REPORT
June 2016
Medicare Advantage Hospital
Networks:
How Much Do They Vary?
Prepared by:
Gretchen Jacobson, Ariel Trilling, and Tricia Neuman
Kaiser Family Foundation
and
Anthony Damico and Marsha Gold
Independent Consultants
Executive Summary ............................................................................................................................................ 1
Introduction and Study Focus ........................................................................................................................ 2
Methods ................................................................................................................................................................ 4
Geographic Focus.............................................................................................................................................. 4
Inclusion Criteria for Medicare Advantage Plans ............................................................................................. 4
Main Sources of Data ........................................................................................................................................ 5
Measures of Hospital Network Size and Composition ..................................................................................... 5
Classification of Networks by Size .................................................................................................................... 5
Analytic Variables: Teaching Hospitals and Cancer Centers ........................................................................... 6
Limitations ........................................................................................................................................................ 6
Results....................................................................................................................................................................7
Breadth of Hospital Networks ...........................................................................................................................7
Inclusion of Teaching Hospitals and Cancer Centers ...................................................................................... 11
Relationship Between Breadth of Network and Other Plan Features ............................................................. 15
Findings on the Adequacy of Provider Directories to Inform Beneficiary Choice ........................... 19
Beneficiary Burden .......................................................................................................................................... 19
Errors in Directories ........................................................................................................................................ 19
Discussion ........................................................................................................................................................... 21
Appendix ............................................................................................................................................................ 23
Methods .......................................................................................................................................................... 23
Limitations ...................................................................................................................................................... 26
Appendix Tables ............................................................................................................................................. 28
Endnotes ............................................................................................................................................................. 37
Medicare Advantage Hospital Networks: How Much Do They Vary? 1
A growing number of Medicare beneficiaries receive their care through HMOs and PPOs, known as Medicare
Advantage plans; yet, little is known about the size and scope of the provider networks available to beneficiaries
enrolled in these plans. Beneficiaries enrolled in Medicare Advantage plans can face significant expense if
treated by an out-of-network provider, except in emergencies.
This report, the first broad-based study of Medicare Advantage networks, takes an in-depth look at plans’
hospital networks, examining their size and composition. The analysis draws upon data from 409 plans,
including 307 HMOs and 102 local PPOs, serving beneficiaries in 20 diverse counties that together accounted
for about one in seven (14%) Medicare Advantage enrollees nationwide in 2015. Key findings include:
On average, Medicare Advantage plan networks included about half (51%) of all hospitals in their county.
Most plans (80%) included an Academic Medical Center in their network, but one in five did not.
Two in five plans in areas with an NCI-designated cancer center did not include the center in their
networks.
Almost one-quarter (23%) of
Medicare Advantage plans in our
study had broad hospital networks in
2015. About one in six plans (16%)
had narrow or ultra-narrow networks
(Figure ES.1).
In 9 of the 20 counties studied, none
of the plans offered in 2015 had a
broad network of hospitals within that
county (Clark, NV; Cook, IL; Davison,
TN; Harris, TX; Jefferson, AL; King,
WA; Los Angeles, CA; Pima, AZ; and
Salt Lake, UT).
Among HMOs, which comprised the
majority of the plans in the study
(75%), broad and narrow network
plans had similar average premiums ($37 vs. $36 per month) and similar quality ratings (3.8 vs. 4.1 stars).
People on Medicare often say that having access to specific doctors and hospitals is a high priority when
choosing their Medicare Advantage plans. Yet, plan directories are often riddled with errors, omissions and
outdated information that makes it difficult and sometimes impossible to tell which hospitals are included in-
network – a finding that emerged over the course of this study.
Creating networks of providers is one of many strategies available to insurers to help control costs and manage
the delivery of care. But narrower networks may also limit consumers’ access to certain providers or increase
costs for care obtained out-of-network. For Medicare Advantage enrollees who place a high value on having
access to a particular set of providers, or a broad range of providers, the findings underscore the importance of
comparing provider networks during the Annual Election Period – a task that is easier said than done.
Exhibit 1
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Hospital Networks Vary Across Medicare Advantage Plans:
16% Have Narrow Networks and 23% Have Broad Networks
Broad
23%
Medium-Large
30%
Medium-Small
31%
Narrow
14%
Ultra-Narrow
2%
Broad: 70% or more
of hospitals
Medium-Large: 50-69%
of hospitals
Medium-Small: 30-49%
of hospitals
Narrow: 10-29%
of hospitals
Ultra-Narrow: less than
10% of hospitals
Total = 409 Medicare Advantage Plans Available in 2015
Figure ES.1
Medicare Advantage Hospital Networks: How Much Do They Vary? 2
A growing share of Medicare beneficiaries receives their care through Medicare Advantage plans. Under such
arrangements, plans offer an integrated benefit package that: combines Medicare Parts A and B, and usually
also Part D; typically reconfigures cost-sharing; and often includes benefits not included in traditional
Medicare. Medicare Advantage plans have proven increasingly popular with Medicare beneficiaries, partly
because they offer “one stop shopping,” and their premiums are typically lower than the costs of stand-alone
prescription drug plans combined with Medigap or other supplemental insurance. The number of Medicare
beneficiaries enrolled in Medicare Advantage plans has more than tripled over the past decade, from about 5.3
million in 2005 to 17.6 million in 2016, and is projected to continue growing over the next decade.
1
Despite the growth of the program, relatively little is known about size and scope of provider networks in
Medicare Advantage plans. While beneficiaries in traditional Medicare can seek care from any provider
participating in Medicare (virtually all hospitals and physicians), Medicare Advantage plans generally restrict
coverage (except in emergencies) to affiliated network providers. Although practices vary, Health Maintenance
Organizations (HMOs), the most common form of Medicare Advantage plan, generally require beneficiaries to
receive care from a provider in the network in order to have the cost of the care covered. Beneficiaries enrolled
in Preferred Provider Organizations (PPOs) can receive care from providers outside of their plan’s network and
have the plan cover the cost of the care, but the cost-sharing for care received outside the network is typically
higher than what beneficiaries would pay if they received the care from an in-network provider.
Beneficiaries can choose a plan or switch between Medicare Advantage and traditional Medicare once a year,
during the annual open enrollment period between October 7 and December 15, and the change is effective
beginning the following January 1. Medicare Advantage plans are allowed to change their networks at any time
during the calendar year; beneficiaries are not allowed to change plans outside of the open enrollment period,
unless they are granted an exception by the Centers for Medicare and Medicaid Services (CMS) if they had, for
example, an ongoing existing relationship with a terminated provider.
2
People on Medicare have said that when considering Medicare Advantage plans, access to certain hospitals and
doctors is a top priority for them.
3
Additionally, the structure of provider networks can influence the way in
which beneficiaries access care, and network adequacy is one of the criteria used by CMS to evaluate plans
before they are approved. CMS requires plans to include a specified number of doctors, hospitals, and other
providers within a particular driving time and distance,
4
but it is unclear how well these requirements are
enforced. Further, according to CMS, Medicare Advantage plans have less prescriptive provider requirements
than Qualified Health Plans (QHPs) or Medicaid Managed Care Organizations (MCOs), and are required to
include fewer data elements in their provider directories.
5
In a recent investigation, the Government Accountability Office (GAO) identified several serious deficiencies in
CMS’s oversight and enforcement of network requirements for Medicare Advantage plans, and strongly
recommended greater scrutiny of the plans’ networks.
6
The GAO found that CMS reviews less than 1 percent of
all networks and does little to assess the accuracy of the network data submitted by the plan. The GAO report
found that CMS relies primarily upon complaints from beneficiaries and their caregivers to identify any
problems with networks and does not assess whether plans that are renewing their current contracts continue
to meet the network requirements.
Medicare Advantage Hospital Networks: How Much Do They Vary? 3
This report is the first broad-based study of how provider networks are structured in Medicare Advantage.
Although some historical work examined provider networks across different payers, these studies are old and
relatively limited in the information they provide.
7
More recent work has focused on health plans participating
in exchanges under the Affordable Care Act (ACA), rather than Medicare Advantage. These more recent
studies found that the scope of networks varies across the country, that some plans in the exchanges have
networks that are substantially narrower than plans in the commercial markets, that HMOs have narrower
networks than PPOs, and that plans with narrower networks may have lower premiums than plans with
broader networks.
8
One study also found that narrow network plans are less likely than broader plans in the
exchanges to include an Academic Medical Center in the network.
9
Plans offered in ACA exchanges with
narrower networks of hospitals have not been found to have lower measures of quality or accessibility than
broader network plans,
10
but one survey showed that consumers in exchange plans with narrow hospital
networks are less satisfied with their plan than consumers in plans with broader networks.
11
Multiple studies also have documented problems with the accuracy, clarity, and ease of use of provider
directories for both plans in the exchanges and Medicare Advantage plans, including one study that found that
only about half of dermatologists listed in Medicare Advantage plans’ provider directories actually accepted the
plan and could be contacted based on information provided in the directory.
12
While this study did not set out
to examine the accuracy of provider listings, we encountered a number of issues related to the accuracy and
reliability of provider directories in the course of our research (see end of the Results section).
This report examines the size and composition of Medicare Advantage plans’ networks, focusing on hospitals.
It presents data based on 20 diverse counties that account for 14 percent of all Medicare Advantage enrollees.
The report addresses three key questions:
1) What share of Medicare Advantage plans have broad, medium, or narrow hospital networks, based on
the share of hospitals and hospital beds included in the plan network, and to what extent does this vary
across counties?
2) Do Medicare Advantage plans typically include Academic Medical Centers and NCI-Designated Cancer
Centers when one is located in the county?
3) What is the relationship between network size and other plan features, including premiums, quality star
ratings, per capita Medicare spending, parent organization, and plan tax status?
Medicare Advantage Hospital Networks: How Much Do They Vary? 4
We describe here the main elements of the study design. For a more detailed description of the study methods,
see the Appendix.
This study examined Medicare Advantage
plans available in 2015 in 20 counties
(Figure 1). The county is the smallest
area, in general, that a Medicare
Advantage plan must cover. Counties
vary greatly in size and may not be the
best metric to assess the health care
market of particular locales. However, an
analysis at the county level provided the
most complete set of data available for
this type of analysis, as well as a
reasonable snapshot of the health care
market accessible to beneficiaries in that
region.
The counties included in this study were
chosen to encompass a sizeable share of Medicare Advantage enrollees, to be geographically dispersed across
the country, and to range in per capita Medicare spending, the number of plans offered to Medicare
beneficiaries, and Medicare Advantage penetration rate. They include large, urban areas with Medicare
Advantage markets led by national firms (e.g., UnitedHealthcare) and local firms (e.g., UAB Health System).
Together, these counties represent 14 percent of all Medicare Advantage enrollees in 2015.
