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When your doctor is in-network one year and out the next

Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.

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Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP). It is funded by the government but is otherwise independent and trains volunteers to provide consumer Medicare counseling in state and local offices around the country. The non-profit Medicare Rights Center is also providing on-going help.

Moeller is a research fellow at the Center on Aging & Work at Boston College and co-author of “How to Live to 100.” Follow him on Twitter @PhilMoeller or e-mail him at medicarephil@gmail.com.


Before answering a particularly thorny Medicare question, here are two recent Centers for Medicare & Medicaid Services (CMS) consumer decisions worth sharing: 1) CMS payments to Medicare Advantage insurers will not change much in 2016 compared with this year; 2) Tougher quality ratings standards for roughly 15,000 nursing homes are now in place.

  1. Medicare Advantage plans have become increasingly popular and are now the choice of roughly 17 million Medicare beneficiaries. They offer more coverage than traditional Medicare and also include some of the features of Medicare Supplement plans, usually at a lower cost. Most MA plans also offer drug coverage under Part D of Medicare, and thus represent a conveniently bundled and often cost-effective choice that consumers find appealing.

    Under earlier government policies, MA plans enjoyed a government subsidy compared with rates for traditional fee-for-service Medicare (parts A and B). Under terms of the Affordable Care Act, CMS has been narrowing this relative pricing edge. For 2016, the agency says, insurers would receive about 1 percent less from CMS. However, once insurers adjust their mix of billed services, quality-based rate adjustments, and other options, CMS said it expects overall insurer revenues to rise by slightly more than 1 percent.

    After allowing for public and industry comments, CMS will lock in next year’s rates in early April, and insurers will use these rates to propose specific plans for the 2016 program year. Given the outlook for minimal changes, it will be important for consumers to check out plan details to make sure their current insurers aren’t shifting costs to consumers. Higher co-pays, deductibles, and drug prices can be harder to spot than premium changes.

  2. Although many nursing homes have improved service in recent years, the government’s rating system was widely considered too easy. It was also based on self-reported quality indicators that were not checked by CMS for accuracy. About 80 percent of all homes received either four or five stars under the old rating system. As of Feb. 20, only 49 percent had such high marks. The number of low-performing one-star nursing homes increased from one in 12 to one in eight.

    The most visible component of the change will penalize homes that make excessive use of anti-psychotic drugs. According to the agency, the new standards will:

    • Include use of antipsychotics in calculation of the star ratings. These medications are often used for diagnoses that do not warrant them. The two existing quality measures – for short-stay and long-stay patients – will now be part of the calculation for the quality measures star rating.
    • Have improved calculations for staffing levels. Research indicates that staffing is important to overall quality in a nursing home.
    • Reflect higher standards for nursing homes to achieve a high rating on the quality measure dimension on the website.

    The new ratings are now posted on Medicare’s Nursing Home Compare website. Consumer advocates say they are a work in progress, with much room for continued improvement.


Ted – N.C.: What can be done when the information about the health care providers in my health insurance network is changed so much from the prior year that it cannot be an accident? The hospital I usually go to was in the 2014 provider network book and not in the 2015 network book, which was not provided to me until after I had enrolled in the plan for 2015.

Further, of the 27 primary doctors that are supposed to be participating members of my health care insurance plan, only six are members. One of the doctors listed has been retired for years. The insurance Company is Cigna HealthSpring MedicareRX Preferred HMO.

Phil Moeller: I’m betting lots of folks are, or at some point will be, in Ted’s shoes. Medicare Advantage plans, as already noted, have become very popular. One of the major ways they can offer attractive coverage options at affordable rates is by setting up cost-effective provider networks that consumers must use, or else pay higher out-of-network prices for their health care needs. For financial and other reasons, there is a lot of competitive pressure on insurers to change network providers. These types of changes caught Ted off guard and, I suspect, will become a growing problem for MA plans and their customers.

Normally, people who sign up for Medicare plans are locked into them for the full ensuing year unless they move or have another life-changing event that would entitle them to a special enrollment period where they could pick a new plan. Several weeks ago, Medicare announced that it would consider letting people out of their Medicare Advantage plans if their insurers made substantial changes to their network providers after a plan year had begun. This new policy was disclosed in connection with major network changes and confusion involving Aetna prescription drug plans.

An Aetna spokeswoman said that CMS’ extension of a special enrollment period to some of its customers was not caused by provider network changes, but by mistaken listings – on CMS and Aetna websites – of pharmacies participating in Aetna’s network. She said the company is monitoring claims from incorrectly listed pharmacies and then working with consumers to help them find an in-network pharmacy and to call CMS to discuss other plan options for 2015.

Separately, she added, Aetna did make substantial network changes last year that took effect in 2015. These changes were properly made and communicated last year, she said, but there has been confusion among some Aetna Medicare Advantage customers. It has thus been offering consumers the temporary right, through the end of February, to have their prescriptions filled at in-network rates at any pharmacy in the company’s network. This temporary action, she noted, is a company decision and not an offer of a special enrollment period under the new CMS guidelines.

Ted’s situation seems significant to me, but Medicare has not provided any public definition of what it considers substantial. This is not easy stuff to do, so I’m not piling on CMS. But this doesn’t help Ted.

“CMS will review provider network changes on a case by case basis to determine when a provider network change is significant,” a spokesman said via email. “Medicare Advantage plans are required to notify affected enrollees at least 30 days prior to the provider termination(s). If the plan is making a significant change to its network, the Medicare Advantage plan must notify CMS 90 days prior to implementation of the changes. Enrollees who have questions should call their Medicare Advantage plan.”

If Ted doesn’t get a satisfactory response from Cigna, he could then complain to Medicare at 1-800-633-4227 (1-800-MEDICARE). The spokesman further said that CMS has not publicly identified such plans.

“While CMS has not announced a new SEP specifically for Aetna or other plan enrollees,” the CMS spokesman said, “it has been the agency’s long-standing policy that any time a beneficiary is provided with misleading marketing information, they may contact 1-800-MEDICARE to report the marketing misinformation and request to switch to a different plan.”

I called Cigna and asked them about changes to this plan. A spokesman said the company would be in touch with Ted but did not comment on his plan or respond to Ted’s claims that it made excessive changes in the provider network used in his plan.

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