There is a tradeoff for seniors when they decide whether to choose a Medicare Advantage (MA) plan or enroll in traditional Medicare. The extra benefits and capped out-of-pocked costs in MA plans are appealing, but a new KFF analysis looks at the downside: Limited provider networks.
MA insurers restrict enrollees’ choice of physicians, hospitals, and other providers to better manage utilization and costs. The problem: Changes to these provider networks can be disruptive for patients when their hospitals and physicians are no longer in-network.
The KFF study, which examined provider directories in 4,200 individual HMO/PPO MA plans from 2022 that covered 20.3 million MA enrollees, found that on average, MA members had access to 48 percent of physicians in their area who were available to people enrolled in traditional Medicare.
The analysis documents how plan networks vary by county, plan characteristics, and physician specialties. Among the key findings:
- Narrow networks: The one-fifth of MA members in plans with the narrowest networks had in-network access to just about one-third of all physicians that were available to people in traditional Medicare. Conversely, the one-fifth of MA enrollees in plans with the broadest networks had in-network access to more than two-thirds of physicians available to beneficiaries in traditional Medicare.
- Wide variation within counties: The size of MA provider networks varies widely both across and within counties, which can make it hard for beneficiaries to decipher which option is best for them when choosing a plan. In counties that had a larger share of people of color, access to physicians was more limited. MA members in counties with the largest share of people of color had access to just 37 percent of the physicians available to traditional Medicare beneficiaries, on average, compared with 52 percent in counties where people of color made up a smaller share of the population.
- Lack of PCPs: The share of physicians available to MA members varied by specialty. Generally, larger shares of outpatient medical and surgical specialists were in MA plan networks than primary care physicians. For example, KFF analysts found that as many as 72 percent of ophthalmologists were available to traditional Medicare beneficiaries in plan networks compared to only 55 percent of primary care physicians, on average.
In August, the Centers for Medicare & Medicaid Services (CMS) announced a fast-track initiative to post 2026 provider directory information for MA plans on the Medicare Plan Finder using information aggregated by a third party. The information was compiled prior to the Medicare open enrollment period that began Oct. 15. But the tool had a shaky start. The Washington Post reported that the Plan Finder contained duplicative addresses and contradictory information, such as providers who show up as both in-network and out-of network. CMS said it would work to fix the issue. In 2027, MA insurers must submit provider information directly to the agency for inclusion in the Medicare Plan Finder.