Only HMOs and local PPOs were included in the analysis because the other types of Medicare Advantage plans
either do not have networks (e.g., some private fee-for-service plans), or networks that are structured to cover
areas larger than a county (e.g., regional PPOs), or are paid in unique ways that influence providers available to
beneficiaries (e.g. cost plans). The analysis also excluded Special Needs Plans (SNPs), employer-sponsored
group plans, and other plans that are not available to all Medicare beneficiaries. In total, across the 20
counties, we included 409 plans, 307 HMOs and 102 local PPOs. Among the 307 HMOs, 10 were closed panel
HMOs, with physicians or groups of physicians directly employed by the HMO, and the remainder were open
panel HMOs. Together, these plans enrolled 1.6 million Medicare beneficiaries in 2015, 92 percent of whom
were in HMOs and 8 percent of whom were in PPOs. Both HMOs and local PPOs were available in all 20
counties, with the exception of Los Angeles where only HMOs were available to Medicare beneficiaries.
Exhibit 2
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Counties Included in the Analysis of Medicare Advantage
Plans’ Hospital Networks
New Haven
Queens
Allegheny
Erie
Cuyahoga
Mecklenburg
Miami-Dade
Fulton
Jefferson
Davidson
Cook
Milwaukee
Harris
Douglas
Pima
Salt Lake
Clark
Los Angeles
Multnomah
King
Figure 1
Medicare Advantage Hospital Networks: How Much Do They Vary? 5
Provider directories were the primary source of data used for the study. The directories were gathered between
November and December 2014, to coincide with the Medicare Annual Election Period for 2015, and were either
downloaded from the company’s website in a PDF format, when possible, or using a searchable directory
embedded in the company website. The information extracted from this data was complemented with other
information available on these plans and counties in CMS’s Medicare Advantage Enrollment file for March
2015 and Landscape file for 2015, and the American Hospital Association’s (AHA) 2014 survey of hospitals.
All short-term general hospitals in the 20 counties included in the study, and their characteristics, were
identified using data from the AHA 2014 survey of hospitals. (To support sensitivity analyses, hospitals in the
adjacent counties were also identified.) Veterans Health Administration hospitals and children’s hospitals
were excluded because of their unique financing or population focus. Two basic measures of network size were
constructed for each health plan by county: (1) the share of hospitals in the county included in the directory,
and (2) the share of hospital beds in the county associated with the hospitals included in the directory.
This study categorized networks into one of four sizes based on the share of hospitals in the county that were
included in the directory: broad (70% or more of the hospitals), medium (30-69% of hospitals), narrow (10-
29% of hospitals), and ultra-narrow (less than 10% of hospitals). Only one other study we know of, conducted
by McKinsey & Company, categorized networks by the share of hospitals in the county included in the network
(Table 1).
13
Broad networks were defined consistently in both studies, but narrower networks were classified
and labeled somewhat differently here.
The McKinsey & Company study examined the size of the networks of plans offered in the ACA exchanges, and
categorized networks into one of three network sizes. The difference between the categories used in this study
and the McKinsey study is that this study includes a category for medium-sized networks. That is, this study
uses the term “medium” to describe the size of networks that McKinsey described as “narrow.”
0-9% Ultra-Narrow
10-29% Narrow
30-69% Medium
Narrow
70%+ Broad
Broad
Ultra-Narrow
SOURCE: Kaiser Family Foundation analysis and Bauman N, Bello J, Coe E, and Lamb J.
“Hospital networks: Evolution of the configurations on the 2015 exchanges,” McKinsey &
Company, April 2015.
Medicare Advantage Hospital Networks: How Much Do They Vary? 6
This study examined the presence of two specific types of hospitals in plan networks: teaching hospitals and
cancer centers. Academic Medical Centers and minor teaching hospitals were identified based upon data from
the AHA 2014 survey of hospitals. Each of the 20 counties had at least one Academic Medical Center within its
borders, 11 of which included more than one, including Cook County with 12 Academic Medical Centers and
Los Angeles County with 8 Academic Medical Centers. All but one of the counties (Mecklenburg) included at
least one minor teaching hospital.
Cancer centers designated by the National Cancer Institute (NCI) were identified through the list of centers on
the NCI website, and cancer centers accredited by the American College of Surgeons (ACS) were identified
based upon data from the AHA 2014 survey of hospitals. Fifteen of the 20 counties in the study had at least
one NCI-Designated Cancer Center within the borders of the county, including Cook, Harris, and Los Angeles
counties that had more than one NCI Cancer Center, and all but one of the counties (Pima) had at least one
hospital with an ACS-accredited cancer program.
This study has some limitations. Notably, counties vary in size and do not necessarily provide a good measure
of the natural market for the health plan and all of its enrollees. The study also focuses on large, urban areas,
and does not provide information about plans’ networks in rural areas that have both fewer beneficiaries and
providers. In many cases, physicians, not the beneficiary, may be key drivers in the choice of health plan and
this analysis provides no information on the effective match between the breadth of physician networks and
hospital networks. Hospital care also is increasingly complex and varied, and a general analysis of hospital
networks provides limited insight into the availability of particular services the enrollee may need and where
these services are best performed in any given community. Ultimately, what may be important to beneficiaries
is the availability and quality of providers in their plan’s network, and not necessarily the size of the network.
Medicare Advantage Hospital Networks: How Much Do They Vary? 7
Counties included in this study differed in size and the number of hospitals, ranging from a high of 106 in Los
Angeles County to a low of 8 in Multnomah County (Table A1). All of the Medicare Advantage plans in this
study engaged in some selectivity in hospitals included in their network, but the share of hospitals included
varied across plans, counties, and types of Medicare Advantage plans.
On average, plans included about half
(51%) of the hospitals in the county in
their network in 2015. About one-quarter
(23%) of Medicare Advantage plans were
classified in our analysis as having broad
networks, meaning that they included at
least 70 percent of the hospitals in the
county (Figure 2). Most plans (61%)
had medium sized networks, with
between 30 and 69 percent of hospitals in
the county. About one in six Medicare
Advantage plans (16%) had narrow
hospital networks, meaning that they
included less than 30 percent of all
hospitals in the county. This includes 8
plans (2%) that had less than 10 percent
of the hospitals in the county within their
network. Three of these 8 plans (in
Multnomah and Fulton counties) did not
include any hospitals within county
borders but included hospitals in
neighboring counties.
14
The share of a county’s hospitals included
in plans’ networks, on average, ranged
from 33 percent in Harris County to 79
percent in Mecklenburg County (Figure
3 and Table A2). These hospitals
accounted for 61 percent of all hospital
beds in the county, ranging from 38
percent in Los Angeles County to 94 percent in Mecklenburg. Measuring the breadth of the plan networks by
the share of hospitals versus by the share of hospital beds included in the plan yielded similar results, such that
plans with less than 30 percent of the hospitals in the county (narrow networks) had 26 percent of the hospital
beds and similarly, plans with 70 percent or more of the hospitals in the county (broad networks) tended to
include approximately 89 percent of the hospital beds in the county.
Exhibit 3
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Distribution of the Size of Plans’ Hospital Networks, 2015
Broad
23%
Medium-Large
30%
Medium-Small
31%
Narrow
14%
Ultra-Narrow
2%
Broad: 70% or more
of hospitals
Medium-Large: 50-69%
of hospitals
Medium-Small: 30-49%
of hospitals
Narrow: 10-29%
of hospitals
Ultra-Narrow: less than
10% of hospitals
16% of Medicare Advantage plans have narrow networks and 23% have broad networks
Figure 2
Total = 409 Medicare Advantage Plans Available in 2015
79%
69%
68%
66%
63%
61%
60%
57%
56%
53%
49%
48% 48%
46%
44%
40%
39%
34% 34%
33%
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Medicare Advantage Plan Networks Include About Half
of All Hospitals in Their County
Average Share of Hospitals in Medicare Advantage Networks = 51%
Figure 3
Medicare Advantage Hospital Networks: How Much Do They Vary? 8
The breadth of hospital networks, and the
availability of broad, medium, and
narrow network plans, varied greatly
across the 20 counties included in the
study (Figure 4 and Table A1). Plans
with broad networks were available in 11
of the 20 counties, and comprised at least
half of the plans available in 4 counties
(Milwaukee, Cuyahoga, Erie, and
Mecklenburg), including one county
(Mecklenburg) in which all plans had
broad networks of hospitals. However, in
nine of the 20 counties, beneficiaries did
not have access to a broad network plan.
In 12 of the 20 counties, one or more
Medicare Advantage plans had narrow
networks, including more than one-third of plans in 3 counties (Multnomah, King, and Harris).
The share of narrow network plans in a county does not appear to be related to the number of hospitals in the
county. While some of the counties with narrow network plans, such as Multnomah, have relatively few
hospitals, other counties with narrow network plans, such as Los Angeles and Harris counties, have many
hospitals. For example, three plans in Los Angeles County included only 5 of the 106 hospitals in the county
and one plan in Harris County included only 2 of the 70 hospitals in the county.
Per capita Medicare spending does not appear to be associated with the size of hospital networks offered by
plans in a given county. The presence of narrow network plans does not appear to be related to whether per
capita Medicare spending is relatively high or low in the county. For example, narrow networks plans are
available in Miami-Dade and Harris counties, both of which have historically had very high per capita Medicare
spending, and in Multnomah and Erie counties, which have historically had low per capita Medicare spending.
In each of the 20 counties, regardless of per capita Medicare spending, beneficiaries have the option of
enrolling in a plan that does not have a narrow network. This finding suggests that plans in high-cost areas are
no more likely than those in low-cost areas to use limited provider networks to reduce their costs.
16%
47%
43%
39%
24%
24%
23%
18%
15%
14%
14%
8%
8%
61%
37%
57%
61%
76%
59%
77%
82%
85%
45%
79%
92%
20%
100% 100%
77%
73%
63%
50%
42%
23%
17%
18%
40%
7%
72%
23%
27%
38%
50%
58%
100%
Broad (70-100%)
Medium (30-69%)
Narrow (0-29%)
Distribution of the Size of Plans’ Hospital Networks,
by County
In 12 of the 20 counties, one or more plans had narrow networks, including more than one-
third of plans in 3 counties
NOTE: Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Figure 4
Medicare Advantage Hospital Networks: How Much Do They Vary? 9
The distribution of plans by network size
is generally similar to the distribution of
enrollees by network size, indicating that
beneficiaries are neither
disproportionately enrolled in broad
networks nor narrow networks (Figure 5
and Table A1). About one in six
Medicare Advantage enrollees (16%) were
in plans with narrow networks, two-
thirds (66%) were in plans with medium
networks, and 18 percent were in plans
with broad networks. In most of the
counties in the study, beneficiaries could
choose only between broad and medium
plans (5 counties) or between medium
and narrow plans (7 counties). (In
Mecklenburg, beneficiaries could only choose among broad network plans, and in Davidson and Cook,
beneficiaries could only choose among medium network plans.) In 2 of the counties (Erie and Queens) with
broad, medium and narrow networks, beneficiaries were disproportionately enrolled in broad network plans,
but in the other 3 counties (Fulton, Miami-Dade, and Multnomah), enrollment in broad network plans was
relatively proportionate to the availability of broad network plans in the county.
HMOs tend to have narrower hospital
networks than PPOs, across the 20
counties studied (Figure 6). In most
counties, a larger share of local PPOs had
broad networks, and a larger share of
HMOs had narrow networks (Tables A3
and A4).
