The Washington Post

Proposed rules would offer more protection for seniors enrolled in Medicare Advantage

Federal officials are considering new Medicare Advantage rules to help protect seniors when insurers make significant reductions to their networks of doctors and other health-care providers.

The proposals follow UnitedHealthcare’s decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.

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

The proposals would give beneficiaries more than 30 days’ notice of network changes and providers at least 60 days’ notice of a contract termination. Even Medicare officials need more notice — “no less than 90 days” — so they can ensure that the remaining providers “will continue to meet required network standards.” Officials are soliciting suggestions on how plans should prove that their reconfigured networks are adequate.

The doctor terminations sparked protests to Medicare and UnitedHealthcare from patients, as well as doctor groups across the country, state officials and members of Congress.

Nearly 16 million people, about a third of Medicare beneficiaries, are enrolled in the 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, “Recent significant mid-year changes to MAOs’ [Medicare Advantage organizations’] provider networks have prompted CMS to reexamine its current guidance on these requirements and to consider augmenting such guidance in response to such changes.”

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 once a year, during the fall seven-week enrollment period. Since most beneficiaries are locked into their plans, CMS is considering whether to restrict insurers’ 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 “required language” to the letter explaining patients’ rights in the event that network providers leave the plan during the plan year.

Final rules are expected as early as April 7.

“These are exactly the things we talked about with CMS back in the fall,” said Mark Thompson, executive director of the Fairfield County (Conn.) Medical Association, which, along with the Hartford County Medical Association, sued UnitedHealthcare to block the terminations. The American Medical Association and 35 state medical associations and doctor advocacy groups filed legal papers in support of the doctors.

“Someone was paying attention and listening to us,” Thompson said.

A federal judge in December issued an injunction 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 that 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’s Health Insurance Plans, which represents more than 1,300 health insurers, warned CMS that the proposed rules could hinder insurers’ contract negotiations with providers, which “occur throughout the year” 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 “would be unnecessarily disruptive,” the group said.

— Kaiser Health News

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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