Medicare Advantage Plans Face Scrutiny Over Network Gaps,Despite Limited Federal Action
WASHINGTON – Complaints regarding insufficient access too care within Medicare Advantage plans are frequent,but federal enforcement actions against thes plans remain uncommon,a KFF Health News investigation reveals. The Centers for Medicare & Medicaid Services (CMS) has issued letters to several plans in recent years citing network deficiencies, yet oversight appears limited despite potential impacts on beneficiary access to healthcare.
CMS sent violation letters to multiple Medicare Advantage providers between 2016 and 2022, detailing gaps in provider networks. In March 2022, CMS informed Provider Partners that its 2021 network had deficiencies in four Ohio counties across four provider types and facilities, requesting the plan expand its provider base to comply with network adequacy standards. This followed Provider Partners’ decision to withdraw from the Ohio market entirely at the end of 2021 after enrolling a small number of members in a single county the previous year.
“We believe CMS’ network adequacy standards are generally clear and appropriate for ensuring beneficiary access,” said Grindrod,a representative for Provider Partners. “While the standards are not difficult to understand, as a provider-sponsored plan with a small footprint, we sometimes face challenges securing contracts with large systems that prioritize larger medicare Advantage plans.”
Other plans have also received similar notices. In 2021,CMS sent a violation letter to North Carolina’s Liberty Advantage,but did not inform the state’s Seniors’ Health Insurance Information program (SHIIP) about the issue,according to SHIIP director Melinda Munden. Liberty Advantage representatives did not respond to requests for comment.
in 2016, CMS alerted CareSource to network deficiencies in its Medicare Advantage plans in Kentucky and Indiana, requesting the company address the problems, including reimbursing members billed for out-of-network services.CareSource responded by implementing a Corrective Action Plan, which CMS subsequently approved.”CMS approved our plan, and no further action was required,” said Vicki McDonald, a CareSource spokesperson.
These instances highlight a pattern of CMS identifying network adequacy concerns but demonstrate a limited scope of enforcement beyond initial violation letters and corrective action plans.The issue underscores ongoing challenges in ensuring Medicare Advantage beneficiaries have consistent access to necessary care, despite the program’s growing popularity.