23%
18%
30%
31%
31%
35%
14%
7%
2%
9%
Distribution of Plan Networks Distribution of Beneficiaries
Ultra-Narrow
(less than 10%)
Narrow
(10-29%)
Medium-Small
(30-49%)
Medium-Large
(50-69%)
Broad
(70-100%)
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Distribution of the Size of Plans’ Hospital Networks
Versus Medicare Advantage Plan Enrollment
Beneficiaries are disproportionately enrolled in plans with ultra-narrow networks
Figure 5
NOTE: Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Broad
20%
Medium-
Large
28%
Medium-
Small
35%
Narrow
16%
Ultra-
Narrow
3%
Distribution of the Size of HMOs’ and Local PPOs’
Hospital Networks
HMOs
Broad
31%
Medium-
Large
38%
Medium-
Small
21%
Narrow
10%
Local PPOs
Broad: 70% or more
of hospitals
Medium-Large: 50-69%
of hospitals
Medium-Small: 30-49%
of hospitals
Narrow: 10-29%
of hospitals
Ultra-Narrow: less than
10% of hospitals
Total = 307 plans Total = 102 plans
A larger share of HMOs than local PPOs have narrow hospital networks
Figure 6
Medicare Advantage Hospital Networks: How Much Do They Vary? 10
Since about three-quarters of the plans
included in this study were HMOs, HMOs
comprised the majority of plans across all
network sizes (Figure 7). However, a
disproportionately large share (85%) of
narrow and ultra-narrow network plans
were HMOs (either closed panel or open
panel HMOs) while only two-thirds of
broad network plans were HMOs.
Similarly, PPOs comprised a smaller
share of narrow network plans (15%) than
broad network plans (34%).
In some cases, HMOs and local PPOs
offered by the same firm in a market
shared the same network, although the
structure of PPOs provides some coverage for the cost of care at hospitals not in the network.
15
About one-third
(37%) of local PPOs shared a provider network (and provider directory) with at least one HMO offered by the
same firm.
Most HMOs have open panel designs in
which the parent organization has non-
exclusive contracts with a range of
providers located in the area, and the
providers typically accept multiple
insurers. A small share of HMOs have
closed panel designs in which the parent
organization has exclusive contracts with
physicians (employed either directly or in
groups) and sometimes also owns
hospitals or contracts with hospitals in
other ways that result in more centralized
hospital capacity. While the data available
to distinguish between closed and open
panel HMOs are limited, such data
suggest that only ten plans in our study
had closed panel designs (Figure 8 and Table A5). Five of the ten plans were offered by Kaiser Permanente
in Los Angeles, Multnomah, and Fulton, and typically had narrower networks than other plans, consistent with
their design. The other five closed-panel HMOs were offered by Group Health Cooperative in King County and
Leon Medical Centers in Miami-Dade County, both of which included a larger share of hospitals in the county
than Kaiser Permanente.
23%
21%
31%
61%
10%
63%
59%
14%
60%
14%
10%
2%
30%
2%
Ultra-Narrow
Networks
Narrow
Networks
Medium
Networks
Broad
Networks
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Distribution of Plans, by Network Size and Plan Type
The vast majority of closed panel HMOs, but a minority of open panel HMOs, have narrow or
ultra-narrow networks
Closed Panel HMOs
Total = 10 plans
Open Panel HMOs
Total = 297 plans
Local PPOs
Total = 102 plans
Total
Total = 409 plans
Figure 8
13%
<1%
72%
76%
66%
15%
24%
34%
Narrow Medium Broad
Local PPOs
Open Panel HMOs
Closed Panel HMOs
NOTE: Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Distribution of HMOs and Local PPOs by Network Size
The vast majority of narrow network plans are HMOs
Figure 7
Medicare Advantage Hospital Networks: How Much Do They Vary? 11
With the exception of Leon Medical Centers, which had a medium-sized network, all of the other nine closed-
panel HMOs had narrow or ultra-narrow networks (as compared to only 16 percent of open-panel HMOs).
However, closed-panel HMOs comprised a small share of all narrow or ultra-narrow network plans, and only
nine of the 67 plans with narrow or ultra-narrow networks (13%) were closed panel HMOs (Figure 8). The
fact that closed-panel HMOs typically have narrow networks is by design; they often operate as systems of care,
where the hospitals are often owned by the parent company and used primarily if not exclusively by members.
Despite the comparatively narrow networks of many of these closed-panel HMOs, they generally attract a
relatively large number of beneficiaries.
While high quality medical care can be provided in a variety of hospital settings, some conditions can benefit
from care provided in certain types of facilities. Access to specialized medical care is also important to many
Medicare beneficiaries since about one-quarter (26%) of Medicare beneficiaries are in fair or poor health and
45 percent have four or more chronic conditions.
16
Academic Medical Centers are more likely than minor
teaching hospitals or other hospitals to have physicians specializing in rarer conditions or operations, such as
liver or bone-marrow transplants, autoimmune disorders such as lupus, or other complex medical conditions.
Academic Medical Centers are also more likely to conduct more surgeries, such as heart surgery, for which
better outcomes have been linked to higher volumes of surgeries. Both Academic Medical Centers (also known
as major teaching hospitals) and minor teaching hospitals have residency and/or internship training programs
(or medical school affiliation reported by the American Medical Association) but, unlike Academic Medical
Centers, minor teaching hospitals are not members of the Council of Teaching Hospitals.
Access to high quality cancer treatment is also important to many Medicare beneficiaries since the incidence of
cancer is more than 10 times higher among people ages 65 and older than among younger people.
17
To gain
insight into the type of cancer treatment available to Medicare Advantage enrollees, this study examined access
to cancer centers designated by the National Cancer Institute (NCI) and hospitals accredited by the American
College of Surgeons (ACS). The NCI has designated 69 cancer centers in 35 states as NCI-Designated Cancer
Centers in recognition of their leadership and resources in the development of more effective approaches to
prevention, diagnosis, and treatment of cancer, and many but not all of these centers are affiliated with
Academic Medical Centers. The ACS Commission on Cancer accredits cancer programs within hospitals that
meet ACS quality and service standards, and this accreditation is designed to be an indicator of higher quality
cancer care.
Medicare Advantage Hospital Networks: How Much Do They Vary? 12
More than three-quarters (80%) of all
Medicare Advantage plans analyzed in
this study included at least one Academic
Medical Center in the county in its
network of hospitals, including 78
percent of HMOs and 88 percent of PPOs
(Figure 9). Another 6 percent of plans
included an Academic Medical Center in
the adjacent county but not in the county
studied (not shown). In total, 86 percent
of plans included an Academic Medical
Center in the primary county or in a
bordering county. Additionally, the vast
majority of plans (92%) included at least
one minor teaching hospital in the
county, including all of the plans in 14
counties. In 15 of the 20 counties, more than three-quarters of the plans included an Academic Medical Center,
including 7 counties in which all of the plans included an Academic Medical Center in the provider network
(Table A6). However, in 2 counties (Jefferson and Multnomah), less than half of all Medicare Advantage
plans included the Academic Medical Center in the county.
Larger plans were more likely to include an Academic Medical Center, on average, and as a result a somewhat
larger share (91%) of Medicare Advantage enrollees are in a plan that includes an Academic Medical Center in
its network.
The vast majority (92%) of broad network
plans included an Academic Medical
Center, while a much smaller share of
plans with narrow networks (51%)
included an Academic Medical Center
(Figure 10). In most counties, a larger
share of plans with broad networks than
plans with narrow networks included at
least one Academic Medical Center
(Table A7).
80%
100%100%100%100%100%100%100%
96%
93%
85% 85%
83%
82% 82%
75%
72%
64%
57%
42%
27%
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Share of Plans Including an Academic Medical Center in
the Hospital Network, by County
More than three-quarters of plans included at least one Academic Medical Center in the county
Figure 9
80%
51%
84%
92%
Average Narrow Networks
(0-29%)
Medium Networks
(30-69%)
Broad Networks
(70-100%)
Share of Plans Including an Academic Medical Center in
the Hospital Network
A smaller share of narrow network plans include an Academic Medical Center
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Figure 10
Medicare Advantage Hospital Networks: How Much Do They Vary? 13
NCI-Designated Cancer Centers tend to have greater access to clinical trials, especially early-stage clinical
trials, than community hospitals and other treatment centers. While many hospitals in a community are likely
to be able to treat multiple types of cancer, access to NCI Cancer Centers may be particularly relevant to
beneficiaries with rarer cancers, more advanced-stage cancers, or other unique complicating conditions.
NCI-Designated Cancer Centers.
Among the 15 counties with an NCI
Cancer Center, 15 percent of Medicare
Advantage plans listed the NCI Cancer
Center in the provider directory, 43
percent of plans included the Academic
Medical Center with which the center was
affiliated (but did not explicitly indicate
that the cancer center was included), and
41 percent did not include the NCI Cancer
Center in the county among providers
listed in the directory (Figure 11 and
Table A7).
In 6 of the 15 counties with an NCI
Cancer Center, the majority of Medicare
Advantage plans did not include the NCI
Cancer Center in its provider network
(Figure 12).
This lack of clarity as to whether an NCI
Cancer Center is included in a plan’s
provider network may be attributable to
the considerable variation in the way in
which the cancer centers are listed in the
plans’ provider directories. For example,
the Huntsman Cancer Institute in Salt
Lake County is affiliated with the
University of Utah and is located across
the street from their main Academic
Medical Center. Some of the provider
directories for Medicare Advantage plans
offered in Salt Lake County list Huntsman Cancer Center explicitly, in addition to listing the University of Utah
Medical Center, but other provider directories only list the University of Utah Medical Center, and do not
mention the Huntsman Cancer Institute. In these situations, it is unclear whether a Medicare beneficiary can
assume that coverage of care at the Academic Medical Center includes care at the affiliated cancer center, and
the answer most likely varies across plans.
NOTE: AMCs are Academic Medical Centers. Excludes 5 counties (Clark, NV; Milwaukee, WI; Queens, NY; Miami-Dade, FL; and
Mecklenburg, NC) that did not have a NCI Cancer Center within the county borders. Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 15 counties, 2016.
Share of Plans Including NCI Cancer Centers in Provider
Networks
Definitely
Included
(NCI Cancer Center
in network)
15%
Possibly Included
(NCI Cancer Center not in
directory; affiliated AMC in
network)
43%
Not Included
(NCI Cancer Center not
mentioned; no affiliated
AMC in network)
41%
Total = 306 plans across 15 counties
More than one-third of plans do not include the NCI Cancer Center in the provider network
Figure 11
15%
12%
62%
72%
65%
43%
21%
23%
27%
24%
42%
62%
73%
75%
76%
23%
16%
93%
93%
35%
41%
100%
79%
77%
73%
65%
58%
38%
27%
25%
24%
15%
12%
7%
7%
Not Included
Possibly Included
Definitely Included
Share of Plans Including the NCI Cancer Center in
Hospital Networks, by County
NOTE: AMCs are Academic Medical Centers. Excludes 5 counties (Clark, NV; Milwaukee, WI; Queens, NY; Miami-Dade, FL; and
Mecklenburg, NC) that did not have a NCI Cancer Center within the county borders. Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 15 counties, 2016.
In at least 6 counties, the majority of plans do not include the NCI Cancer Center in the county
Figure 12
Medicare Advantage Hospital Networks: How Much Do They Vary? 14
NCI Cancer Centers were less likely to be
included in plans with narrow networks
than plans with broader networks
(Figure 13). These results were
generally consistent across the counties.
