As we age, we may experience occasional aches and pains, but aging can also bring unexpected health issues and serious illnesses. Having long-term relationships with trusted doctors can make even bad news more bearable. Losing that support—especially in the midst of a health crisis—can be terrifying. That’s why there are little-known federal requirements that are supposed to protect people with Medicare Advantage coverage, operated by private insurers, when contractual disputes cause health care providers and insurers to part ways.
However, government documents obtained by KFF Health News show that the agency overseeing Medicare Advantage is not making a strong effort to enforce long-standing rules to ensure that the 35 million enrollees can access their doctors first and foremost. In response to a Freedom of Information Act request covering the last decade, the Centers for Medicare and Medicaid Services (CMS) provided letters sent to only five insurers between 2016 and 2022, after seven of their plans failed to meet the minimum network requirements. These failures could, in some cases, impact patient care.
According to the letters, agency officials noted that some plans did not have enough primary care doctors, specialists, or hospitals. They warned that non-compliance with these requirements could result in the suspension of new enrollments and promotions, fines, or even plan closure.
CMS did not explain why they found so few plans with network infractions over those 10 years. “The number of identified infractions reflects the results of specific reviews, not a comprehensive audit of all plans in all years,” said Catherine Howden, a CMS spokesperson.
Officials in states with network infractions in Advantage plans claim that CMS did not notify them, including directors of the State Health Insurance Assistance Program (SHIP), which helps people navigate Medicare and is government-funded.
“I find it hard to believe that only seven Medicare Advantage plans have violated network rules,” said David Lipschutz, co-director of the Center for Medicare Advocacy, a nonprofit organization. “We often hear from people—especially in rural areas—that they have to travel long distances to find contracted providers.”
Medicare Advantage is becoming an increasingly popular alternative to traditional Medicare, managed by the government, which covers people over 65 and some with disabilities. Of the 63 million Americans eligible to join Advantage plans instead of traditional Medicare, 54% did so this year.
These plans usually offer lower out-of-pocket costs and additional benefits, such as vision, dental, and hearing coverage, but generally require enrollees to use specific networks of doctors, hospitals, and other providers. Last year, the federal government paid about $494 billion to Advantage plans for care for their enrollees.
In comparison, traditional Medicare has no network and is accepted by nearly all doctors and hospitals in the country.
Conflicts between Medicare Advantage plans and the doctors, hospitals, and other providers that care for their enrollees are common. Just this year, at least 38 hospital systems in 23 states stopped working with 11 Advantage plans, as they could not reach agreements on payments and other issues, according to a review of press releases and news reports. Over the past three years, breakups between Advantage plans and health systems increased by 66%, according to FTI Consulting, a consulting firm that monitors these conflicts.
After March, Advantage enrollees generally have to stay in their plan until the next open enrollment period, which is currently ongoing and extends until December 7th, for coverage starting on January 1st. However, hospitals, doctors, pharmacies, and other health providers can leave plans at any time.
When a separation occurs between providers and insurers, enrollees may lose access to their trusted doctors or preferred hospitals midway through the year. In response, CMS sometimes offers Advantage enrollees a little-known option: a Special Enrollment Period (SEP) to switch plans or move to traditional Medicare mid-year.
How CMS decides who qualifies for an SEP is a mystery even to experienced state regulators and senators overseeing federal health programs. Senator Ron Wyden, a Democrat from Oregon and a member of the Senate Finance Committee, and Senator Mark Warner, a Democrat from Virginia, referenced previous reports from KFF Health News on Medicare Advantage in a letter dated October 30th, requesting an explanation from Mehmet Oz, the CMS administrator.
“Despite the significant impact of SEPs on enrollees and the market, the process for determining who qualifies is opaque, leaving enrollees and state regulators in the dark,” they wrote.
“Seniors deserve to know that their Medicare plan won’t abandon them midway through the year,” Wyden told KFF Health News.
“Help us”
Oz spoke to representatives of Medicare Advantage insurers on October 15th at a conference organized by Better Medicare Alliance, a private sector group, and encouraged them to help CMS combat fraud in the program.
“Be our early warning system,” he said. “Tell us what issues you are seeing. Help us find better ways to address them.”
At the end, he sat next to Mary Beth Donahue, president and CEO of the group, and posed for photos.
In six letters obtained by KFF Health News, CMS officials informed five insurers that performance violations in their networks could affect enrollees’ access to health care. Five letters listed the number or types of specialists or medical centers missing from their networks. In three cases, CMS pointed out that plans could have requested exceptions to the rules, but did not. In one letter, CMS requested that enrollees be allowed to receive out-of-network care at no additional cost. Four letters required specific steps to address deficiencies, such as providing evidence that more doctors had been added to the networks.
