacist and co-owner of Pucci’s Pharmacy in Sacramento, California. “If I’m losing money on it, it’s a no.”

A regulation that took effect in January changes prescription prices for Medicare beneficiaries. For years, prices included pharmacy performance incentives, possible rebates, and other adjustments made after the prescription was filled. Now the adjustments are made first, at the pharmacy counter, reducing the overall cost for patients and the government. But the new system means less money for pharmacies that acquire and stock medications, pharmacists say.

Pharmacies are already struggling with staff shortages, drug shortages, fallout from opioid lawsuits, and rising operating costs. While independent pharmacies are most vulnerable, some big chain pharmacies are also feeling a cash crunch — particularly those whose parent firms don’t own a pharmacy benefit manager, companies that negotiate drug prices between insurers, drug manufacturers, and pharmacies.

A top official at the Centers for Medicare & Medicaid Services said it’s a matter for pharmacies, Medicare insurance plans, and PBMs to resolve.

“We cannot interfere in the negotiations that occur between the plans and pharmacy benefits managers,” Meena Seshamani, director of the Center for Medicare, said at a conference on June 7. “We cannot tell a plan how much to pay a pharmacy or a PBM.”

Nevertheless, CMS has reminded insurers and PBMs in several letters that they are required to provide the drugs and other benefits promised to beneficiaries.

Several independent pharmacists told ºÚÁϳԹÏÍø News they’ll soon cut back on the number of medications they keep on shelves, particularly brand-name drugs. Some have even decided to stop accepting certain Medicare drug plans, they said.

As he campaigns for reelection, President Joe Biden has touted his administration’s moves to make prescription drugs more affordable for Medicare patients, hoping to appeal to voters troubled by rising health care costs. His achievements , the Inflation Reduction Act, that caps the price of insulin at $35 a month for Medicare patients; caps Medicare patients’ drug spending at $2,000 a year, beginning next year; and allows the program to bargain down drug prices with manufacturers.

More than 51 million people have Medicare drug coverage. CMS officials estimated the new rule reducing pharmacy costs would save beneficiaries $26.5 billion from 2024 through 2032.

Medicare patients’ prescriptions can account for at least 40% of pharmacy business, according to a by the National Community Pharmacists Association.

Independent pharmacists say the new rule is causing them financial trouble and hardship for some Medicare patients. Hopkins, in Sacramento, said that some of his newer customers used to rely on a local grocery pharmacy but came to his store after they could no longer get their medications there.

The crux of the problem is cash flow, the pharmacists say. Under the old system, pharmacies and PBMs reconciled rebates and other behind-the-scenes transactions a few times a year, resulting in pharmacies refunding any overpayments.

Now, PBM clawbacks happen immediately, with every filled prescription, reducing pharmacies’ cash on hand. That has made it particularly difficult, pharmacists say, to stock brand-name drugs that can cost hundreds or thousands of dollars for a month’s supply.

Some patients have been forced to choose between their pharmacy and their drug plan. Kavanaugh Pharmacy in Little Rock, Arkansas, no longer accepts Cigna and Wellcare Medicare drug plans, said co-owner and pharmacist Scott Pace. He said the pharmacy made the change because the companies use Express Scripts, a PBM that has cut its reimbursements to pharmacies.

“We had a lot of Wellcare patients in 2023 that either had to switch plans to remain with us, or they had to find a new provider,” Pace said.

Pace said one patient’s drug plan recently reimbursed him for a fentanyl patch $40 less than his cost to acquire the drug. “Because we’ve had a long-standing relationship with this particular patient, and they’re dying, we took a $40 loss to take care of the patient,” he said.

Conceding that some pharmacies face cash-flow problems, Express Scripts recently decided to accelerate payment of bonuses for meeting the company’s performance measures, said spokesperson Justine Sessions. She declined to answer questions about cuts in pharmacy payments.

Express Scripts, which is owned by The Cigna Group, last year, second to CVS Health, which had 34% of the market.

In North Carolina, pharmacist Brent Talley said he recently lost $31 filling a prescription for a month’s supply of a weight control and diabetes drug.

To try to cushion such losses, Talley’s Hayes Barton Pharmacy sells CBD products and specialty items like reading glasses, bath products, and books about local history. “But that’s not going to come close to making up the loss generated by the prescription sale,” Talley said.

His pharmacy also delivers medicines packaged by the dose to Medicare patients at assisted living facilities and nursing homes. Reimbursement arrangements with PBMs for that business are more favorable than for filling prescriptions in person, he said.

When Congress added drug coverage to Medicare in 2003, lawmakers privatized the benefit by requiring the government to contract with commercial insurance companies to manage the program.