Even when NCI-Designated Cancer
Centers are excluded from the provider
network, plans may choose to selectively
refer enrollees to them, when
appropriate, although it is beyond the
scope of this analysis to assess the extent
to which these referrals occur. Contract
negotiations with cancer centers can be
complex, particularly when a cancer
center is in a strong negotiating position,
which may explain why many plans do not include them in the plan networks.
ACS-Accredited Cancer Programs.
The vast majority of plans (94%) included
at least one hospital with a cancer
program accredited by the ACS
Commission on Cancer. A larger share
(21%) of narrow network plans than
medium (4%) or broad network plans
(0%) did not include at least one hospital
with a cancer program accredited by the
ACS (Figure 14). Plans’ inclusion of
hospitals with ACS-accredited cancer
programs also varied somewhat across
counties. In 13 counties, every plan
included at least one hospital with an
ACS-accredited cancer program, while 12
percent of plans in Los Angeles did not
include such a hospital in their network; however, in all counties, most of the plans without a hospital with an
ACS-accredited cancer program had narrow networks.
Overall, 3 percent of plans had neither a hospital with an ACS-accredited cancer program nor an NCI Cancer
Center in their provider network. While few beneficiaries are evaluating provider networks based on their
access to cancer centers, if beneficiaries wanted to know whether a network included hospitals affiliated with
an NCI Cancer Center or hospitals with ACS-accredited cancer programs, they would need to use data sources
other than the provider directory because these designations are not indicated in the directories.
15%
4%
9%
48%
43%
22%
48%
48%
41%
75%
43%
4%
Average Narrow Networks
(0-29%)
Medium Networks
(30-69%)
Broad Networks
(70-100%)
Not Included
Possibly Included
Definitely Included
NOTE: Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 15 counties, 2016.
Share of Plans Not Including an NCI Cancer Center, by
Network Size
A much larger share of narrow network plans do not include the NCI Cancer Center
Figure 13
94%
79%
96%
100%
6%
21%
4%
Average Narrow Networks
(0-29%)
Medium Networks
(30-69%)
Broad Networks
(70-100%)
No hospital with
accredited cancer
program included
Hospital with
accredited cancer
program included
NOTE: ACS is the American College of Surgeons Commission on Cancer.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Share of Plans Not Including a Hospital With a Cancer
Program Accredited by the ACS, by Network Size
A larger share of narrow network plans do not include a hospital with a cancer program
accredited by the ACS
Figure 14
Medicare Advantage Hospital Networks: How Much Do They Vary? 15
For specialty care more broadly, unless the affiliate is explicitly mentioned in the provider directory, it is
unclear whether a hospital’s affiliates are also covered by a plan, or whether coverage is restricted to acute care
hospitalization at the specific hospital listed in the directory. For example, it is often unclear as to whether a
hospital’s affiliated heart center, rehabilitation center, or women’s center is included in the plan network that
includes the main, acute care hospital. This lack of clarity makes it difficult for beneficiaries to determine
which affiliated providers would be in a plan’s network.
Average premiums for Medicare
Advantage plans generally increased with
the size of the network (Figure 15). The
average premium for Medicare Advantage
plans with broad networks ($51 per
month) was almost 50 percent higher
than the average premium for narrow
network plans ($35 per month).
However, the correlation between
premiums and network size disappeared
after comparing networks within plan
types. Among HMOs, the average
premium for narrow network plans ($36
per month) was the same as the average
premium for broad network plans.
Among PPOs, the average premium for narrow network plans is much lower ($28 per month) than for medium
network plans ($87 per month) and broad network plans ($79 per month). However, since only 10 local PPOs
had narrow networks, more research with a larger sample of narrow network local PPOs is needed to confirm
these findings. Overall, premiums varied more between HMOs and local PPOs than by network size.
$35
$36
$28
$39
$24
$87
$51
$37
$79
Total HMOs Local PPOs
Narrow
Networks
(0-29%)
Medium
Networks
(30-69%)
Broad
Networks
(70-100%)
Average Premiums of Medicare Advantage Plans, by
Network Size and Plan Type
Broad and narrow network HMOs have similar average premiums
Figure 15
Average across
all plans
$41 $29 $79
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 16
The size and composition of the plans’
provider networks are not used by CMS to
assign star quality ratings to the plans;
however, the ratings may nonetheless be
correlated with the size of the networks if
the hospitals excluded from the narrower
networks had either a positive or negative
effect on plan ratings. Overall, the
average star quality ratings for narrow
network plans (4.1 stars) were similar to
the average ratings for medium or broad
network plans (3.7 and 3.9 stars,
respectively; Figure 16).
Within counties, the relationship between
plan ratings and network sizes was
inconsistent. In some counties, narrow network plans had higher average quality ratings than medium or
broad network plans, but in other counties the narrow network plans had lower average quality ratings.
Among local PPOs, the average plan ratings generally increased with the size of the network, and plans with
broader networks had somewhat higher average ratings (4.1 stars) than plans with narrow networks (3.6 stars).
However, more research with a larger sample of narrow network local PPOs is needed to confirm these findings
since only 10 local PPOs in our study had narrow networks. Among HMOs, there was a different dynamic
between plan ratings and the size of the network, and narrow network HMOs had higher plan ratings (4.1 stars)
than HMOs with broad networks (3.8 stars). Taken as a whole, the relationship between plans’ quality ratings
and the size of plans’ networks is likely more closely related to factors other than the size of plans’ networks.
Among the firms offering plans in these 20 counties, none were more likely than others to have narrow
networks in multiple counties, with the exception of Kaiser Permanente, which only has narrow hospital
networks (Table A8). For example, while Humana included more than 70 percent (broad network) of the
hospitals in Mecklenburg, it had narrow provider networks in 5 counties (Harris, Los Angeles, Multnomah,
Queens, and Salt Lake) and medium networks in 12 other counties. Likewise, some Blue Cross Blue Shield
(BCBS) affiliated plans had broad hospital networks in some counties (e.g., Cuyahoga, Miami-Dade), but had
narrow hospital networks in other counties (e.g., Harris).
Interestingly, among plans with the same name that were offered in multiple counties, the size of the plan
network often varied across counties. For example, the Humana Choice plan in Multnomah, Oregon included
only 13 percent of the hospitals in the county, whereas the Humana Choice plan in Cuyahoga, Ohio included 70
percent of the hospitals in the county. As a consequence, enrollees cannot use the firm or the plan name as a
signal about the size of the plan network. This finding also suggests that local market characteristics typically
are a stronger influence on network design than particular firm philosophies.
4.1
4.1
3.6
3.7
3.6
3.9
3.9
3.8
4.1
Total HMOs Local PPOs
Narrow
Networks
(0-29%)
Medium
Networks
(30-69%)
Broad
Networks
(70-100%)
Average Star Quality Ratings of Medicare Advantage
Plans, by Network Size and Plan Type
Figure 16
Average across
all plans
3.8 stars 3.8 stars 3.9 stars
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Broad and narrow network HMOs have similar average star quality ratings
Medicare Advantage Hospital Networks: How Much Do They Vary? 17
The size of the hospitals (measured by the number of beds) included in provider networks could provide some
information about the plan’s capacity to provide inpatient care to enrollees, and may have some relationship to
the quality of care and enrollees’ satisfaction with their care, although the evidence for this is mixed. Several
studies have found that larger hospitals have lower mortality rates than smaller hospitals;
18
however, patients
have also rated lower their satisfaction with the care received at large hospitals than at smaller hospitals.
19
Across the 20 counties, Medicare
Advantage plans were more likely to
include larger hospitals (400 beds or
more) than smaller hospitals (less than
100 beds). While 17 percent of all
hospitals in the 20 counties were large
hospitals, they accounted for 29 percent
of all hospitals in the plans’ provider
networks (Figure 17).
Similarly, while 29 percent of all hospitals
were small, these hospitals accounted for
only 14 percent of the hospitals in the
plans’ provider networks. These findings
were generally consistent at the county-
level, and, in all counties, large hospitals
were either over-represented or proportionately represented in plan networks.
Network size did not appear to be correlated with the size of the hospitals included in the network. Large
hospitals comprised more than one-third of hospitals in both narrow and broad network plans (37% and 35%,
respectively), but a smaller share (23%) of hospitals in medium networks.
Most hospitals operate on a not for profit basis, so it is not surprising that such hospitals also constituted most
of the hospitals in plans’ networks. However, relative to their prevalence in the counties, plan networks were
less likely to include for-profit hospitals, which accounted for 39 percent of the hospitals in the counties, but
only one-quarter (26%) of the hospitals in the plan networks. These findings generally are consistent across
the individual counties studied.
29%
14%
55%
57%
17%
29%
Distribution of Hospitals
Available in the Counties
Distribution of Hospitals
Included in Plans' Networks
Large hospitals
(400+ beds)
Medium hospitals
(100-399 beds)
Small hospitals
(< 100 beds)
NOTE: Percentages may not sum to 100% due to rounding.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Share of Hospitals Available Versus Included in Plans’
Hospital Networks, by Hospital Size
Plan networks disproportionately include large hospitals
Figure 17
Medicare Advantage Hospital Networks: How Much Do They Vary? 18
In theory, a plan’s tax status could
influence the firm’s approach towards
creating the plan’s provider network,
since not-for-profit plans may be able to
dedicate a larger share of their revenue
towards payments to providers and
benefits for enrollees. A larger share of
not-for-profit plans (28%) than for-profit
plans (21%) had broad hospital networks
(Figure 18). At the same time, a larger
share of not-for-profit plans (22%) than
for-profit plans (15%) had narrow or
ultra-narrow hospital networks. These
findings greatly varied across counties,
and not-for-profit plans did not
consistently have narrower or broader
networks than for-profit plans in the same county.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital networks in 20 counties, 2016.
Broad
21%
Medium-
Large
28%
Medium-
Small
37%
Narrow
12%
Ultra-
Narrow
2%
Distribution of the Size of Plans’ Hospital Networks, by
Tax Status of the Plan
For-Profit Plans
Broad
28%
Medium-
Large
33%
Medium-
Small
17%
Narrow
20%
Ultra-
Narrow
2%
Not-for-Profit Plans
Broad: 70% or more of
hospitals
Medium-Large: 50-69%
of hospitals
Medium-Small: 30-49%
of hospitals
Narrow: 10-29% of
hospitals
Ultra-Narrow: less than
10% of hospitals
Total = 286 plans Total = 123 plans
A larger share of not-for-profit plans have narrow or broad hospital networks
Figure 18
Medicare Advantage Hospital Networks: How Much Do They Vary? 19
Provider directories are the main resource available to beneficiaries who want to know which providers are in
the different networks of Medicare Advantage plans. Plans are required by CMS to make a provider directory
available to all current and potential enrollees, but the CMS website used by consumers to compare plans does
not include a link to plan directories or provide a tool that can be used by plan shoppers to check to see whether
their preferred doctors or hospitals are included in plans’ networks. While this analysis focused only on
hospitals, and not physicians or other providers, it adds to a growing body of literature that shows that provider
directories currently have a number of problems that limit their value in helping to inform beneficiaries. These
limitations generally fall into two categories: burden and accuracy of information.