Three letters required a “corrective action plan,” set deadlines to resolve the issues, and warned that non-compliance could result in enrollment and promotion suspension, fines, or plan closure. The other three letters were “non-compliance notices,” urging insurers to comply with legal requirements.
Although CMS considers these letters as the first step in their oversight process, the agency did not provide information on whether the infractions were resolved or resulted in sanctions.
The Medicare Payment Advisory Commission, a group created by Congress to oversee the program, noted in a June 2024 report that “CMS has the authority to impose intermediate sanctions or fines for non-compliance with network adequacy standards, but has never done so.”
One of the letters on these infractions was sent in November 2020 to Vitality Health Plan of California. This occurred after five hospitals and 13 nursing homes in one county and four hospitals in another county left their network, according to the letter signed by Timothy Roe, then director of the Compliance, Oversight, and Promotion Division at CMS. Two months before sending that letter, CMS granted a Special Enrollment Period to Vitality plan enrollees.
Beneficiaries appreciated that opportunity, according to Marcelo Espiritu, director of the Health Insurance Advocacy Program in Santa Clara County, California. But Espiritu did not know at that time that Vitality’s limited network violated CMS requirements, which, according to Roe, “jeopardized the health of Vitality beneficiaries.”
“People need to know that information,” said Espiritu.
“They would not receive the promised benefits, there would be delays in care, and a lot of frustration in trying to find a new plan,” he noted. “We would definitely alert people about that plan and remove it from our material.”
Representatives of Commonwealth Care Alliance, which acquired Vitality in 2022, did not respond to requests for comments.
Network minimums
Federal law requires Medicare Advantage plans to include a minimum of 29 types of health care providers and 14 types of medical centers in their networks, which beneficiaries can visit within certain distances and travel times. The standards, which vary by county population and density, also establish how long a patient should wait for a medical appointment. The agency reviews compliance every three years, or more frequently if complaints are received.
Networks can vary significantly even within the same county, as the minimum requirements apply to the insurer, not to each plan they offer, according to a KFF report. An insurer may offer the same network to enrollees of multiple plans in one or more counties, or create a different network for each plan.
In Maricopa County, Arizona, KFF researchers found that in 2022, UnitedHealthcare offered 12 plans with 12 different networks. Depending on the plan, the insurer’s customers had access to between 37% and 61% of the doctors available to traditional Medicare beneficiaries in that area.
In early 2016, CMS allowed 900 people enrolled in an Advantage plan in Illinois, operated by Harmony—a WellCare subsidiary at the time—to leave the plan after Christie Clinic, a large medical center, left the network. WellCare’s plan continued to operate without the clinic. But in June 2016, CMS informed the plan, in one of the letters obtained by KFF Health News, that the loss of Christie Clinic meant that the remaining network no longer met federal requirements.
It was “a significant change in the network with a considerable impact on beneficiaries,” the letter stated.
Claudia Lennhoff said that her group was not aware of the letter at that time. Lennhoff is the executive director of Champaign County Health Care Consumers, a government-funded Medicare counseling service that helped WellCare enrollees.
“Not disclosing that information is a breach of trust,” said Lennhoff. “It could lead someone to make a decision that harms them or that they deeply regret later.”
Centene Corp. acquired WellCare in 2020, and representatives of the St. Louis-based company declined to comment on events prior to that acquisition.
CMS sent two letters for infractions to Provider Partners Health Plan in Ohio, in 2019 and 2022. The Ohio Department of Insurance was not aware, according to spokesperson Todd Walker, who said the state’s Senior Health Insurance Information Program was also not notified.
In 2021, CMS also sent an infraction letter to Liberty Advantage in North Carolina. But the state’s Senior Health Insurance Information Program director, Melinda Munden, said they were not informed about this letter.
Representatives of Liberty did not respond to requests for comments.
CMS sent a letter in 2016 to CareSource about network deficiencies in some of their Advantage plans sold in Kentucky and Indiana. The agency asked the company to correct the issues, including reimbursing any enrollee who had received bills for out-of-network services.
“In response to the 2016 infractions, we immediately implemented a Corrective Action Plan, which included a thorough review of our provider network to ensure that adequate performance standards were met,” said Vicki McDonald, a CareSource spokesperson. “CMS approved our plan, and no further action was necessary.”
Susan Jaffe: Jaffe.KHN@gmail.com, @susanjaffe
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