Don’t Assume Your Doctor Still Accepts Medicare Advantage—Some Are Dropping the Program

It’s a good idea to check your plan’s provider network every year and make sure all your doctors and hospitals are still in-network for the following year. But it’s become even more important now that some major U.S. health systems have recently canceled or plan to cancel their contracts with Medicare Advantage, according to Becker’s ASC Review.

Among the latest examples: two physician groups affiliated with San Diego-based Scripps Health, which filed termination notices with Medicare Advantage plans used by thousands of San Diego County patients, effective Jan. 1, 2024, as well as Cameron Regional Medical Center in Cameron, Mo., which canceled contracts with Cigna and
Humana
Medicare Advantage plans. The Cigna termination took effect on Jan. 1, 2023 and the Humana termination took effect this September, says Joe Abrutz, the hospital’s administrator.

“Be sure that doctors and specialists and hospitals that matter to you are in a preferred plan’s network,” says Tricia Neuman, executive director for Program on Medicare Policy at KFF, a nonprofit health policy organization. The best way to do so is to call the doctor’s office directly, since online provider directories can be out of date.

About half of the nation’s 65 million Medicare beneficiaries are enrolled in Medicare Advantage, which is run by private insurance carriers that contract with the government to provide bundled Part A inpatient hospital coverage, Part B outpatient coverage, and often, Part D drug coverage. By contrast, original Medicare—also known as traditional Medicare or fee-for-service Medicare—is run by the government. Original Medicare has no network of participating providers: beneficiaries can visit any doctor or hospital in the country that takes Medicare.

Canceling Medicare Advantage contracts carries serious consequences for both health systems and patients, Neuman says. The health system could lose patients and revenue, while patients could lose access to trusted providers and face disruptions to their care.

So why would the health systems take such a step? Those that terminated their relationship with Medicare Advantage cited low payments and administrative hassles among the reasons for their split, Becker’s ASC Review reports. Many Medicare Advantage plans require what’s known as prior authorization before certain prescriptions are filled and procedures performed. This creates more work for the provider and can cause delays in and even rejections of requested care. 

A report last year by the U.S. Department of Health and Human Services’ Office of Inspector General found that, among the prior authorization requests that Medicare Advantage organizations denied, 13% met Medicare coverage rules. In other words, a patient with original Medicare would likely have had no problem accessing that service or medication in those cases.

Those who don’t want to face as many prior authorization requests or restrictions on the providers they see could consider switching back to original Medicare. While that move is always allowed during open enrollment, keep in mind that—with a few exceptions—you’re not guaranteed the right to buy a Medigap supplement plan outside of your original eligibility period when you first enroll in Medicare. At all other times, your health status could disqualify you or cause you pay more. Without a Medigap plan, you’re on the hook for about 20% of your covered care costs under original Medicare.

Those on Medicare Advantage will have another chance to switch plans from Jan. 1-March 31 of next year, during the annual Medicare Advantage open enrollment period. But to the extent that you do the legwork now, it will help you avoid unpleasant surprises in the new year.

Write to Elizabeth O’Brien at [email protected]