Medicare Advantage Doctor Networks Are Shockingly Cruel

 

Am I the only one that thinks Medicare Advantage doctor networks can be shockingly cruel? When you purchase a private Medicare plan, your agent will have confirmed that all of your doctors and specialists currently accept the plan. Key word: currently. The government basically locks Medicare members into their plan for a calendar year. Plans can be changed each fall between October 15 – December 7th. The first quarter of the new year brings the option to make one change. After March 31 (or earlier if you change in January) you can no longer change plans unless you have a special circumstance. Moving to a new state, going into a nursing home, getting Medicaid—there are many special exceptions. In general, most people must keep the plan they have on January 1st of each year. This is called “lock in.”

Shocked?

What comes as a shock is that the plan your agent carefully vetted to ensure all your doctors and hospitals were in the network—those networks are not locked in along with you. Those network contracts can change during the year. This famously disrupted Fort Wayne a few years ago. One of the largest insurance companies couldn’t reach an agreement with Parkview, the largest hospital system in the city. The hospital sent out letters to alarm members that they would soon have to pay higher out of network costs if the negotiation didn’t resolve. Parkview took out full page ads in the newspaper.

Many of my clients send me the ads and share their dismay at the situation. I told them that I see this all the time on a national level. Since I work in all 50 states, I know that the fights between the hospitals and insurance companies get ugly, but almost always resolve before the deadlines. Which is what happened in Fort Wayne. Sometimes it doesn’t resolve and creates an unfortunate mess for the Medicare members.

What’s the Take Away Here?

The take away here is that this is something that is legal and could happen to you. Since Medicare members are locked into their plans for a calendar year, while the doctor’s and hospitals are not locked in for the same calendar year, you could buy a PPO and three months later get notice that your doctor is no longer in network. It doesn’t seem fair. Before you complain about your insurance agent— know we hate this rule more than you do.

Insurance agents are not privy to the expiration of these doctor and hospital contracts. All we can see if who is in the network today. Agents have no way to know which contract is expiring soon. Yet, Medicare members who get caught in this trap are likely to call 1-800-Medicare to complain about being mislead by their agent. Even though this is out of the agent’s control, a complaint process against the agent will commence. This system drives us agents crazy.

Be Aware, Stay Flexible

This is an easy fix. The government could require that network contracts coincide with the calendar years and make contract expiration data available to all. Medicare Advantage doctor networks can be shockingly cruel. Since this will likely not be fixed anytime soon, just be aware and stay flexible. Private Medicare Advantage plans have a lot of attractive extras, but you must remain flexible. Flexibility may mean changing doctors and hospitals mid year.