Federal officials are considering new Medicare Advantage rules to help protect seniors when insurers make significant reductions to their networks of doctors and other health care providers.
The proposals follow UnitedHealthcare鈥檚 decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.
The government鈥檚 response is part of the聽聽of proposed rules and payment rates for next year鈥檚 Medicare Advantage plans released last month by the U.S. Centers for Medicare & Medicaid Services. Officials say that the terminations only a few weeks before Medicare鈥檚 Dec. 7 enrollment deadline may not have given seniors enough time to find new doctors, choose a different plan or rejoin traditional Medicare, which does not restrict beneficiaries to a limited network of providers.
The proposals would give beneficiaries more than 30 days鈥� advance notice of network changes and providers at least 60 days鈥� advance notice of a contract termination. Even Medicare officials need more advance notice 鈥� 鈥渘o less than 90 days鈥� 鈥� so they can ensure that the remaining providers 鈥渨ill continue to meet required network standards.鈥� Officials are soliciting suggestions on how plans should prove that their reconfigured networks are adequate.
The physician terminations sparked protests to Medicare and UnitedHealthcare from patients, as well as physician groups across the country, state officials and members of Congress.
Nearly 16 million people, about a third of Medicare beneficiaries, are enrolled in private Medicare Advantage plans, which are an alternative to traditional Medicare. The government reimburses insurers to care for these seniors.
Although the announcement does not name any insurance companies, officials prefaced the proposals by writing, 鈥淩ecent significant mid-year changes to MAOs鈥� [Medicare Advantage organizations鈥橾 provider networks have prompted CMS to reexamine its current guidance on these requirements and to consider augmenting such guidance in response to such changes.鈥�
Medicare Advantage rules allow beneficiaries to change plans if they move out of the coverage area or for other special reasons, but not if they lose their doctors or hospitals. Otherwise, they can switch plans only once a year, during the annual seven-week, fall enrollment period. Since most beneficiaries are locked into their plans, CMS is considering whether to restrict insurers鈥� ability to drop doctors during the plan year.
If insurers expect to drop providers in the coming year, they should say so in the letter highlighting changes that they are required to send to plan members every year before the open enrollment season. CMS would also add 鈥渞equired language鈥� to the letter explaining patients鈥� rights in the event that network providers leave the plan during the plan year.
Final rules are expected as early as April 7.
鈥淭hese are exactly the things we talked about with CMS back in the fall,鈥� said Mark Thompson, executive director of the Fairfield County (Conn.) Medical Association, which, along with the Hartford County Medical Association,聽 to block the terminations. The American Medical Association and 35 state medical associations and physician advocacy groups filed legal papers in support of the doctors.
鈥淪omeone was paying attention and listening to us,鈥� Thompson said.
A federal court judge in December聽issued an injunction聽halting the cancellations in those counties and a panel of three federal appeals court judges in February upheld that decision until the doctors had time to challenge their terminations before independent arbitrators.
Representatives for UnitedHealthcare and Humana, the two leading Medicare Advantage insurers, declined to answer questions or provide copies of their comments to CMS related to the proposals. UnitedHealthcare said earlier the cancellations were partly the result of cuts in federal reimbursements required by the Affordable Care Act and also part of an effort to improve quality and reduce costs.
However, America鈥檚 Health Insurance Plans, which represents more than 1,300 health insurers, warned CMS that the proposed rules could hinder insurers鈥� contract negotiations with providers, which 鈥渙ccur throughout the year鈥� and could also weaken enforcement of contract terms that allow for provider terminations. In addition, notifying beneficiaries of potential terminations before contracts may be successfully completed 鈥渨ould be unnecessarily disruptive,鈥� the group says.
Contact Susan Jaffe at Jaffe.KHN@gmail.com