Insurers offer two options: Medicare Advantage plans, which usually cover medications, in addition to hospital care, doctor visits, and other services; as well as stand-alone drug plans for people with traditional Medicare. The insurers then contract with PBMs to negotiate drug prices and pharmacy costs with drug manufacturers and pharmacies.

The terms of PBM contracts are generally secret and restrict what pharmacists can tell patients — for example, if they’re asked why a drug is out of stock. (It took an act of Congress in 2018 to eliminate restrictions on disclosing a drug’s cash price, which can sometimes be less than an insurance plan’s copayment.)

The Pharmaceutical Care Management Association, a trade group representing PBMs, warned CMS repeatedly “that pharmacies would likely receive lower payments under the new Medicare Part D rule,” spokesperson Greg Lopes said. His group opposes the change.

Recognizing the new policy could cause cash-flow problems for pharmacies, Medicare officials had delayed implementation for a year before the rule took effect, giving them more time to adjust.

“We have heard pharmacies saying that they have concerns with their reimbursement,” Seshamani said.

But the agency isn’t doing enough to help now, said Ronna Hauser, senior vice president of policy and pharmacy affairs at the National Community Pharmacists Association. “They haven’t taken any action even after we brought potential violations to their attention,” she said.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 1864843 Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage /news/article/medicare-advantage-breakups-contracts-hospitals-doctors-patients-choice/ Fri, 29 Mar 2024 09:00:00 +0000 /?post_type=article&p=1833221 Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.

The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.

Klion refused to pick the lesser of two bad options without a fight.

He contacted Humana, the Saratoga hospital, and the health system. The couple’s doctors “are an exceptional group of caregivers and have made it possible for us to live an active and productive life,” he wrote to the hospital’s CEO. He called his wife’s former employer, which requires its retirees to enroll in a Humana Medicare Advantage plan to receive company health benefits. He also contacted the , one of the nationwide State Health Insurance Assistance Programs .

Klion said they all told him the same thing: Keep your doctors or your insurance.

With , Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time.

Disputes between insurers and providers can lead to entire hospital systems suddenly leaving the plans. Insurers must comply with extensive regulations from the Centers for Medicare & Medicaid Services, including little-known protections for beneficiaries when doctors or hospitals leave their networks. But the news of a breakup can come as a surprise.

In the nearly three decades since Congress created a private-sector alternative to original, government-run Medicare, the plans have enrolled a record 52% of Medicare’s 66 million older or disabled adults, according to the CMS. But along with getting extra benefits that original Medicare doesn’t offer, Advantage beneficiaries have discovered downsides. One common complaint is the requirement that they receive care only from networks of designated providers.

Many hospitals have also become disillusioned by the program.

“We hear every day, from our hospitals and health systems across the country, about challenges they experience with Medicare Advantage plans,” said Michelle Millerick, senior associate director for health insurance and coverage policy at the American Hospital Association, which represents about 5,000 hospitals. The hurdles include prior authorization restrictions, late or low payments, and “inappropriate denials of medically necessary covered services,” she said.

“Some of these issues get to a boiling point where decisions are made to not participate in networks anymore,” she said.

An Escape Hatch

CMS gives most Advantage members two chances to change plans: during the annual open enrollment period in the fall and from January until March 31.

But a few years ago, CMS created an escape hatch by expanding , or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare.

According to CMS rules, there’s an SEP patients may use if their health is in jeopardy due to problems getting or continuing care. This may include situations in which their health care providers are leaving their plans’ networks, said David Lipschutz, an associate director at the .

Another SEP is available for beneficiaries who experience “significant” network changes, although CMS officials declined to explain what qualifies as significant. However, in 2014, CMS offered this SEP to UnitedHealthcare Advantage members after the insurer terminated contracts with providers in 10 states.

When providers leave, CMS ensures that the plans maintain “adequate access to needed services,” Meena Seshamani, CMS deputy administrator and director of the federal Center for Medicare, said in a statement.

While hospitals say insurers are pushing them out, insurers blame hospitals for the turmoil in Medicare Advantage networks.

“Hospitals are using their dominant market positions to demand unprecedented double-digit rate increases and threatening to terminate their contracts if insurers don’t agree,” said Ashley Bach, a spokesperson for Regence BlueShield, which offers Advantage plans in Idaho, Oregon, Utah, and Washington state.

Patients get caught in the middle.

“It feels like the powers that be are playing chicken,” said Mary Kay Taylor, 69, who lives near Tacoma, Washington. Regence BlueShield was in a weeks-long dispute with MultiCare, one of the largest medical systems in the state, where she gets her care.

