Ama Policy

Ban on Medicare Advantage “No Cause” Network Terminations H-285.902

Directories-Med. Adv., Network Adequacy-Med. Adv., Termination-Med. Adv.

1. Our AMA urges the Centers for Medicare & Medicaid Services (CMS) to further enhance the agency’s efforts to ensure directory accuracy by:

a. Requiring Medicare Advantage (MA) plans to submit accurate provider directories to CMS every year prior to the Medicare open enrollment period and whenever there is a significant change in the physicians included in the network;

b. Conducting accuracy reviews on provider directories more frequently for plans that have had deficiencies;

c. Publicly reporting the most recent accuracy score for each plan on Medicare Plan Finder;

d. Indicating to plans that failure to maintain complete and accurate directories, as well as failure to have a sufficient number of physician practices open and accepting new patients, may subject the MA plans to one of the following: (i) civil monetary penalties; (ii) enrollment sanctions; or (iii) incorporating the accuracy score into the Stars rating for each plan;

e. Offering plans the option of using AMA/Lexis-Nexis VerifyHCP system to update provider directory information;

f. Requiring MA plans immediately remove from provider directories providers who no longer participate in their network.

2. Our AMA urges CMS to ensure that network adequacy standards provide adequate access for beneficiaries and support coordinated care delivery by:

a. Requiring plans to report the percentage of the physicians, broken down by specialty and subspecialty, in the network who actually provided services to plan members during the prior year;

b. Publishing the research supporting the adequacy of the ratios and distance requirements CMS currently uses to determine network adequacy;

c. Conducting a study of the extent to which networks maintain or disrupt teams of physicians and hospitals that work together;

d. Evaluating alternative/additional measures of adequacy.

3. Our AMA urges CMS to ensure lists of contracted physicians are made more easily accessible by:

a. Requiring that MA plans submit their contracted provider list to CMS annually and whenever changes occur, and post the lists on the Medicare Plan Finder website in both a web-friendly and downloadable spreadsheet form;

b. Linking the provider lists to Physician Compare so that a patient can first find a physician and then find which health plans contract with that physician. Our AMA urges CMS to simplify the process for beneficiaries to compare network size and accessibility by expanding the information for each MA plan on Medicare Plan Finder to include: (i) the number of contracted physicians in each specialty and county; (ii) the extent to which a plan’s network exceeds minimum standards in each specialty, subspecialty, and county; and (iii) the percentage of the physicians in each specialty and county participating in Medicare who are included in the plan’s network.

4. Our AMA urges CMS to measure the stability of networks by calculating the percentage change in the physicians in each specialty and subspecialty in an MA plan’s network compared to the previous year and over several years and post that information on Plan Finder.

5. Our AMA urges CMS to develop a marketing/communication plan to effectively communicate with patients about network access and any changes to the network that may directly or indirectly impact patients; including updating the Medicare Plan Finder website.

6. Our AMA urges CMS to develop process improvements for recurring input from in-network physicians regarding network policies by creating a network adequacy task force that includes multiple stakeholders including patients.

7. Our AMA urges CMS to ban “no cause” terminations of MA network physicians during the initial term or any subsequent renewal term of a physician’s participation contract with a MA plan.

Policy Timeline 

BOT Rep. 17, A-19, Reaffirmation: I-19