New Bill Ends No-Cause Provider Terminations

On June 26, Sen. Sherrod Brown (D-OH), Richard Blumenthal (D-CT) and Rep. Rosa DeLauro (D-CT) introduced legislation that responds to the egregious practice of health plans dropping providers, namely physician specialists, from their Medicare Advantage networks during the middle of the plan year without cause.

In a press release accompanying release of the bill, Rep. DeLauro stated, “The timing and scale of UnitedHealth Group’s provider cuts have been extremely disruptive to their Connecticut patients and put them at risk.” Rep. DeLauro added that these companies need to be held accountable and not put profits before care.

The “Medicare Advantage Participant Bill of Rights” (S. 2552/ H.R. 4998) aims to protect Medicare beneficiary access to their providers, but it would also help providers stand up against health plans. Specifically, a Medicare Advantage plan could not remove a provider from its network without cause during a plan year except in cases where there is a finding of medical negligence against a provider, if a provider violates any legal or contractual requirement, or is found to be otherwise unfit to provide services. While these exceptions on their face could still leave providers vulnerable to mid-year terminations, the bill would be subject to additional agency regulations that will hopefully establish some strong boundaries of what constitutes cause.

Under the bill, plans would be required to finalize their Medicare Advantage plan provider networks 60 days in advance of the annual enrollment period and provide enhanced notice to enrollees when a provider is removed from the plan, including the contact information of other in-network providers offering items and services that are “the same or similar” to those offered by the removed provider, and information regarding options for the individual to requires the continuation of medical treatment with the removed provider.

The bill also helps physicians appeal termination by a network by requiring the Medicare Advantage plan to provide explanation for the reason(s) why they were removed from the plan.

Leave a Reply

Your email address will not be published. Required fields are marked *