Plans are required to make their provider directory available to current and potential enrollees, and typically
provide the information on the firm’s website. In gathering information for our study, we found accessing and
using these directories to identify provider networks to be challenging. The plan websites varied in overall
layout, the grouping of plans into provider directories, and the format in which the directory is available. Some
companies have only one directory that includes all of its HMO and PPO plans, others have separate directories
for each individual plan, and some do not have a current directory available at all.
As an example, in 2015, a Medicare beneficiary in Cook County, Illinois could choose from 19 HMO or local
PPO Medicare Advantage plans, which had 10 unique provider networks offered by eight different firms. Once
beneficiaries go to the applicable firm’s website, locate the link to learn about plans offered in their area, and
input some geographic information, they have access to information about the plan’s provider network, but the
information is not available in a consistent format across plans. In Cook County, seven of the 10 plan networks
had a provider directory that could be downloaded as a PDF from the firm website. For two networks (covering
five plans), the only way to learn about the providers in the network was to search the firm’s online database by
type of provider or facility to generate a list of providers. For the one remaining network in Cook County (one
plan), the provider network was available as a separate downloadable list for each type of provider.
Among the seven directories that were available as a PDF document in Cook County, the content and
organization varies. Three of the seven list the network pharmacies, while the other four have a separate
document or require an online search to find pharmacy coverage. Dental and vision services are also only
included in three of the directories. Information about other services, such as transplant facilities or providers
with translation capabilities, is included in some but not all directories. One of the Cook County directories
does not include a table of contents or index and is over 600 pages long. (Similarly, other counties, such Los
Angeles, have directories with page-counts in the thousands.)
In all 20 counties included in this study, errors in the provider directories were common. For example, some
directories list facilities as acute-care hospitals when the facilities are actually outpatient centers or
rehabilitation institutes. Hospitals with the same address are frequently listed by different names across
directories, often reflecting failures to update the directories when hospitals change their names or ownership.
In other cases, there are blatant errors. For example, a directory for a plan in Miami-Dade County lists Larkin
Medicare Advantage Hospital Networks: How Much Do They Vary? 20
Community Hospital twice, once with the correct address and once with the address of St. Catherine’s
Rehabilitation Hospital.
One of the most obvious signs that some directories are not up-to-date is that some directories include
hospitals that have been closed for several years. In 2015, 11 out of the 231 directories examined in this study
include hospitals that had been closed or torn down, including one directory that listed a hospital that had been
closed since 2005. Another plan’s website provided a directory for its 2015 plan that stated it was last updated
in August 2013. A call to the plan’s customer service line confirmed that all of the most current documents
were posted online, but that the online search tool should be used for the most up-to-date information.
Similarly, this study excluded seven plans offered by three companies because either a provider directory was
not available for 2015 and the company declined to provide a directory when contacted, or the searchable
directory embedded in the company website did not allow for information to be saved.
Overall, while information about provider networks is available for the vast majority of plans, finding the
information often requires Medicare beneficiaries to invest significant time to locate the directories, many of
which are inaccurate or incomplete, and none of which facilitate comparisons across multiple plans or firms.
Medicare Advantage Hospital Networks: How Much Do They Vary? 21
This study documents, for the first time, considerable diversity in the breadth of hospital networks used by
Medicare Advantage plans– an issue of potential importance to people on Medicare who say having access to
specific hospitals and physicians is a high priority when choosing a plan. Medicare Advantage plans are
generally selective, with their networks including only a subset of the hospitals in the area. The average size
and composition of hospital networks varies within and across counties. Plans with broader hospital networks
are more likely to include Academic Health Centers and NCI-approved cancer centers than plans with narrow
networks. In 9 out of the 20 counties in the study, broad network plans were not offered and beneficiaries in
these counties can only select a Medicare Advantage plan with a narrow or medium-sized network.
In general, hospital network size was not correlated with factors such as star quality ratings, plan premiums
(for HMOs), per capita Medicare spending, number of hospitals in the county, or specific firms. None of the
firms (with the exception of Kaiser Permanente) were more (or less) likely than others to have broad or narrow
network plans across counties. The size of a plan’s network may instead be explained more by the ability of
individual plans to negotiate favorable rates with hospitals in their service area, as well as other market
conditions.
While not the focus of this study, we encountered a number of issues in compiling this information that could
pose challenges to consumers trying to determine the breadth of the hospital networks of Medicare Advantage
plans offered in their area. The Medicare Plan Finder does not include any information on provider networks.
Plans are required to make network information available to consumers upon request, but CMS does not
require plans to release this information in a uniform format, putting the burden on consumers to sort through
directories and search tools to determine if a particular provider is in a given plan’s network. In the course of
our research, it became clear that the directories used in this study were often riddled with errors, including the
incorrect names or addresses for the hospitals, and other blatant mistakes such as the inclusion of hospitals
that no longer existed.
It is not entirely clear how the networks of Medicare Advantage and ACA marketplace plans compare.
McKinsey & Company released a report in 2015 that examined the networks of plans offered in exchanges,
using a similar but not identical taxonomy for classifying hospital network size. Although the studies are not
directly comparable because they used different methods (e.g., included different counties), this analysis
suggests that a much smaller share of Medicare Advantage plans than exchange plans have broad hospital
networks (23% of Medicare Advantage plans compared to 55% of ACA marketplace plans).
20
Further research
is needed to compare the size and scope of plan networks in Medicare, the ACA marketplace, Medicaid, and
employer sponsored insurance.
It is important to note that Medicare Advantage enrollees have the option of switching to traditional Medicare
during the annual open enrollment period, and that traditional Medicare includes the vast majority of
providers and arguably the broadest possible provider network. Yet, switching between Medicare Advantage
and traditional Medicare can be complicated by considerations such as the availability of Medigap plans and
other supplemental coverage, and the need for a separate Part D drug plan.
21
For these and other reasons,
switching rates between Medicare Advantage and traditional Medicare are typically low.
22
Medicare Advantage Hospital Networks: How Much Do They Vary? 22
Policymakers could consider a number of options to improve the accuracy of information in the provider
directories and the extent to which plans comply with network adequacy requirements. CMS could, for
example, review the provider directories more frequently for errors and compliance with network adequacy
requirements. As noted by the GAO,
23
CMS currently reviews less than 1 percent of all provider directories and
does not routinely review the networks of plans that are renewing their current contract. More frequent
reviews by CMS could encourage plans to keep their directories up-to-date and in compliance with CMS
network requirements.
Additionally, CMS has stated that Medicare Advantage plans have less prescriptive network adequacy
requirements than the ACA Qualified Health Plans (QHPs) and Medicaid Managed Care Organizations
(MCOs). While these three programs serve different purposes and different populations,
24
CMS may want to
review areas in which Medicare Advantage requirements are more lenient, and potentially beef up the
requirements for Medicare Advantage plans and harmonize the requirements across the three programs, as
CMS has suggested.
25
CMS could also take steps to make it easier for consumers to obtain and compare information about Medicare
Advantage provider networks. Medicare.gov could post on its Medicare Plan Finder each plan’s provider
network to make it easier for beneficiaries to access provider networks when they are comparing other features
of Medicare Advantage plans. CMS could require all plans to publish network information in a uniform format
and develop a consumer-friendly online tool with up-to-date information on each Medicare Advantage plan’s
provider network to facilitate plan comparisons. CMS could also categorize the size of plans’ networks to allow
beneficiaries and their caregivers to use this information when selecting a plan. While the size of the network
would likely not be the sole factor used to select a plan, it could be an important, relevant consideration when
deciding between two otherwise similar plans.
Creating networks of providers is one of many strategies available to insurers to help control costs and manage
the delivery of care, but narrow networks may also limit consumers’ access to certain providers and increase
the cost for care obtained out-of-network. For Medicare Advantage enrollees who place a high value on having
access to a particular set of providers, or a broad range of providers, the results of this study underscore why it
is important for beneficiaries to review provider networks before choosing among Medicare Advantage plans,
despite the difficulties of doing so. The study also underscores the need for accurate, readily available
information to make it easier for consumers, insurance counselors and others to compare provider networks
across plans, and for ongoing oversight of network requirements to meet the expected and unexpected health
care needs of beneficiaries enrolled in Medicare Advantage plans.
Medicare Advantage Hospital Networks: How Much Do They Vary? 23
This study examined Medicare Advantage plans available in 2015 in 20 counties: Allegheny County, PA; Clark
County, NV; Cook County, IL; Cuyahoga County, OH; Davidson County, TN; Douglas County, NE; Erie County,
NY; Fulton County, GA; Harris County, TX; Jefferson County, AL; King County, WA; Los Angeles County, CA;
Mecklenburg County, NC; Miami-Dade County, FL; Milwaukee County, WI; Multnomah County, OR; New
Haven County, CT; Pima County, AZ; Queens County, NY; and Salt Lake County, UT. The county is the
smallest area, in general, that a Medicare Advantage plan must cover. Counties vary greatly in size and may
not be the best metric to assess the health care market of particular locales, but an analysis at the county level
provided the most complete set of data available for this type of analysis as well as a reasonable snapshot of the
health care market accessible to beneficiaries in that region.
The counties were chosen so as to encompass a sizeable share of Medicare Advantage enrollees, be
geographically dispersed across the country, include large, urban areas with many Medicare beneficiaries,
include Medicare Advantage markets that are led by national firms (e.g., UnitedHealthcare) and local firms
(e.g., UAB Health System), and range in per capita Medicare spending, number of plans offered to Medicare
beneficiaries, and Medicare Advantage penetration rate (Table 2). Together, these counties account for 14
percent of all Medicare Advantage enrollees in 2015.
Allegheny, PA Pittsburgh
247,434 62% 41% 1 1985 Yes Yes
Clark, NV Las Vegas
294,530 38% 51% 1 1985 Yes No
Cook, IL Chicago
769,309 17% 32% 1 1985 Yes Yes
Cuyahoga, OH Cleveland
241,669 37% 33% 2 1987 Yes Yes
Davidson, TN Nashville
89,800 42% 48% 1 1996 Yes Yes
Douglas, NE Omaha
75,402 23% 58% 2 1985 Yes Yes
Erie, NY Buffalo
185,347 56% 62% 4 1985 Yes Yes
Fulton, GA Atlanta
118,697 35% 33% 2 1997 Yes Yes
Harris, TX Houston
465,027 39% 21% 1 1988 Yes Yes
Jefferson, AL Birmingham
123,132 42% 39% 1 1994 Yes Yes
King, WA Seattle
283,171 34% 30% 3 1980 Yes Yes
Los Angeles Los Angeles
1,344,850 43% 40% 1 1985 Yes Yes
Mecklenburg, NC Charlotte
119,517 31% 39% 3 1985 Yes No
Miami-Dade Miami
420,702 62% 28% 1 1986 Yes No
Milwaukee, WI Milwaukee
145,125 41% 73% 2 1995 Yes No
Multnomah, OR Portland
110,238 58% 27% 4 1980 Yes Yes
New Haven, CT New Haven
153,214 28% 41% 1 1996 Yes Yes
Pima, AZ Tucson
187,732 46% 53% 3 1986 Yes Yes
Queens, NY New York City
326,376 43% 26% 1 1986 Yes No
Salt Lake, UT Salt Lake City
122,904 41% 43% 3 2003 Yes Yes
SOURCE: Kaiser Family Foundation analysis of CMS Medicare Advantage enrollment and landscape files for 2015.
