{"id":311851,"date":"2025-10-17T22:36:12","date_gmt":"2025-10-17T22:36:12","guid":{"rendered":"https:\/\/www.europesays.com\/us\/311851\/"},"modified":"2025-10-17T22:36:12","modified_gmt":"2025-10-17T22:36:12","slug":"medicare-advantage-enrollees-face-growing-uncertainty-choosing-plans-keeping-doctors","status":"publish","type":"post","link":"https:\/\/www.europesays.com\/us\/311851\/","title":{"rendered":"Medicare Advantage enrollees face growing uncertainty choosing plans, keeping doctors"},"content":{"rendered":"

Thousands of Medicare<\/a> Advantage beneficiaries are quietly confronting a dilemma this fall: should they pick a new plan \u2014 or risk losing access to the doctors and hospitals they rely on?<\/p>\n

During the open enrollment window for 2026, from Oct. 15 to Dec. 7, many seniors are discovering that choosing a plan is no longer just about premiums or supplemental benefits. Increasingly, it\u2019s a question of whether their existing physicians and hospitals will remain in-network.<\/p>\n

For decades, Medicare Advantage plan sponsors \u2014 private insurers who manage Medicare benefits \u2014 negotiated quietly with hospitals and physician groups. But recently, the tension has become public and more frequent, forcing patients to weigh whether network stability matters more than benefits or premiums.<\/p>\n

\u201cHistorically these disputes between health systems and insurers would come up in employer-based insurance coverage,\u201d Paul Ginsburg, health policy professor at the University of Southern California. \u201cWhat\u2019s different now is that this is the first time these disputes have affected Medicare Advantage plans. \u2026 It\u2019s a new phenomenon that\u2019s very upsetting to people.\u201d<\/p>\n

For patients caught in the middle, these disputes can be devastating. Some need to switch doctors or insurance plans or potentially pay higher, out-of-network rates at a time when many Americans are already struggling to afford the rising cost of medical care, Ginsburg said.<\/p>\n

In Oregon, one striking example has been Oregon Health & Science University, which nearly severed its contract with UnitedHealthcare over reimbursement disputes. Had no agreement been reached, more than 61,400 Medicare Advantage members <\/a>would have lost in-network access to OHSU\u2019s hospitals and clinics. <\/p>\n

Ultimately, the two parties agreed<\/a> to stay in-network, but only after a standoff that played out in public with dueling direct-mail and advertising campaigns.<\/p>\n

Earlier this year, negotiations between Salem Health \u2014 which operates one of the busiest emergency departments in the West Coast<\/a> \u2014 and Regence BlueCross BlueShield broke down entirely. As of Jan. 1, Salem Health\u2019s hospitals and clinics left Regence\u2019s network<\/a>. For seniors with Medicare Advantage plans through Regence, going to Salem Health\u2019s facilities to get care means paying higher out-of-pocket costs.<\/p>\n

These are not isolated incidents. Across the country, more health systems are pulling back from Medicare Advantage agreements. In the first half of 2025 alone, 28 health systems dropped Medicare Advantage contracts, according to Becker\u2019s Hospital Review<\/a>. <\/p>\n

Experts say these disputes could be an early warning sign of more contract terminations ahead as hospitals and large doctor groups seek higher payments to offset inflation, health care workers\u2019 wage increases and escalating prices for medical supplies and drugs.<\/p>\n

At OHSU, hospital leaders said that a key strategy to shore up the academic medical center\u2019s finances is securing higher reimbursement rates from private insurers. Dr. Shareef Elnahal, OHSU\u2019s new president, said the university successfully negotiated better rates from UnitedHealthcare and is now in the middle of negotiations with Regence BlueCross Blue Shield and Kaiser Permanente.<\/p>\n

Ginsburg, the USC professor and former vice chair of the Medicare Payment Advisory Commission, a panel that makes recommendations to Congress on Medicare policy, said rising provider cost pressures, higher demands from health systems and growing denial or prior authorization burdens have pushed more providers to reconsider their Medicare Advantage participation<\/a>. <\/p>\n

Ginsburg said these disputes also make health care access less predictable for seniors. He said there\u2019s no easy way for beneficiaries to anticipate future disputes when choosing plans during the open enrollment period.<\/p>\n

Under current rules, most Medicare Advantage enrollees can switch only during the annual open enrollment window. If a provider exits their plan\u2019s network mid-year, such a disruption does not automatically trigger a special enrollment period, Ginsburg said. He said the Centers for Medicare and Medicaid Services has allowed special enrollment windows for those who lose access to critical providers, but only in a few isolated cases.<\/p>\n

Some Medicare Advantage enrollees this open enrollment season may be considering switching back to traditional Medicare, which allows access to nearly any provider and generally has less prior authorization requirements. <\/p>\n

But traditional Medicare lacks a built-in maximum out-of-pocket cap, which means enrollees often rely on supplemental Medigap insurance plans to fill cost gaps. <\/p>\n

Purchasing this supplemental insurance can be unaffordable or even impossible for those who want to get on traditional Medicare after previously enrolling in an Advantage plan. That\u2019s because MediGap insurers can deny coverage for existing health conditions such as diabetes or heart disease, or charge consumers more.<\/p>\n

Ginsburg said older Americans typically have only one chance to buy Medigap without medical underwriting, and that\u2019s when they first enroll in Medicare. Most states do not guarantee Medigap access after the initial enrollment window, the exceptions being Connecticut, Massachusetts, Maine and New York. <\/p>\n

Meanwhile, some Medicare Advantage enrollees may find out this fall that their plan has been discontinued. If they\u2019re not automatically enrolled in a new plan, they qualify for a special enrollment period to choose another Medicare Advantage plan or switch to original Medicare. <\/p>\n

Those who opt for original Medicare because their Medicare Advantage plan ended have guaranteed rights to buy a Medigap policy, meaning they can\u2019t be denied coverage or charged more for preexisting conditions. But this Medigap guaranteed issue window typically lasts about 60 days after their Medicare Advantage coverage ends, which often happens on Dec. 31.<\/p>\n

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