Feds Issue Rules To Protect Seniors Enrolled In Medicare Advantage Plans

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UnitedHealthcare’s decision last fall to drop thousands of doctors from its Medicare Advantage plans in Connecticut and across the country has spurred Medicare officials to improve protections for seniors who lose their doctors.

The new measures were announced late Monday along with a slight increase in next year’s payment rates to Medicare Advantage insurers who provide policies as an alternative to the traditional government-run Medicare program.

Nearly 16 million older Americans have enrolled in a Medicare Advantage plan, including more than 147,000 in Connecticut, which requires members to get treatment only from a network of health care providers. They cannot change plans during the year if their doctor leaves their network.

The new rules require insurers to provide at least 90 days advance notice of significant changes in their provider networks and allow members to switch plans under certain circumstances. Companies must also include in annual member notices new information about seniors’ options in the event of a provider termination.

Officials at the U. S. Centers for Medicare and Medicaid Services, which oversee the Medicare Advantage program, did not name any insurance companies in the announcement but introduced the new rules by explaining, “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.”

“I doubt that CMS would have given this as much attention without patients, providers and advocates demonstrating how deep and broad the effect was and how much pain and anguish it caused,” said U.S. Sen. Richard Blumenthal.

Blumenthal, a Democrat, held a Senate hearing on the network changes, intervened on behalf of individual seniors who lost their doctors and filed legal papers in support of the Fairfield and Hartford counties medical associations’ lawsuit against UnitedHealthcare to stop the company from dropping some 2,200 physicians in Connecticut from its Medicare Advantage plans.

While the new rules may have been prompted by protests in Connecticut, elected officials, doctors and seniors’ advocates are still critical of the results.

“These are some important first steps but more is needed to ensure that Medicare Advantage enrollees have adequate protection when Medicare Advantage plans terminate providers from their networks,” said David Lipschutz, policy attorney at the Mansfield-based Center for Medicare Advocacy, which provides legal representation and other services for some Connecticut seniors.

Starting next year, insurers selling Medicare Advantage policies will be required to notify CMS at least 90 days in advance “when they are planning networks changes that the MAO [Medicare Advantage organizations] deems significant,” the announcement says.

Although Medicare officials cited “significant mid-year changes” in provider networks as the reason for the new rules, officials are letting the insurers determine what “significant” means.  They decided to so because they said there was no consensus among the organizations that submitted comments on the preliminary rules proposed in February “regarding how to define a ‘significant’ network change.”

Blumenthal said he was concerned that it “leaves the plans vulnerable to real manipulation because the MAOs are defining what they think is significant.”

“I think CMS is still kowtowing to the managed care companies if they can’t figure out what a significant network change is,” said Dr. Robin Oshman, a Westport dermatologist who is president of the Fairfield County Medical Association.

UnitedHealthcare and Humana, the nation’s leading Medicare Advantage providers, would not answer questions about the rules or provide copies of their comments on the draft proposals.

Also beginning next year, Medicare Advantage members will be granted a “special enrollment period” to change plans or return to traditional Medicare if their provider networks are reduced, depending on the number of members affected and other factors.

Last fall, Attorney General George Jepsen and other Connecticut officials asked Medicare to give seniors losing their doctors a special enrollment period but it was not provided. Generally, seniors can choose a Medicare Advantage plan only during the annual enrollment period from Oct. 15 through Dec. 7.

Medicare officials conceded that seniors would be best protected if insurers were not allowed to drop doctors during the year.  But they rejected that idea because such a prohibition would interfere with insurers’ ability to negotiate with providers and establish “cost-effective, high-performing networks,” which would then negatively affect all enrollees.

“Businesses have a right to make business decisions,” said U.S. Rep. Rosa DeLauro, a Democrat from New Haven. “But as an alternative to the federally administered Medicare program, they also have the responsibility to provide quality, accessible care.”

Last month, DeLauro spearheaded a request on behalf of Connecticut’s House members for an investigation into Medicare’s oversight of the Medicare Advantage program by the General Accountability Organization, the investigative arm of Congress. The investigation is now underway.

Medicare officials are requiring insurers to include new information about network changes in the annual letter they send to members that summarizes upcoming changes in their coverage to help them decide whether to renew their policy another year. The required text describes patients’ rights in the event that their provider leaves their plan.  For example, patients must now be told:

• “If you are undergoing medical treatment, you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.”

• “If you believe we have not furnished you with a qualified provider to replace your previous provider so that your care is not being appropriately managed, you have the right to file an appeal of our decision.”

Also, officials recommended several other measures insurers should follow as “best practices,” though they are not required.  These include providing members more than 30 days advance notice that their provider will be dropped by their plan.  That notice should include other information in addition to the name of the provider being terminated, such as how members can request continuation of ongoing medical treatment from that provider.

“Why make it so complicated?” asked Oshman. “If UnitedHealthcare says your cardiologist is no longer in the plan, the patient should be able to allowed to go back to Medicare,” which does not confine beneficiaries to a provider network.

 Contact Susan Jaffe at Jaffe.KHN@gmail.com.






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