Medicare Advantage Plans Face Scrutiny Over Network Gaps,Despiteโ Limited Federal Action
WASHINGTON – Complaints regarding insufficient access too care within Medicare Advantage plans are frequent,but federal enforcement actions โขagainst thes plans remain uncommon,a KFF Health News investigation reveals. The Centers for Medicare & Medicaid Servicesโค (CMS) has issued โletters to several plans in โฃrecent years citing network deficiencies, yet oversight appears limited despite โpotential impacts on โbeneficiary accessโข to healthcare.
CMS sent violationโค letters to multiple Medicareโ 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 countiesโค across fourโ provider types and facilities, requesting the plan โขexpand its provider โขbase to โขcomply with networkโค adequacy standards. This followed Provider Partners’ โdecision to withdraw from the Ohio market entirely at the end of 2021 after enrolling a small number of members in a โsingle โฃcounty the previous year.
“We believe CMS’ network adequacy standards โขare generally clear and โappropriate for ensuring beneficiary access,” said Grindrod,a representative for Provider Partners. “While the standards โare not difficultโฃ to understand, as a provider-sponsored plan with aโ small footprint, we sometimesโข face challenges โขsecuring โฃcontracts with large systems that prioritize larger medicare Advantage plans.”
Other plans have also โคreceived similar notices. โIn โข2021,CMS sent a violation letter to North Carolina’s Liberty Advantage,but did โnot inform the state’s Seniors’ Health Insurance Information program (SHIIP) about the issue,accordingโ toโข SHIIP director Melinda Munden. Liberty Advantage โฃrepresentatives did not โrespond to requests for comment.
in 2016, CMS alerted CareSource to network deficiencies in its Medicare Advantage plans in Kentucky and Indiana, requesting theโ company addressโ the problems, including reimbursing members billed for out-of-network services.CareSource responded by implementingโ a โฃCorrective Actionโ Plan, which CMS โขsubsequently approved.”CMS approved our plan, and no further action was required,”โค said Vicki McDonald, a CareSource spokesperson.
These instances highlight a pattern of CMS identifying network adequacy concerns โbut demonstrate a limited scope of enforcement beyondโค initial violation letters and corrective โฃaction plans.The issue underscores ongoing challenges in ensuring Medicare Advantage beneficiaries have consistent access to necessary care, despite the program’s growing popularity.