Medicare Advantage Hospital Networks: How Much Do They Vary? 24
Only HMOs and local PPOs were included in the analysis because the other types of Medicare Advantage plans
either do not have networks (e.g., some private fee-for-service plans), or networks that are structured to cover
areas larger than a county (e.g., regional PPOs), or are paid in unique ways that influence providers available to
beneficiaries (e.g. cost plans). The analysis also excluded Special Needs Plans (SNPs), employer-sponsored
group plans, and other plans that are not available to all Medicare beneficiaries. In total, across the 20
counties, we included 307 HMOs and 102 local PPOs. Among the 307 HMOs, 10 were closed panel HMOs, with
physicians or groups of physicians directly employed by the HMO, and the remainder were open panel HMOs.
Together, these plans enrolled 1.6 million Medicare beneficiaries in 2015, 92 percent of whom were in HMOs
and 8 percent of whom were in PPOs. Both HMOs and local PPOs were available in all 20 counties, with the
exception of Los Angeles County where only HMOs were available to Medicare beneficiaries.
Provider directories were the primary source of data used for the study. The directories were gathered between
November and December 2014, to coincide with the Medicare Annual Election Period for 2015, and were either
downloaded from the company’s website in a PDF format, when possible, or downloaded using the searchable
directory embedded in the company website. The information extracted from these data was complemented
with other information available on these plans and counties in CMS’s Medicare Advantage Enrollment file for
March 2015, CMS’s Medicare Advantage Landscape file for 2015, and the American Hospital Association’s
(AHA) 2014 survey of hospitals.
Seven plans offered by three companies were excluded from the analysis because either a provider directory
was not available for 2015 and the company declined to provide a directory when contacted, or the searchable
directory embedded in the company website did not allow for information to be saved.
Two counties from our sample include HMOs with tiered networks of hospitals. The difference in tier
designates a difference in co-pay for a hospital admission. Consequently, even though all of the hospitals listed
in the directory are considered “in-network,” the cost for a hospital stay will differ depending on the hospital’s
tier. While the provider directories designate each hospital’s tier, the information about the difference in cost-
sharing only can be found in the plan’s Summary of Benefits document.
The two plans with tiered networks were different with respect to the breakdown of the hospitals into more
expensive and less expensive tiers and the disparities in cost-sharing for hospital stays between the two tiers.
For the tiered network in Cook County, the difference in co-pay between tier 1 and tier 2 is $50 per day for days
1 through 4 ($200 total potential difference). The less expensive tier (tier 1) only includes five hospitals, all
owned by Advocate Health Care. The majority of the hospitals in the network (22 facilities) are in tier 2, with
the more expensive co-pay. In contrast, most of the hospitals in Erie County’s tiered network plan are in the
less expensive tier. For this plan’s tier A hospitals, there is a co-pay of $400 per admission, while tier B
hospitals require a co-pay of $900 per admission. However, only one of the network’s eight hospitals in Erie
County is in tier B. For both of these plans with tiered networks, the analysis included all hospitals in either
tier as in-network hospitals because in Cook County the difference in cost-sharing for hospitals in the two tiers
Medicare Advantage Hospital Networks: How Much Do They Vary? 25
was relatively nominal and for the plan in Erie County, the set of hospitals in the second tier was deemed to be
sufficiently small. Overall, the inclusion of hospitals in both tiers likely had a negligible effect on the results of
the analysis.
The data from the provider directories was inputted twice, by two independent people, and all discrepancies in
the data entry were resolved by manually checking the relevant provider directory. Whenever directories
contained typos or slight variations in the name of a hospital, the addresses were used to verify a hospital’s
inclusion in the network. The Centers for Medicare and Medicaid Services’ Provider of Services (POS) file was
used to match each hospital location with its unique provider identification number.
All short-term general hospitals in the 20 counties included in the study and their characteristics were
identified using the data from the AHA 2014 survey of hospitals. (To support sensitivity analyses, hospitals in
the adjacent counties were also identified.) Veterans Health Administration hospitals and children’s hospitals
were excluded because of their unique financing or population focus. Two basic measures of network size were
constructed for each health plan by county: (1) the share of hospitals in the county that were listed in the
directory; and (2) the share of hospital beds in the county that were associated with the hospitals listed in the
directory.
This study categorized networks into one of four sizes based on the share of hospitals in the county that were
included in the directory: broad (70% or more of the hospitals), medium (30-69% of hospitals), narrow (10-
29% of hospitals), and ultra-narrow (less than 10% of hospitals). These definitions differ from those used by
the only other known study, conducted by McKinsey & Company, that categorized networks by the share of
hospitals in the county included in the network. The McKinsey & Company study examined the size of
networks of plans in the Affordable Care Act (ACA) exchanges, and categorized networks into one of three
network sizes; the difference between the categories used in this study and the McKinsey study is that this
study includes a category for medium-sized networks. That is, this study uses the term “medium” to describe
the size of networks that McKinsey described as “narrow”.
For the 10 plans that were closed-panel HMOs, the study used the same four categories to characterize the size
of the network. HMOs with closed panel designs are those in which the parent organization has exclusive
contracts with physicians (employed either directly or in groups) and sometimes also owns hospitals or
contracts with hospitals in other ways that result in more centralized hospital capacity. HMOs with open panel
designs, which include the majority of HMOs today, are those in which the parent organization has non-
exclusive contracts with a range of providers located in the area, and the providers typically accept multiple
insurers. One of the primary reasons people enroll in closed panel HMOs is because they want to have access
to the plan’s network of hospitals and doctors, whereas people in other plans generally do not have access to
these physicians and facilities.
Medicare Advantage Hospital Networks: How Much Do They Vary? 26
Access to specialized medical care is important to many Medicare beneficiaries since about one-quarter (26%)
of Medicare beneficiaries are in fair or poor health and 45 percent have four or more chronic conditions.
26
This
study examined the presence of two types of specialty hospitals in plan networks: teaching hospitals and
cancer centers. Teaching hospitals can provide access to more specialized care and may provide better care for
complex medical conditions, such as organ transplants, certain cancer surgeries, and autoimmune disorders.
Both Academic Medical Centers (also known as major teaching hospitals) and minor teaching hospitals have
residency and/or internship training programs (or medical school affiliation reported by the American Medical
Association) but, unlike Academic Medical Centers, minor teaching hospitals are not members of the Council of
Teaching Hospitals. Academic Medical Centers and minor teaching hospitals were identified based upon data
from the AHA 2014 survey of hospitals. Each of the 20 counties had at least one Academic Medical Center
within its borders, 11 of which included more than one, including Cook County with 12 Academic Medical
Centers and Los Angeles County with 8 Academic Medical Centers. All but one of the counties (Mecklenburg)
included at least one minor teaching hospital.
To gain insight into the type of cancer treatment available to Medicare Advantage enrollees, the study
examined access to cancer centers designated by the National Cancer Institute (NCI) and hospitals accredited
by the American College of Surgeons (ACS). The NCI has designated 69 cancer centers in 35 states as NCI-
Designated Cancer Centers in recognition of their leadership and resources in the development of more
effective approaches to prevention, diagnosis, and treatment of cancer, and many but not all of these centers
are affiliated with Academic Medical Centers. The ACS Commission on Cancer accredits cancer programs
within hospitals that meet ACS quality and service standards, and this accreditation is designed to be an
indicator of higher quality cancer care. NCI-Designated Cancer Centers were identified through the list of
centers on the NCI website, and ACS-accredited cancer centers were identified based upon data from the AHA
2014 survey of hospitals. Fifteen of the 20 counties in the study had at least one NCI Cancer Center within the
borders of the county, including Cook, Harris, and Los Angeles counties that had more than one NCI Cancer
Center, and all but one of the counties (Pima) had at least one hospital with an ACS-accredited cancer program.
The report does not assess several important questions about provider networks. The report does not assess
whether networks are adequate to meet the needs of plan enrollees nor does it assess whether the networks
meet the minimum requirements for Medicare Advantage provider networks as specified by CMS.
27
The report
also does not assess whether the quality of providers or the quality of care received varies by the size of a plan’s
network of providers. Additionally, the report only assesses the network of hospitals included in a plan’s
provider network, and does not examine the physicians and other types of providers in the plans’ networks.
Also, this report looked only at urban areas where Medicare Advantage plans should have access to a sufficient
supply of providers with which to contract; in rural areas, provider networks may be quite different.
The largest limitation of this analysis stems from the fact that Medicare Advantage plan networks vary widely
in the size of the geographic region that they cover. While the networks of some plans are limited to a single
county, other plans available in that county offer beneficiaries access to hospitals in neighboring counties and
Medicare Advantage Hospital Networks: How Much Do They Vary? 27
even in bordering states. In order to compare the breadth of coverage for plans within a particular area, we
chose to analyze each plan’s network within the county because this is the largest geographic measure that all
plans are required to cover. The county analysis therefore provides the most complete set of data available for
this type of analysis. For most of the selected counties, this geographic restriction also provides a reasonable
snapshot of the health care market accessible to seniors in that region.
However, in some major metropolitan areas where residents frequently cross county lines, this method of
analysis is flawed. For example, the proximity and accessibility of Queens County to New York, Kings, and
Bronx counties, and the distribution of major medical centers in these neighboring areas, means that many
Queens residents go to hospitals outside of their county. In this case, counting the number of hospitals that a
plan network covers within Queens County is not necessarily a good measure of a network’s coverage.
Although counties were chosen as the geographical lens for this study, there are other established regional
divisions that could be used to evaluate the size of provider networks. The extent to which these regions
overlap with counties gives a sense of how significantly the results may differ depending upon the way the
country is divided into coverage areas. The Dartmouth Atlas of Health Care created Hospital Referral Regions
(HRR) as representations of regional health care markets that include a major referral center.
28
The overlap of
these HRRs with counties is highly variable, although it depends somewhat on whether a county is primarily
rural or urban. In the more rural counties, the entire county accounts for only one small portion of an HRR (all
of Fulton County in Georgia accounts for only 15% of HRR 144). For big counties with a larger urban
population, one county may contain several HRRs (Cook County in Illinois spans eight different HRRs,
including all of HRR 156). In only one case is there almost exact overlap between the county and a single HRR
(Clark County in Nevada with HRR 279).
Another potential way to analyze network coverage is Metropolitan Statistical Areas (MSAs), established by the
Office of Management and Budget based on core urban areas and their surrounding economically integrated
regions.
29
Every MSA includes at least one entire county. For 4 of the counties (Clark, Pima, Salt Lake, and
New Haven), the county accounts for 95-100% of its MSA. Two counties represent less than 20 percent of the
MSA (17% for Fulton and 11% for Queens) and the remaining counties represent between 33 percent
(Multnomah) and 81 percent (Erie) of the MSA in which they are located. This could indicate that by
restricting our analysis to the county in these areas, we may have excluded some portion of a county resident’s
health care market.
