Complaints about gaps in Medicare Advantage networks are common. Federal enforcement is rare.

Growing older comes with its fair share of challenges, including health setbacks and serious diseases. For many seniors, having a trusted relationship with their doctors can make navigating these issues a bit easier. However, when contract disputes between health care providers and insurers lead to disruptions in care, it can be a terrifying experience, especially for those with privately run Medicare Advantage coverage.

The Centers for Medicare & Medicaid Services (CMS) is responsible for overseeing Medicare Advantage plans and ensuring that about 35 million plan members have access to the care they need. However, recent documents obtained by KFF Health News reveal that CMS is not effectively enforcing the rules meant to protect patients when their providers and insurers part ways.

According to the documents, CMS sent warning letters to only five insurers between 2016 and 2022 after seven of their plans failed to meet provider network adequacy requirements. These lapses could potentially harm patient care by limiting access to primary care clinicians, specialists, or hospitals. The letters warned of consequences such as marketing and enrollment freezes, fines, or plan closure for non-compliance.

Despite these violations, state officials and Medicare counseling services were not always notified by CMS, leaving many unaware of the potential risks to patients. This lack of transparency raises concerns about the effectiveness of CMS’s oversight of Medicare Advantage plans.

Medicare Advantage is a popular alternative to traditional Medicare, offering lower out-of-pocket costs and additional benefits like vision and dental coverage. However, these plans often require members to stay within specific networks of providers, leading to conflicts when providers and insurers cannot agree on terms.

In response to these conflicts, CMS sometimes grants Medicare Advantage members a special enrollment period to change plans or enroll in traditional Medicare. However, the criteria for determining who qualifies for this special enrollment period are unclear, leaving both patients and regulators in the dark.

CMS has the authority to impose sanctions or penalties on plans that violate network adequacy standards, but it has never done so. This lack of enforcement raises questions about the agency’s commitment to ensuring patient access to care.

Overall, the enforcement of network adequacy requirements for Medicare Advantage plans remains a critical issue that requires greater oversight and transparency. Patients deserve to know that their health care needs will be met, regardless of changes in provider networks or insurer contracts.