“Those of us that need this care and coverage are really inconsequential to them,” she said. “We’re left in limbo and uncertainty.”

Other breakups this year include Baton Rouge General hospital in Louisiana leaving Aetna’s Medicare Advantage plans and Baptist Health in Kentucky leaving UnitedHealthcare and Wellcare Advantage plans. In San Diego, Scripps Health has left nearly all the area’s Advantage plans.

In North Carolina, UNC Health and UnitedHealthcare renewed their contract just three days before it would have expired, and only two days before the deadline for Advantage members to switch plans. And in New York City, Aetna told its Advantage members this year to be prepared to lose access to the 18 hospitals and other care facilities in the NewYork-Presbyterian Weill Cornell Medical Center health system, before reaching an agreement on a contract last week.

Limited Choices

Taylor didn’t want to lose her doctors or her Regence Advantage plan. She’s recovering from surgery and said waiting to see how the drama would end “was really scary.”

So, last month, she enrolled in another plan, with help from Tim Smolen, director of Washington’s SHIP, Statewide Health Insurance Benefits Advisors program. Soon afterward, Regence and MultiCare agreed to a new contract. But Taylor is allowed only one change before March 31 and can’t return to Regence this year, Smolen said.

Finding an alternative plan can be like winning at bingo. Some patients have multiple doctors, who all must be easy to get to and covered by the new plan. To avoid bigger, out-of-network bills, they must find a plan that also covers their prescription drugs and includes their preferred pharmacies.

“A lot of times, we may get through the provider network and find that that’s good to go but then we get to the drugs,” said Kelli Jo Greiner, state director of Minnesota’s SHIP, Senior LinkAge Line. Since Jan. 1, counselors there have helped more than 900 people switch to new Advantage plans after HealthPartners, a large health system based in Bloomington, left Humana’s Medicare Advantage plans.

Choices are more limited for low-income beneficiaries who receive subsidies for drugs and monthly premiums, which only a few plans accept, Greiner said.

, a former employer and requires them to enroll in it to receive retiree health benefits. If they want to keep a provider who leaves that plan, those beneficiaries must forfeit all their employer-subsidized health benefits, often including coverage for their families.

The threat of losing coverage for their providers was one reason some New York City retirees sued Mayor Eric Adams to stop efforts to force 250,000 of them into an Aetna Advantage plan, said Marianne Pizzitola, president of the New York City , which filed the lawsuit. The retirees won three times, and city officials are appealing again.

CMS requires Advantage plans to notify their members 45 days before a primary care doctor leaves their plan and 30 days before a specialist physician drops out. But counselors who advise Medicare beneficiaries say the notice doesn’t always work.

“A lot of people are experiencing disruptions to their care,” said Sophie Exdell, a program manager in San Diego for California’s SHIP, the Health Insurance Counseling & Advocacy Program. She said about 32,000 people in San Diego lost access to Scripps Health providers when the system left most of the area’s Advantage plans. Many didn’t get the notice or, if they did, “they couldn’t get through to someone to get help making a change,” she said.

CMS also requires plans to comply with network adequacy rules, which limit how far and how long members must travel to primary care doctors, specialists, hospitals, and other providers. The agency checks compliance every three years or more often if necessary.

In the end, Bart Klion said he had no alternative but to stick with Humana because he and his wife couldn’t afford to give up their retiree health benefits. He was able to find doctors willing to take on new patients this year.

But he wonders: “What happens in 2025?”

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 1833221 Dodging the Medicare Enrollment Deadline Can Be Costly /news/article/medicare-open-enrollment-deadline-cost-of-not-choosing/ Thu, 07 Dec 2023 17:15:00 +0000 /?post_type=article&p=1783638 Angela M. Du Bois, a retired software tester in Durham, North Carolina, wasn’t looking to replace her UnitedHealthcare Medicare Advantage plan. She wasn’t concerned as the Dec. 7 deadline approached for choosing another of the privately run health insurance alternatives to original Medicare.

But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.

Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.

Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that switched Medicare Advantage plans in 2019.

Once open enrollment ends, there are limited options for a do-over. People in Medicare Advantage plans can go to another Advantage plan or back to the original, government-run Medicare from January through March. And the Centers for Medicare & Medicaid Services has expanded the criteria for granting a “special enrollment period” to make changes in drug or Advantage plans anytime.

But most seniors will generally allow their existing policy to renew automatically, like it or not.