Medicare Advantage Hospital Networks: How Much Do They Vary? 28
Allegheny, PA
Pittsburgh
22 13 9 25 4 0% 0% 73% 27% 0% 0% 80% 20%
Clark, NV
Las Vegas
11 6 5 31 1 0% 18% 82% 0% 0% 3% 97% 0%
Cook, IL
Chicago
19 13 6 62 12 0% 0% 100% 0% 0% 0% 100% 0%
Cuyahoga, OH
Cleveland
26 19 7 20 3 0% 0% 42% 58% 0% 0% 26% 75%
Davidson, TN
Nashville
15 11 4 15 2 0% 0% 100% 0% 0% 0% 100% 0%
Douglas, NE
Omaha
13 8 5 13 2 0% 0% 77% 23% 0% 0% 77% 23%
Erie, NY
Buffalo
25 18 7 11 1 0% 8% 20% 72% 0% 1% 3% 97%
Fulton, GA
Atlanta
17 11 6 13 3 6% 18% 59% 18% 0% 16% 68% 16%
Harris, TX
Houston
28 19 9 70 4 4% 36% 61% 0% 0% 23% 77% 0%
Jefferson, AL
Birmingham
12 9 3 16 1 0% 8% 92% 0% 0% 4% 96% 0%
King, WA
Seattle
23 18 5 22 3 0% 43% 57% 0% 0% 41% 59% 0%
Los Angeles, CA
Los Angeles
34 34 0 106 8 12% 12% 76% 0% 34% 7% 59% 0%
Mecklenburg, NC
Charlotte
15 9 6 10 1 0% 0% 0% 100% 0% 0% 0% 100%
Miami-Dade, FL
Miami
29 26 3 28 2 0% 14% 79% 7% 0% 0% 91% 9%
Milwaukee, WI
Milwaukee
6 4 2 16 3 0% 0% 50% 50% 0% 0% 10% 90%
Multnomah, OR
Portland
30 17 13 8 1 7% 40% 37% 17% 24% 26% 38% 13%
New Haven, CT
New Haven
16 14 2 11 1 0% 0% 63% 38% 0% 0% 70% 30%
Pima, AZ
Tucson
13 12 1 14 2 0% 23% 77% 0% 0% 14% 86% 0%
Queens, NY
New York City
42 38 4 11 1 0% 14% 45% 40% 0% 2% 10% 88%
Salt Lake, UT
Salt Lake City
13 8 5 16 1 0% 15% 85% 0% 0% 3% 97% 0%
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
NOTES: AMCs are Academic Medical Centers.
Numbers may not sum to 100% due to rounding.
Medicare Advantage Hospital Networks: How Much Do They Vary? 29
Allegheny, PA
Pittsburgh
15 61% 5,286 81% N/A N/A 76% 92%
Clark, NV
Las Vegas
12 39% 2,758 55% N/A 29% 61% N/A
Cook, IL
Chicago
33 53% 8,767 54% N/A N/A 54% N/A
Cuyahoga, OH
Cleveland
13 66% 4,188 69% N/A N/A 35% 93%
Davidson, TN
Nashville
9 60% 3,061 70% N/A N/A 70% N/A
Douglas, NE
Omaha
7 57% 1,409 66% N/A N/A 56% 99%
Erie, NY
Buffalo
8 69% 3,086 78% N/A 57% 54% 87%
Fulton, GA
Atlanta
6 48% 2,045 56% 0% 30% 62% 80%
Harris, TX
Houston
23 33% 6,461 55% 5% 37% 68% N/A
Jefferson, AL
Birmingham
7 46% 2,588 70% N/A 28% 73% N/A
King, WA
Seattle
9 40% 1,997 48% N/A 32% 61% N/A
Los Angeles, CA
Los Angeles
36 34% 8,534 38% 4% 16% 47% N/A
Mecklenburg, NC
Charlotte
8 79% 2,294 94% N/A N/A N/A 94%
Miami-Dade, FL
Miami
13 48% 4,488 62% N/A 36% 65% 77%
Milwaukee, WI
Milwaukee
11 68% 2,221 80% N/A N/A 67% 93%
Multnomah, OR
Portland
4 44% 1024 40% 0% 16% 49% 91%
New Haven, CT
New Haven
7 63% 1,939 77% N/A N/A 66% 96%
Pima, AZ
Tucson
5 34% 1,692 63% N/A 35% 71% N/A
Queens, NY
New York City
6 56% 2,491 59% N/A 27% 51% 79%
Salt Lake, UT
Salt Lake City
8 49% 1,609 63% N/A 41% 67% N/A
NOTES: N/A indicates not applicable.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 30
Allegheny, PA
Pittsburgh
13 25 0% 0% 77% 23% 0% 0% 83% 17%
Clark, NV
Las Vegas
6 31 0% 33% 67% 0% 0% 4% 96% 0%
Cook, IL
Chicago
13 62 0% 0% 100% 0% 0% 0% 100% 0%
Cuyahoga, OH
Cleveland
19 20 0% 0% 58% 42% 0% 0% 30% 70%
Davidson, TN
Nashville
11 15 0% 0% 100% 0% 0% 0% 100% 0%
Douglas, NE
Omaha
8 13 0% 0% 75% 25% 0% 0% 83% 17%
Erie, NY
Buffalo
18 11 0% 0% 28% 72% 0% 0% 3% 97%
Fulton, GA
Atlanta
11 13 9% 18% 64% 9% 0% 21% 75% 3%
Harris, TX
Houston
19 70 5% 42% 53% 0% 0% 24% 76% 0%
Jefferson, AL
Birmingham
9 16 0% 11% 89% 0% 0% 6% 94% 0%
King, WA
Seattle
18 22 0% 56% 44% 0% 0% 51% 49% 0%
Los Angeles, CA
Los Angeles
34 106 12% 12% 76% 0% 34% 7% 59% 0%
Mecklenburg, NC
Charlotte
9 10 0% 0% 0% 100% 0% 0% 0% 100%
Miami-Dade, FL
Miami
26 28 0% 15% 77% 8% 0% 0% 91% 9%
Milwaukee, WI
Milwaukee
4 16 0% 0% 50% 50% 0% 0% 10% 90%
Multnomah, OR
Portland
17 8 12% 53% 24% 12% 34% 36% 13% 18%
New Haven, CT
New Haven
14 11 0% 0% 71% 29% 0% 0% 72% 28%
Pima, AZ
Tucson
12 14 0% 25% 75% 0% 0% 14% 86% 0%
Queens, NY
New York City
38 11 0% 16% 45% 39% 0% 2% 9% 89%
Salt Lake, UT
Salt Lake City
8 16 0% 0% 100% 0% 0% 0% 100% 0%
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 31
Allegheny, PA
Pittsburgh
9 25 0% 0% 67% 33% 0% 0% 70% 30%
Clark, NV
Las Vegas
5 31 0% 0% 100% 0% 0% 0% 100% 0%
Cook, IL
Chicago
6 62 0% 0% 100% 0% 0% 0% 100% 0%
Cuyahoga, OH
Cleveland
7 20 0% 0% 0% 100% 0% 0% 0% 100%
Davidson, TN
Nashville
4 15 0% 0% 100% 0% 0% 0% 100% 0%
Douglas, NE
Omaha
5 13 0% 0% 80% 20% 0% 0% 36% 64%
Erie, NY
Buffalo
7 11 0% 29% 0% 71% 0% 8% 0% 92%
Fulton, GA
Atlanta
6 13 0% 17% 50% 33% 0% 5% 49% 46%
Harris, TX
Houston
9 70 0% 22% 78% 0% 0% 7% 93% 0%
Jefferson, AL
Birmingham
3 16 0% 0% 100% 0% 0% 0% 100% 0%
King, WA
Seattle
5 22 0% 0% 100% 0% 0% 0% 100% 0%
Los Angeles, CA
Los Angeles
0 106 N/A N/A N/A N/A N/A N/A N/A N/A
Mecklenburg, NC
Charlotte
6 10 0% 0% 0% 100% 0% 0% 0% 100%
Miami-Dade, FL
Miami
3 28 0% 0% 100% 0% 0% 0% 100% 0%
Milwaukee, WI
Milwaukee
2 16 0% 0% 50% 50% 0% 0% 11% 89%
Multnomah, OR
Portland
13 8 0% 23% 54% 23% 0% 0% 97% 3%
New Haven, CT
New Haven
2 11 0% 0% 0% 100% 0% 0% 0% 100%
Pima, AZ
Tucson
1 14 0% 0% 100% 0% 0% 0% 100% 0%
Queens, NY
New York City
4 11 0% 0% 50% 50% 0% 0% 36% 64%
Salt Lake, UT
Salt Lake City
5 16 0% 40% 60% 0% 0% 16% 84% 0%
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
Fulton Kaiser Permanente No 2 1 2 0 13 15% 48%
King Group Health Cooperative Yes 4 1 6 1 21 27% 40%
Los Angeles Kaiser Permanente Yes 1 1 8 7 99 8% 34%
Multnomah Kaiser Permanente No 2 1 0* 0 8 0% 44%
Miami-Dade Leon Medical Centers (CIGNA) No 1 1 13 0 28 46% 48%
NOTE: *Kaiser Permanente's HMO in Multnomah included one hospital in 2014, but this hospital w as dropped from the netw ork in 2015; the 2015 Kaiser Permanente
plan in Multnomah includes hospitals in neighboring counties.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans’ hospital netw orks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 32
Allegheny, PA
Pittsburgh
4 100% 100% 100% N/A N/A
100% 100%
Clark, NV
Las Vegas
1 64% 67% 60% N/A 0% 78% N/A
Cook, IL
Chicago
12 100% 100% 100% N/A N/A 100% N/A
Cuyahoga, OH
Cleveland
3 100% 100% 100% N/A N/A 100% 100%
Davidson, TN
Nashville
2 93% 91% 100% N/A N/A 93% N/A
Douglas, NE
Omaha
2 100% 100% 100% N/A N/A 100% 100%
Erie, NY
Buffalo
1 72% 72% 71% N/A 0% 0% 100%
Fulton, GA
Atlanta
3 82% 73% 100% 0% 33% 100% 100%
Harris, TX
Houston
4 96% 95% 100% 0% 100% 100% N/A
Jefferson, AL
Birmingham
1 42% 33% 67% N/A 0% 45% N/A
King, WA
Seattle
3 83% 78% 100% N/A 100% 69% N/A
Los Angeles, CA
Los Angeles
8 82% 82% N/A 25% 25% 100% N/A
Mecklenburg, NC
Charlotte
1 100% 100% 100% N/A N/A N/A 100%
Miami-Dade, FL
Miami
2 100% 100% 100% N/A 100% 100% 100%
Milwaukee, WI
Milwaukee
3 100% 100% 100% N/A N/A 100% 100%
Multnomah, OR
Portland
1 27% 12% 46% 0% 0% 45% 60%
New Haven, CT
New Haven
1 75% 71% 100% N/A N/A 60% 100%
Pima, AZ
Tucson
2 85% 83% 100% N/A 33% 100% N/A
Queens, NY
New York City
1 57% 53% 100% N/A 67% 42% 71%
Salt Lake, UT
Salt Lake City
1 85% 75% 100% N/A 100% 82% N/A
NOTES: AMCs are Academic Medical Centers. N/A indicates not applicable.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 33
Allegheny
Univeristy of Pittsburgh Cancer
Center
Yes
UPMC Shadyside
22 21 0 9
Cook
Robert H. Lurie Comprehensive
Cancer Center
Yes
Northwestern Memorial
Hospital
19 0 0 0
Cook
University of Chicago
Comprehensive Cancer Center
Yes
University of Chicago Medical
Center
19 4 0 4
Cuyahoga
Seidman Cancer Center
Yes
University Hospitals Case
Medical Center
26 26 15 11
Davidson
Vanderbilt-Ingram Cancer Center Yes Vanderbilt Medical Center 15 14 0 14
Douglas
Buffett Cancer Center Yes Nebraska Medical Center 13 8 0 8
Erie
Roswell Park Cancer Institute Yes Buffalo General Hospital 25 22 18 4
Fulton
Winship Cancer Institute Yes Emory University Hospitals 17 13 0 13
Harris
University of Texas M.D.
