Medicare Advantage plans could lose members to feds

If Medicare Advantage plans drop a significant amount of providers from their networks, their affected members can leave those plans and enroll instead in traditional Medicare, Kaiser Health News reported.

The Centers for Medicare & Medicaid Services has said that, if certain conditions are met, it will establish a special three-month enrollment period after a Medicare Advantage plan makes changes to its provider network that are "considered significant based on the [effect] or potential to affect, current plan enrollees," according to an update to Medicare's Managed Care Manual.

During that special enrollment, Medicare Advantage members could either enroll in traditional Medicare or choose a different Medicare Advantage plan that covers their doctors.

"If CMS does not prohibit midyear network terminations then a special enrollment period is the next best thing for beneficiaries," David Lipschutz, senior policy attorney at the Center for Medicare Advocacy, a nonprofit law firm that works on behalf of Medicare patients, told KHN.

Lipschutz is referring to UnitedHealth's decision last year to drop more than 19 percent of its networked providers in Pennsylvania. The move led to CMS releasing new proposed rules calling for insurers to give members and providers more notice of major network changes and terminations, FierceHealthPayer previously reported.

Although the CMS update didn't define "significant" network changes, Medicare spokesman Raymond Thorn told KHN that the agency will make that determination on a "case-by-case" basis, taking into consideration the number of beneficiaries affected, the amount of notice they received, the size of the plan's service area and the time of year the terminations occur.

When CMS decides that the right conditions have been met, it will require the Medicare Advantage plan notify its members about their new options.

To learn more:
- read the Kaiser Health News article