Introduction to Medicare Advantage Network Issues
As individuals age, they often face unexpected health challenges and serious illnesses. Maintaining long-term relationships with trusted healthcare providers can make these challenges more manageable. However, when these relationships are disrupted, especially during a health crisis, it can be distressing. Federal regulations are designed to protect individuals with Medicare Advantage plans from losing access to their healthcare providers due to contract disputes between insurers and providers. Despite these regulations, enforcement appears to be lacking.
Limited Enforcement of Network Adequacy Rules
Documents obtained by KFF Health News reveal that the Centers for Medicare & Medicaid Services (CMS), the agency responsible for overseeing Medicare Advantage, has taken minimal action to enforce rules ensuring that approximately 35 million plan members have access to necessary healthcare providers. From 2016 to 2022, CMS sent letters to only five insurers regarding seven plans that failed to meet network adequacy requirements, potentially impacting patient care.
Insufficient Provider Networks
According to CMS officials, some plans lacked sufficient primary care clinicians, specialists, or hospitals. The agency warned that failing to meet these requirements could lead to marketing and enrollment freezes, fines, or even plan closures. However, CMS did not provide detailed explanations for the limited number of identified violations, stating that the findings were based on targeted reviews rather than comprehensive audits.
State-Level Awareness and Concerns
State officials, including directors of the State Health Insurance Assistance Program, were not notified of these violations. David Lipschutz, co-director of the Center for Medicare Advocacy, expressed skepticism about the low number of reported violations, noting frequent complaints from individuals, particularly in rural areas, who struggle to find contracted providers.
Popularity and Challenges of Medicare Advantage
Medicare Advantage is a popular alternative to traditional Medicare, offering lower out-of-pocket costs and additional benefits such as vision, dental, and hearing care. However, these plans typically require members to use specific networks of doctors and hospitals. In 2025, 54% of the 63 million Americans eligible for Medicare chose Advantage plans. Despite their popularity, conflicts between Advantage plans and healthcare providers are common, with numerous hospital systems severing ties with plans over payment disputes.
Impact on Beneficiaries
After March, Medicare Advantage beneficiaries are generally locked into their plans for the year, with the annual open enrollment period running until December 7 for coverage starting January 1. However, healthcare providers can leave plans at any time, potentially leaving members without access to preferred doctors or hospitals midyear. In such cases, CMS may grant a “special enrollment period” (SEP) allowing members to switch plans or enroll in traditional Medicare.
Opaque SEP Determination Process
The process for determining who qualifies for an SEP is unclear, even to state insurance regulators and U.S. senators overseeing federal health programs. Senators Ron Wyden and Mark Warner have requested an explanation from CMS Administrator Mehmet Oz regarding the opaque SEP determination process, emphasizing the need for transparency to protect seniors.
CMS’s Call for Industry Cooperation
At a recent conference, Oz encouraged Medicare Advantage insurers to assist CMS in identifying and addressing fraud within the program. He urged insurers to act as an “early-warning system” and report any issues they observe.
Details from CMS Violation Letters
KFF Health News obtained six letters from CMS to five insurers regarding network adequacy violations. These letters highlighted missing medical specialists or facilities and, in some cases, requested that plans allow members to receive out-of-network care at no additional cost. Some letters required corrective action plans and set deadlines for resolving issues, warning of potential penalties for non-compliance.
Lack of Penalties and Resolution Information
Despite CMS’s authority to impose sanctions or penalties for non-compliance, the agency has never done so, according to the Medicare Payment Advisory Commission. The lack of information on whether violations were resolved or resulted in penalties raises concerns about the effectiveness of CMS’s enforcement efforts.
Case Studies of Network Violations
Several case studies illustrate the impact of network violations. For example, Vitality Health Plan of California faced a network adequacy violation in 2020 after multiple hospitals and nursing homes left its network. CMS granted a special enrollment period for affected members, but local program managers were unaware of the violation at the time.
Federal Requirements and Compliance Checks
Federal law mandates that Medicare Advantage plans include a minimum number of healthcare providers and facilities within specific distances and travel times. Compliance is checked every three years or more frequently if complaints are received. However, network adequacy can vary significantly even within a single county.
Conclusion
The limited enforcement of Medicare Advantage network adequacy rules raises concerns about beneficiaries’ access to timely and necessary care. While traditional Medicare offers broader provider access, the popularity of Medicare Advantage plans continues to grow. Ensuring that these plans meet federal requirements is crucial to maintaining trust and protecting the health of millions of Americans.
🔗 **Fuente:** https://medicalxpress.com/news/2025-11-complaints-gaps-medicare-advantage-networks.html