Letter to CMS

Guard Against Narrow Networks in Medicare Advantage Plans, Says AAFP

February 18, 2015 07:24 pm News Staff

As CMS plans to publish its 2016 requirements for Medicare Advantage plans, the AAFP and other organizations are asking the agency to better protect patients from insurers' practice of narrowing their plans' provider networks.

[Stock photo of physician examining older woman]

The AAFP and 30 other medical organizations sent a letter(4 page PDF) to CMS in advance of its planned 2016 Call Letter, which advises insurers about Medicare Advantage plan policies. The signers asked the agency to prohibit the practice of dropping physicians from plan networks without cause during a benefit year and to require that network provider directories be kept accurate and up-to-date to help patients make informed decisions about their plans.

"We urge CMS to ensure that Medicare Advantage plans provide adequate networks, that frail elderly patients are not being disproportionately discriminated against when plans terminate physicians, and that they continue to have an adequate network available," the letter reads.

Story highlights
  • The AAFP and other medical organizations are urging CMS to limit health insurers' practice of narrowing their provider networks.
  • Medicare Advantage beneficiaries should be protected against inaccurate information in insurance directories that influences their plan choice, the organizations wrote to CMS.
  • The organizations want insurers to be prohibited from removing a physician from a network in the middle of a contract year without cause.

Moreover, the AAFP and others asked CMS to ensure that if changes are made to the network during the benefit year, patients would be allowed to continue with their physicians on an in-network basis until the next enrollment period, subject to the physicians' consent.

Both state and federal studies have revealed that many insurance directories contain inaccurate information, which keeps patients from knowing which physicians are in a particular network. Patients should be allowed to change plans if they select insurance based on inaccurate information about a physician's status, the organizations said.

During the past two years, many physicians have been dropped from insurance networks that participate in the Medicare Advantage program without reason, disrupting care for seniors who have maintained long-term relationships with their physicians.

In 2014, patients in Connecticut, Tennessee and other states reported that United Healthcare sent letters informing beneficiaries that their physicians were being dropped from their insurance plans and telling them to select a new physician on short notice. The insurer did not say why the physicians were being removed from the network. Nationally, several insurers have sought to reduce the number of physicians in their networks without providing alternatives to patients.

In their letter, the AAFP and the other medical organizations asked CMS to ensure that if an insurer decides to reduce a plan's provider network, the network would continue to provide adequate coverage by documenting the remaining number of primary care physicians, other specialists and subspecialists in an area.

"The provision of health insurance is not simply a calendar year transaction, particularly for those with chronic conditions or acute conditions that continue beyond December 31st," the letter reads.

In addition, insurance directories are often inflated to present networks as being much larger than they actually are, said the groups, which makes it difficult for patients to select a plan.

The letter also asks CMS to evaluate narrow networks to determine if eliminating a physician or group practice is being undertaken as a "covert methodology" to reduce the number of sick or elderly patients being covered in a plan.

Finally, the letter notes that to calculate network adequacy, CMS uses a physician-to-covered-person ratio that does not properly account for the number of available physicians in a given area. Instead, the AAFP and others recommend that the agency change the calculation to use the full-time equivalent of those physicians.

"Physicians frequently practice part-time in multiple locations, thereby distorting the physician-to-covered-persons ratio," the letter reads.

Related AAFP News Coverage
Guard Against Provider Network Inadequacy, AAFP Tells CMS
Academy Tackles Narrow Networks Issue at Federal, State Levels