Keeping her doctor was not Du Bois’ only reason for switching plans, though. With help from Senior PharmAssist, a Durham nonprofit that advises seniors about Medicare, she found a Humana Medicare Advantage plan that would not only be accepted by her providers but also cover her medications — saving her more than $14,000 a year, said Gina Upchurch, the group’s executive director.

Senior PharmAssist is one of the federally funded State Health Insurance Assistance Programs, known as SHIPs, available across the country to provide unbiased assistance during the open enrollment season and year-round to help beneficiaries appeal coverage denials and iron out other problems.

“Many people are simply overwhelmed by the calls, ads, the sheer number of choices, and this ‘choice overload’ contributes to decision-making paralysis,” said Upchurch. Seniors in Durham have as many as 74 Advantage plans and 20 drug-only plans to choose from, she said.

Upchurch said the big insurance companies like the way the system works now, with few customers inclined to explore other plans. “They call it ‘stickiness,’” she said. “If we had fewer and clear choices — an apple, orange, grape, or banana — most people would review options.”

In Washington state, one woman switched from a plan she had had for more than a decade to one that will cover all her drugs and next year will save an estimated $7,240, according to Tim Smolen, director of the state’s SHIP, Statewide Health Insurance Benefits Advisors.

In Northern California, another woman changed drug plans for the first time since 2012, and her current premium of $86 will plummet to 40 cents a month next year, an annual savings of about $1,000, said Pam Smith, a local director for California’s SHIP, called the Health Insurance Counseling & Advocacy Program.

And in Ohio, a woman sought help after learning that her monthly copayment for the blood thinner Eliquis would rise from $102 to $2,173 next year. A counselor with Ohio’s SHIP found another plan that will cover all her medications for the year and cost her just $1,760. If she stuck with her current plan, she would be paying an additional $24,852 for all her drugs next year, said Chris Reeg, who directs that state’s program.

In some cases, CMS tries to persuade beneficiaries to switch. Since 2012, it has sent letters every year to thousands of beneficiaries in poorly performing Advantage and drug plans, encouraging them to consider other options. These are plans that have received less than three out of five stars for three years from CMS.

“You may want to compare your plan to other plans available in your area and decide if it’s still right for you,” the letter says.

CMS allows low-scoring plans to continue to operate. In an unusual move, officials recently found that one plan had such a terrible track record that they will with government health programs next December.

CMS also contacts people about changing plans during open enrollment if they get a subsidy — called “extra help” — that pays for their drug plan’s monthly premium and some out-of-pocket expenses. Because some premiums will be more expensive next year, CMS is warning beneficiaries that they could be in for a surprise: a monthly bill to cover cost increases the subsidy doesn’t cover.

But many beneficiaries receive no such nudge from the government to find out if there is a better, less expensive plan that meets their needs and includes their health care providers or drugs.

That leaves many people with Medicare drug or Advantage plans on their own to decipher any changes to their plans while there is still time to enroll in another. Insurers are required to alert members with an “annual notice of change,” a booklet often more than two dozen pages long. Unless they plow through it, they may discover in January that their premiums have increased, the provider network has changed, or some drugs are no longer covered. If a drug plan isn’t offered the next year and the beneficiary doesn’t pick a new one, the insurer will select a plan of its choosing, without considering costs or needed drug coverage.

“Every year, our call volume skyrockets in January when folks get invoices for that new premium,” said Reeg, the Ohio program director. At that point, Medicare Advantage members have until March 30 to switch to another plan or enroll in government-run Medicare. There’s no similar grace period for people with stand-alone drug plans. “They are locked into that plan for the calendar year.”

One cost-saving option is the government’s , which helps low-income beneficiaries pay their monthly premium for Medicare Part B, which covers doctor visits and other outpatient services. for subsidies announced in September will extend financial assistance to an estimated 860,000 people — if they apply. In the past, only about half of those eligible applied.

Fixing a mistake after the open enrollment period ends Dec. 7 is easy for some people. Individuals who receive “extra help” to pay for drug plan premiums and those who have a subsidy to pay for Medicare’s Part B can change drug plans every three months.

At any time, beneficiaries can switch to a Medicare Advantage plan that earns the top five-star rating from CMS, if one is available. “We’ve been able to use those five-star plans as a safety net,” said Reeg, the Ohio SHIP director.

Other beneficiaries may be able to get a “special enrollment period” to switch plans after the open enrollment ends if they meet certain conditions. can help people make any of these changes when possible.

Reeg spends a lot of time trying to ensure that unwelcome surprises — like a drug that isn’t covered — don’t happen in the first place. “What we want to do is proactively educate Medicare patients so they know that they can go to the doctors and hospitals they want to go to in the upcoming year,” she said.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).

]]> 1783638