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This week, the General Accounting Office (GAO) issued a report entitled “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network Adequacy” (August 2015, publicly released September 28, 2015).  This report reviews how the Centers for Medicare and Medicaid Services (CMS) ensures adequate access to care for Medicare Advantage (MA) enrollees.

The report was requested by Connecticut’s House Representatives, along with Senators Richard Blumenthal (CT), Sherrod Brown (OH) and Sheldon Whitehouse (RI), spurred largely by MA plan sponsor United Healthcare’s termination of contracts with providers in 24 states in 2014, including over 1,440 providers in Connecticut alone.  

GAO examined several factors relating to CMS’ oversight of MA organization (MAO) network adequacy, and made corresponding findings, including:

  • How CMS defines network adequacy and how its criteria compares with other programs: GAO concluded that “MA criteria do not reflect aspects of provider availability, such as how often a provider practices at a given location …[w]ithout taking availability into account, as is done in some other programs, MA provider networks may appear to CMS and beneficiaries as more robust than they actually are.”
  • How and when CMS applies its network adequacy criteria: GAO concluded that CMS applies such standards “narrowly” – for example, from 2013 to 2015, CMS’ reviews accounted for less than 1% of all networks; CMS currently facilitates reviews of networks via standardized data collection; GAO concluded that “[u]ntil CMS takes steps to verify MAO provider information … the agency cannot be confident that MAOs meet network adequacy criteria.”
  • The extent to which CMS conducts ongoing monitoring of MA organization networks: GAO found that “CMS does not require MAOs to routinely submit updated network information for review” and while CMS may learn of any network adequacy issues through broader oversight and/or complaints, “contrary to internal control standards, CMS does not measure ongoing MAO networks against its current MA criteria.”  GAO concludes: “Because a plan’s providers may change at any time, CMS cannot be assured that networks continue to be adequate and provide sufficient access for enrollees until the agency collects evidence of compliance on a regular basis.”; and
  • How CMS ensures that MA organizations inform beneficiaries about terminations: GAO found that while CMS requires MAOs to provide enrollees with advance notice of provider terminations, “the agency has not established information requirements for those notices and does not review sample notices sent to enrollees” and concluded that “[w]ithout a minimum set of required information elements and a check on adherence to them, the agency cannot ensure that MAO communications are clear, accurate, and consistent.”

As a result of this review and these findings, GAO recommended that “[t]he Administrator of CMS should augment oversight of MA networks to address provider availability, verify provider information submitted by MAOs, conduct more periodic reviews of MAO network information, and set minimum information requirements for MAO enrollee notification letters.”   GAO noted that the Department of Health and Human Services (HHS), the federal department within which CMS is housed, “concurred with the recommendations.”

The Center for Medicare Advocacy applauds the GAO report, which confirms our fears about the criteria surrounding network adequacy and CMS' oversight.  We strongly urge adoption of all GAO recommendations, and further, we strongly urge Congress to pass the Medicare Advantage Bill of Rights, about to be reintroduced in both the House and the Senate, which provides additional protections.

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