Federal investigators have found that Medicare officials rarely enforce rules for private insurance plans intended to make sure beneficiaries will be able to see a doctor when they need care. It’s a problem many Connecticut seniors know too well. In 2013, UnitedHealthcare, the nation’s largest health insurance company, dropped hundreds of health care providers from its Connecticut Medicare Advantage plan, including 1,200 doctors at the Yale Medical Group and Yale-New Haven Hospital. Medicare Advantage beneficiaries scrambled to find new insurance or new doctors while the Fairfield and Hartford counties medical associations went to court to try to stop the terminations. The report by the Government Accountability Office, the investigative arm of Congress, said that Medicare did not check provider networks to ensure that doctors were available to beneficiaries and cited Connecticut as a “case study” in what can go wrong.
Next year, seniors with private Medicare Advantage insurance policies whose doctors leave their plan may be able to leave, too, under a new Medicare rule. The Centers for Medicare & Medicaid Services (CMS), which oversee Medicare Advantage programs, will create a special three-month enrollment period in any state where insurers make network changes “considered significant based on the affect or potential to affect, current plan enrollees,” according to an update to Medicare’s Managed Care Manual. The special enrollment period – if granted by CMS – would allow Medicare Advantage members to switch out of their plans and join traditional Medicare or another Medicare Advantage plan whose provider network includes their doctors. The mid-year special enrollment period wasn’t an option in 2013 when more than 32,000 UnitedHealthcare Medicare Advantage members in Connecticut were affected by the company’s decision to drop thousands of doctors from its network of providers. The Fairfield County Medical Association sued the company to stop the terminations but was ultimately unsuccessful.