Tag: In-network care

If your doctor leaves your Medicare Advantage plan mid-year, you may be able to switch plans
There are reasons you should not trust your health plan’s provider directory, and you can read about them on Just Care here. One reason is that health plans have the right to change their network of doctors and hospitals at any time during the year and, until recently, there was little members could do about it. Beginning this year, if your doctor leaves your Medicare Advantage plan mid-year, you may be able to switch plans.

At the end of last year, the Centers for Medicare and Medicaid Services issued a new protection for people in Medicare Advantage plans whose doctors leave the network mid-year. Under the new policy, CMS may grant members of a Medicare Advantage plan the right to switch plans as a result of a “significant” change in the provider network. CMS does not define “significant.” But, according to Kaiser Health News, it has been granting this right to some health plan members who have seen changes in their networks.

If your network doctors leave your Medicare Advantage plan, and you want to switch plans, contact your local state health insurance program for help. You may have the right to switch to another Medicare Advantage plan or to traditional Medicare.

Even if CMS does not notify you of a right to switch, it still might offer you the right to switch as a special protection. You may need to be persistent and explain why it’s important you continue care with your current doctors.

For other situations in which CMS allows Medicare Advantage members to switch plans, click here.

For more from Just Care:
April 12, 2016
The price you pay for a narrow network
These days, choosing a health plan that saves you money is a bit like throwing a dart. If you have commercial insurance or a Medicare Advantage plan, you can know the monthly premium and the deductible. And, you can keep those costs down, a top priority for many people, if you choose a plan with a narrow network. But, at what price?

Regardless of whether the plan you choose has a large or small network, if it has little or no out-of-network coverage, you limit your access to care and take a risk. You could pay a lot out-of-pocket if you get diagnosed with cancer or hit by a car. The copays are hard enough to predict and can add up to serious money. But doctors and hospital care could cost you tens of thousands of dollars more if you feel you need to go out of network and do not get in-network care.

Most people opt to keep their up-front costs down and to keep their current doctor when choosing a health plan. And, they often don’t think about whether the best hospitals are in the network. Perhaps, that’s a gamble worth taking. A recent study of people enrolled in narrow network California health plans found that “access and quality did not differ significantly” among plans in a given region.

A larger plan network does not assure you get to use the doctors in that network. Even if doctors are in the plan network, they might not be taking new patients or might have a wait for an appointment beyond what is reasonable for your needs. The real question is whether the network has top doctors and hospitals and whether you will have access to them if needed. And, that’s generally hard to know.

So, are you buying better hospital quality if you pay more in premiums? The study of California health plans found only a “modest relationship” between health plan premiums and hospital quality. But, this is one study and results will differ by region and by health plans. You can get a better understanding of the risks you take with network health plans, along with your protections if you have Medicare, here.

Here’s more information from Just Care on choosing a health plan:
March 24, 2016
Health plan networks limit access to care
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.
February 10, 2016