Debate Intensifies Over Medicare Advantage Plans’ Removal of Providers

Which is more important in a Medicare Advantage plan:  the plan’s flexibility to change its provider list during the plan year, or the enrollees’ right to confidence that their providers won’t be removed from the plan after they sign up?

That’s the issue at the heart of an ever-intensifying debate in Washington.  And last month a bipartisan group of United States Senators and Representatives sent CMS Administrator Marilyn Tavenner a letter weighing in on behalf of enrollees.

The letter, with 20 Congressional signatures, asked that new protections be included in CMS’s 2016 Call Letter, which likely will be issued next month.  CMS already requires that it be notified within 90 days of “significant” terminations and already allows enrollees to change plans in a special enrollment period (SEP) if the terminations are without cause.

But the signatories to the letter want more protections.  They want a clear definition of “significant” terminations, monitoring of plan marketing to minimize gaming and discrimination by plans, 60- rather than 30-day notice before open enrollment of any provider changes, up-to-date provider directories and inclusion of essential community providers.

Not all the arguments are on the side of limiting the right of plans to drop providers.  Last summer America’s Health Insurance Plans provided written Congressional testimony noting the need for flexibility to enable plans to promote quality, efficiency and innovations in the delivery of care to seniors.