Medicare Advantage, healthcare exchange plans must list doctor directories or face fines

Inaccuracies in Medicare Advantage directories can result in penalties of up to $25,000 per day per beneficiary or bans on new listings and marketing.

Starting next year, the federal government will require health insurers to give millions of Americans enrolled in Medicare Advantage plans or policies sold in the federally run health exchange details to update on doctors who are in their plans and taking on new patients.

Medicare Advantage plans and most exchange plans limit coverage to a network of doctors, hospitals, and other health care providers that may change during the year. Networks can also vary between plans offered by the same insurer. So it’s not always easy to know who is and who isn’t, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.

Under a rule released last month by the Centers for Medicare & Medicaid Services, Medicare Advantage plans must contact doctors and other providers every three months and update their online directories in “real time.” Online directories of policies sold through, the federally-run healthcare law exchange in 37 states, must be updated monthly, CMS said in a separate rule.

Inaccuracies in Medicare Advantage directories can result in penalties of up to $25,000 per day per beneficiary or bans on new listings and marketing. CMS will also use the directories to help determine whether insurers have enough doctors to meet beneficiary needs.

Federal exchange plans could face penalties of up to $100 per day per affected beneficiary for issues in their directories.

“Studies have shown massive error rates in these directories, including state in federal scholarships,” said Lynn Quincy, associate director of health policy at Consumers Union. “If consumers choose a health plan because they think their hospital or doctor is a participating provider and it later turns out to be wrong, right now, they rarely have a cure – they’re stuck with this plan for the year.”

“Regulators also rely on these vendor directories to assess network suitability,” Quincy said. “And when provider directories include physicians who are deceased, who have moved out of state, or who are not accepting new patients, we overstate the adequacy of the network.”

Last year, the administration announced rules designed to ensure that these networks have a sufficient number of providers. The latest rules will help ensure consumers get the right information on these networks.

Nearly 9 million people signed up for plans in the federal market for 2015, officials said.

Some states that operate their own health exchanges, including New York and California, also require frequent directory updates.

Californians struggled to find doctors in their plans and others who were misled into thinking their providers were in-network were ‘swamped with huge out-of-network bills’, the insurance commissioner said of California, Dave Jones, who issued an emergency rule requiring plans to update their directories weekly.

The new Medicare Advantage rules are a response to complaints from beneficiaries and physicians about “directories including providers who are no longer under contract with the [plan], retired, moved or died,” CMS officials said in the notice to insurers. Some directories also list providers who are still in the plan’s network but are not available to new patients.

About 16 million seniors have private Medicare Advantage plans, which provide an alternative to traditional health insurance.

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“We’ve had clients either start treatment with a doctor who doesn’t stay in the network for the whole year, or think they’re choosing a plan that covers a certain doctor and then finds out it’s not the case,” said Jen Tayabji, coordinator of the Medicare Healthcare Consumer Task Force for Champagne County in central Illinois. Since most Medicare Advantage members are locked into their plans for the calendar year, she said they often don’t have good alternatives when their provider networks shrink.

“It’s extremely important that people on Medicare have timely access to the information they need to make decisions about their care,” Medicare spokesman Raymond Thorn said. “Reflecting this priority, Medicare will require health plans to ensure their online directories are up-to-date and accurate whenever their networks change.”

Medicare Advantage plans have had mixed reactions to the new rules. Some worry about the increased cost of compliance. Matt Burns, spokesman for UnitedHealthcare, one of the largest Medicare Advantage providers, said the company is still reviewing the rules. Other companies have referred questions to an industry trade association, the US Health Insurance Plans.

“It is important to keep in mind that the maintenance and accuracy of online directories goes both ways and it is often difficult to get providers to report status changes in a timely manner,” said said association spokeswoman Clare Krusing.

“This is definitely the direction we need to go to make sure Medicare Advantage plans don’t drain their networks,” said Mark Thompson, executive director of the Fairfield County Medical Association, which sued UnitedHealthcare in 2013 to stop the layoffs. from Connecticut. doctors from its Medicare Advantage plans.

Cigna’s Medicare Advantage directories are updated weekly during the open enrollment period and monthly the rest of the year, spokesperson Joe Mondy said. Aetna’s Medicare Advantage directories are updated nightly, six days a week, and weekly for subsidiary Coventry directories, spokesperson Kendall Marcocci said.

Kaiser Health News is a national health policy information service. It is an independent editorial program of the Henry J. Kaiser Family Foundation.

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