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Network shakeups hit Medicare Advantage, forcing retirees to pay up or find new care
Millions of Americans lose their Medicare Advantage plans each year, or their plan’s network changes and their doctors and hospital systems are no longer covered.
Breakups are on the rise as hospitals and physician groups grow increasingly exasperated with insurance companies blocking medical care through preauthorizations and other red tape. At the same time, some insurers are jettisoning plans, hospital systems, and doctors.
A prime example: UnitedHealthcare (UNH) and Johns Hopkins Medicine ended their network contract in August. That meant most Johns Hopkins facilities and providers became out of network for patients with UnitedHealthcare Medicare Advantage plans.
For Medicare Advantage enrollees caught in the fray, it can be an expensive bad dream. When your long-standing doctor or preferred hospital is no longer covered by your insurance plan, for example, you’re considered out of network.
That means you’re seeing a healthcare provider or receiving services at a medical center that doesn’t have an agreement with your health insurance plan to pick up most, if not all, of the bill. The upshot for you: Pay the steep out-of-pocket costs, or find a new provider.
Proposed rule abandoned
Last fall, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would revise the process for Medicare Advantage enrollees who experience midyear provider network changes, according to a CMS fact sheet.
When providers and insurers split up, CMS reportedly gives enrollees a “special enrollment period” to change plans or enroll in traditional Medicare midyear. But how that works has been unclear and confusing. That prompted the proposed provision to make it easier.
Now CMS has dropped the proposal, which would have taken effect in 2027.
“We were disappointed that CMS did not finalize the provision to help more MA enrollees impacted by midyear network changes keep their doctor,” Lindsey Copeland, director of federal policy at the Medicare Rights Center, told Yahoo Finance.
“Abruptly losing access to a trusted provider is a difficult experience, especially for people with complex or serious conditions,” she said.
Medicare vs. Medicare Advantage
Medicare Advantage is an alternative health insurance program to traditional Medicare for those ages 65 and older. The plans are run by private insurance companies and cover benefits not included in traditional Medicare, such as drug coverage (Part D), eyeglasses, dental care, and fitness classes. Plus, they typically have very low or even no premium costs.
There’s a flip side. Unlike original Medicare, depending on the Advantage plan, you’re limited to a specific network of doctors and other healthcare providers, and those networks are ever-changing.
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