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Health plan networks limit access to care

Written by Diane Archer

One of the biggest problems with health insurance companies is that they generally offer health plans that limit coverage to doctors and hospitals in their networks. And, too often their networks of doctors and hospitals are inadequate, even though they may seem adequate at first glance. So, what you see is not what you get, and people have access to care problems. Two recent reports reveal problems with the adequacy of health plan networks, as well as a high frequency of people in private Medicare Advantage plans switching to traditional Medicare when they need costly care because access to care is so much easier.

Traditional Medicare offers people the choice of coverage from virtually any doctor or hospital in the United States. That’s why about seven out of 10 people with Medicare are enrolled in traditional Medicare.  People with employer coverage or enrolled in a state health exchange plan do not have the choice of a plan like traditional Medicare. (Bernie Sanders is proposing to give everyone that option.)

People  in HMOs and other commercial health plans face four key problems with in-network care.

  1. Many of the doctors listed in their network may no longer be in their network or, if they are, they may not be taking new patients. So, protect yourself, and don’t trust your health plan’s provider directory;
  2. The doctors listed may have offices that are difficult to access;
  3. The doctors listed may not have the skills to treat people with a range of serious and complex conditions; and,
  4.  Doctors in network at the start of the year may leave the network any time during the year. (Notice is required.)

Moreover, a recent study from the Government Accountability Office (GAO) found that the Centers for Medicare and Medicaid Services does not do a good job of ensuring that the Medicare Advantage plans have adequate networks.  For example, while there are standards to help ensure Medicare Advantage plans have adequate networks, CMS has approved 90 percent of requests from these health plans to be relieved of the responsibility of ensuring that people do not have to travel more than five miles (10 minutes) to see a doctor or use a hospital.

Why are Medicare Advantage and other commercial health plan networks often inadequate? Another Health Affairs study by Rahman, Keohane, Trivedi and Mor, High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare, explains that commercial health plans that contract with Medicare have a financial incentive to keep patients with costly needs from both joining their plans and remaining in their plans. As a result, their networks are likely not to meet the needs of high-cost patients, particularly patients needing home health care, skilled nursing care and acute inpatient care.

People with costly health care needs enrolled in Medicare Advantage plans are more likely to leave a Medicare Advantage plan for traditional Medicare. Fortunately, they can switch plans. (Here’s how to choose.) But, unfortunately, they can only do so once a year during open enrollment season. So, if they need specialty services that they cannot get from their Medicare commercial health plan, they will either need to pay out of pocket for the care or forego it until they are able to switch to traditional Medicare.


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