March 24, 2014 - 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
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
years Medicare Advantage plans released last month by the U.S. Centers
for Medicare & Medicaid Services. Officials say that the terminations
only a few weeks before Medicare's Dec. 7 enrollment deadline may not
have given seniors enough time to find new doctors, choose a different
plan or rejoin traditional Medicare, which does not restrict
beneficiaries to a limited network of providers.
The proposals would give
beneficiaries more than 30 days' advance notice of network changes and
providers at least 60 days' advance notice of a contract termination.
Even Medicare officials need more advance 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
The physician terminations sparked
protests to Medicare and UnitedHealthcare from patients, as well as
physician groups across the country, state officials and members of
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, "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 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' 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 physician advocacy groups filed legal papers in
support of the doctors.
"Someone was paying attention and
listening to us," Thompson said.
A federal court 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.
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'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 says.
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