Smiling DoctorStarting this year, the federal government will require health insurers to give millions of Americans enrolled in Medicare Advantage plans or in policies sold in the federally run health exchange up-to-date details about which doctors are in their plans and accepting new patients.

Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. Networks can also vary among plans offered by the same insurer. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.

Under a rule published in April, 2015 by the Centers for Medicare & Medicaid Services, Medicare Advantage plans must contact doctors and other providers every three months and update their online directories in “real time.” Online directories for policies sold through healthcare.gov, the health law exchange run by the federal government in 37 states, must be updated monthly, CMS announced in a separate rule.

Inaccuracies in the Medicare Advantage directories may trigger penalties of up to $25,000 a day per beneficiary or bans on new enrollment and marketing. CMS will also use the directories to help determine whether insurers have enough doctors to meet beneficiaries’ needs.

The federal exchange insurer plans could face penalties of up to $100 per day per affected beneficiary for problems in their directories.

Studies have shown massive error rates in these directories, including states in the federal exchanges. If consumers select a health plan because they believe their hospital or physician is a participating provider and it later turns out that’s an error, they could be stuck with that plan for the year.

Regulators also rely on these provider directories to make assessments about network adequacy.  And when provider directories include physicians who have died, moved out of state, or aren’t accepting new patients, adequacy of the network is overstated.

The administration last year [2015] announced rules designed to make sure those networks have adequate numbers of providers. The newest rules will help guarantee that consumers get good information on those networks.

People in some states have had trouble finding doctors in their plans and others who were misled into thinking their providers were in network have been socked with huge out-of-network bills.

The new Medicare Advantage rules are a response to complaints from beneficiaries and doctors about “directories including providers who are no longer contracting with the [plan], have retired from practice, have moved locations, or are deceased,” CMS officials said in the notice to insurers. Some directories also list providers who are still in the plan’s network but not available to new patients.

About 16 million seniors have enrolled in the private Medicare Advantage [Part C] plans, which are an alternative to traditional Medicare.

Sometimes people start treatment with a doctor who doesn’t stay in the network for the  whole year or think they are they are picking a plan that covered a certain doctor and then discover it did not. Because most Medicare Advantage members are locked into their plans for the calendar year, they don’t often have good alternatives when their provider networks shrink.

It is critically important that people with Medicare have timely access to the information they need to make decisions about their care. Reflecting this priority, Medicare will be requiring health plans to ensure that their online directories are up-to-date and accurate as soon as their networks change.

Medicare Advantage insurers have mixed reactions to the new rules. Some are concerned about the increased cost of compliance. A spokesperson from one of the largest Medicare Advantage providers, said the company is still reviewing the rules.