Voices of Medicare | Medicare Advantage Network Inadequacy

We recently heard from a Medicare Advantage (MA) enrollee from the Dallas-Forth Worth metropolitan area who went several months without seeing a gastroenterologist due to Cigna’s failure to contract with such specialists. She received no prior notice that her old provider would go out-of-network. She tried for months to schedule an appointment with a different provider, but was misled by Cigna’s materials, which falsely continued to list out-of-network providers as being in-network. Cigna denied her requests for out-of-network coverage. This network adequacy issue likely affected hundreds, if not thousands of Cigna enrollees within the same area over the past year.   

This enrollee had Cigna’s Preferred Medicare PPO plan. She had been seeing the same gastroenterologist for about 5 years. She has a complicated medical history including Crohn’s disease, resulting in multiple surgeries, and now receives medicine and nutrition through a central venous catheter. She learned that Cigna’s network had changed from the gastroenterologist’s office only after their contract with Cigna terminated on September 1, 2021. Her gastroenterologist belonged to a large group, who all cared for Cigna enrollees under the same contract. Cigna’s directories continued to list these out-of-network providers as being in-network after that date. Cigna finally entered a new contract with a different group of providers in March of 2022. Despite multiple complaints from this enrollee and the gastroenterologist’s office directly, Cigna only removed the out-of-network providers upon securing contracts with new providers.

Cigna’s shortcomings violated network adequacy requirements, general MA disclosure requirements, and changes to provider network notification requirements:

• All MA organization offering coordinated care plans (HMOs, PSOs, and PPOs), network-based private fee-for service (PFFS) plans, and network-based medical saving account (MSA) plans are required to maintain a network of appropriate providers that is sufficient to provide adequate access to covered services to meet the needs of the population served. See 42 C.F.R. § 422.116. Regulations specify the network must be one of contracted providers for 27 different specialty types (including gastroenterology) and 13 different facility types. See 42 C.F.R. § 422.116(b).

• Each MA organization must post an online provider directory on its website and maintain a written directory.  See 42 C.F.R. §§ 422.111(a) and 422.111(h). CMS instruction specifies that only currently contracted and credentialed providers should be listed in these directories.

• MA organizations “must make a good faith effort to provide written notice of a termination of a contracted provider at least 30 calendar days before the termination effective date to all enrollees who are patients seen on a regular basis by the provider.” See 42 C.F.R. § 422.111(e).

Despite violations of these provisions, when this enrollee contacted both Cigna and CMS, they were unable to get any relief and were unable to determine how to get her medically necessary gastroenterology care covered.

Here at the Center for Medicare Advocacy, we are concerned with this type of network inadequacy, the lack of oversight of network adequacy requirements, and the lack of available relief to enrollees who are unable to get needed care due to MA organizations failing to properly contract with providers. Enrollees should be assured that all MA plans have adequate provider networks, as is the case with traditional Medicare. Further, when MA organizations make changes to their provider networks, enrollees need to be made aware. Without transparency of provider networks, enrollees are unable to make informed decisions about their coverage and care, which is a fundamental component of the MA program.