Anderson Cancer Institute
Yes
UTHealth - Memorial Hermann
Texas Medical Center
28 26 0 26
Harris
Baylor Dan L. Duncan Cancer
Institute
Yes
Baylor St. Luke's Medical
Center
28 13 0 13
Jefferson
UAB Comprehensive Cancer
Institute
Yes
UAB Hospital
12 5 0 5
King
Fred Hutchinson Cancer Institute
Yes
University of Washington
Medical Center
23 10 0 10
Los Angeles
USC Norris Comprehensive
Cancer Center
Yes
USC Keck
34 6 4 2
Los Angeles
Jonsson Comprehensive Cancer
Center UCLA
Yes
UCLA Medical Center
34 8 0 8
Los Angeles
City of Hope No N/A 34 N/A 2 N/A
Multnomah
Knight Cancer Institute Yes OHSU Hospital 30 8 0 8
New Haven
Yale Cancer Center Yes Yale New Haven Hospital 16 12 0 12
Pima
University of Arizona Cancer
Center
Yes
University of Arizona Medical
Center
13 3 0 3
Salt Lake
Huntsman Cancer Institute Yes University of Utah Hospital 13 11 8 3
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
NOTES: AMCs are Academic Medical Centers. N/A indicates not applicable.
Medicare Advantage Hospital Networks: How Much Do They Vary? 34
Advantra (Aetna) 19,759
20%
6 100% 76% 92%
BCBS 45,089
45%
9 100% 60% 87%
Humana 426
<1%
1 100% 36% 33%
UPMC for Life 35,558
35%
6 100% 52% 68%
Aetna 4,626
5%
4 100% 48% 59%
Humana 36,985
37%
3 33% 43% 64%
UnitedHealth Group 57,156
58%
4 50% 27% 45%
Aetna 2,321
3%
4 100% 66% 68%
BCBS 10,179
13%
5 100% 48% 53%
Cigna 11,591
15%
3 100% 48% 49%
Community Care Alliance of Illinois 354
<1%
1 100% 47% 39%
Humana 32,373
41%
2 100% 60% 65%
Meridian Health Plan <50
<1%
1 100% 44% 43%
UnitedHealth Group 14,494
18%
1 100% 44% 49%
Anthem 8,484
11%
2 100% 47% 44%
Aetna 5,364
12%
5 100% 87% 93%
Anthem 27,373
59%
3 100% 85% 94%
Gateway Health Medicare Assured 419
1%
3 100% 85% 97%
HealthSpan 616
1%
4 100% 35% 24%
Humana 2,838
6%
2 100% 68% 78%
Paramount Elite <50
<1%
3 100% 80% 92%
SummaCare Medicare Advantage Plans 920
2%
4 100% 40% 32%
UnitedHealth Group 8,493
18%
2 100% 45% 44%
BCBS 6,804
25%
5 100% 61% 72%
Cigna 16,215
59%
3 100% 67% 79%
Humana 2,984
11%
3 100% 67% 79%
UnitedHealth Group 1,032
4%
1 0% 47% 47%
WellCare 125
<1%
2 100% 40% 46%
Anthem 464
2%
1 100% 67% 73%
Aetna 4,155
27%
4 100% 81% 92%
Health Alliance Medicare 118
1%
3 100% 38% 46%
HeartlandPlains Health 404
3%
1 100% 46% 52%
Humana 2,231
14%
3 100% 46% 48%
UnitedHealth Group 8,593
55%
2 100% 58% 80%
BCBS 13,769
19%
5 100% 82% 92%
Excellus Health Plan 8,350
11%
4 100% 82% 92%
Fidelis Care 375
1%
3 0% 36% 31%
Independent Health 49,262
67%
5 100% 82% 94%
MVP Health Care 97
<1%
4 100% 73% 70%
Universal American 383
1%
2 0% 27% 57%
WellCare 1,807
2%
2 0% 64% 88%
Aetna 4,522
20%
5 100% 68% 71%
Anthem 886
4%
2 100% 54% 59%
Cigna 1,011
4%
1 100% 54% 56%
Humana 7,309
32%
2 100% 50% 79%
Kaiser Permanente 3,382
15%
2 0% 15% 29%
Piedmont WellStar HealthPlans 961
4%
1 100% 38% 36%
UnitedHealth Group 1,955
9%
2 100% 38% 45%
WellCare 2,774
12%
1 100% 69% 82%
Anthem <50
<1%
1 0% 0% 0%
NOTES: AMCs are Academic Medical Centers. BCBS are BlueCross BlueShield affiliates.
Denominator of Medicare Advantage enrollees only includes plans that were analyzed as part of this analysis.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 35
Aetna 7,065 6% 6 100% 47% 65%
BCBS 2,265 2% 3 67% 23% 39%
Cigna 25,642 21% 2 100% 39% 72%
Humana 5,834 5% 2 100% 29% 56%
KelseyCare Advantage 19,045 16% 5 100% 16% 35%
Memorial Hermann Health Insurance
Company
1,116 1% 2 100% 16% 31%
UnitedHealth Group 11,613 9% 2 100% 35% 54%
Universal American 37,346 30% 3 100% 50% 75%
WellCare 8,362 7% 2 100% 40% 61%
Anthem 4,550 4% 1 100% 24% 52%
BCBS 10,318
29%
2 100% 56% 90%
Cigna 5,383
15%
2 0% 44% 61%
Humana 1,342
4%
2 0% 31% 55%
UnitedHealth Group 6,129
17%
2 0% 44% 61%
VIVA Medicare 12,690
35%
4 75% 52% 75%
BCBS 18,273
25%
7 100% 34% 47%
Group Health Cooperative 19,714
27%
4 100% 27% 31%
Humana 6,640
9%
5 100% 40% 50%
Soundpath Health 4,310
6%
4 0% 50% 50%
UnitedHealth Group 24,366
33%
2 100% 64% 81%
Anthem 673
1%
1 100% 36% 51%
Aetna 1,735
<1%
2 100% 45% 44%
BCBS 29,463
8%
2 100% 26% 31%
Anthem 4,581
1%
2 100% 55% 58%
Care1st Health Plan 14,580
4%
2 100% 52% 56%
Central Health Medicare Plan 12,850
3%
2 100% 39% 36%
Citizens Choice Health Plan 6,340
2%
3 100% 37% 36%
Health Net 30,421
8%
5 100% 40% 47%
Humana 7,426
2%
3 0% 5% 2%
Inter Valley Health Plan 5,103
1%
1 0% 17% 19%
Kaiser Permanente 122,794
32%
1 100% 8% 10%
SCAN Health Plan 46,013
12%
2 100% 41% 49%
UnitedHealth Group 74,072
19%
4 100% 39% 53%
Universal American 723
<1%
1 100% 37% 34%
WellCare 7,944
2%
2 100% 41% 37%
Anthem 17,990
5%
2 0% 12% 18%
Aetna 3,756
14%
4 100% 90% 98%
BCBS 7,717
29%
5 100% 70% 92%
Humana 6,145
23%
2 100% 80% 92%
UnitedHealth Group 8,917
34%
4 100% 80% 92%
Aetna 11,487 6% 6 100% 45% 60%
AvMed Medicare 14,446 7% 1 100% 75% 65%
BCBS 3,992 2% 1 100% 82% 88%
Cigna 44,416 22% 1 100% 46% 70%
CarePlus Health Plans 14,994 7% 2 100% 54% 73%
Freedom Health <50 <1% 2 100% 21% 36%
HealthSun Health Plans 22,221 11% 3 100% 43% 57%
Humana 33,361 16% 3 100% 58% 74%
Optimum HealthCare <50 <1% 2 100% 18% 36%
UnitedHealth Group 52,113 25% 3 100% 55% 70%
WellCare 924
<1%
2 100% 64% 70%
Anthem 6,549 3% 3 100% 44% 61%
NOTES: AMCs are Academic Medical Centers. BCBS are BlueCross BlueShield affiliates.
Denominator of Medicare Advantage enrollees only includes plans that were analyzed as part of this analysis.
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
Medicare Advantage Hospital Networks: How Much Do They Vary? 36
Anthem 823 3% 1 100% 69% 87%
Humana 4,677 14% 2 100% 56% 70%
UnitedHealth Group 27,020 83% 3 100% 75% 81%
BCBS 6,407 15% 4 100% 63% 60%
CareOregon Advantage 558 1% 1 100% 63% 60%
FamilyCare Health Plans 124
<1%
5 0% 25% 20%
Health Net 6,973 16% 4 0% 63% 42%
Humana 956 2% 2 0% 13% 10%
Kaiser Permanente 10,385 24% 2 0% 0% 0%
MODA Health Plan 387 1% 3 100% 100% 100%
PacificSource Medicare <50
<1%
1 0% 38% 30%
Providence Health Plans 10,188 23% 5 0% 13% 16%
UnitedHealth Group 7,942 18% 3 0% 71% 65%
Aetna 8,387 24% 4 100% 73% 97%
Anthem 390 1% 1 100% 64% 89%
ConnectiCare 16,688 48% 5 100% 64% 94%
UnitedHealth Group 7,400 21% 4 0% 45% 25%
WellCare 1,879 5% 2 100% 73% 94%
BCBS 9,203 17% 1 100% 36% 65%
Health Net 5,454 10% 2 100% 36% 69%
Humana 6,262 11% 3 100% 40% 77%
Phoenix Health Plans 70
<1%
2 100% 36% 65%
SCAN Health Plan 659 1% 1 100% 43% 66%
UnitedHealth Group 28,645 51% 2 100% 36% 65%
Anthem 5,461 10% 2 0% 14% 28%
Access Medicare 554 1% 2 100% 55% 55%
Aetna 2,435 3% 3 100% 82% 87%
Affinity Health Plan 82
<1%
3 0% 55% 47%
AgeWell New York <50 <1% 1 0% 27% 22%
AlphaCare of New York 140
<1%
1 0% 45% 48%
Amida Care <50
<1%
1 100% 45% 49%
Anthem 16,640 21% 2 100% 73% 72%
Centers Plan for Healthy Living <50 <1% 1 0% 36% 42%
Easy Choice Health Plan of New York 104
<1%
1 0% 27% 28%
Elderplan 3,048 4% 2 100% 55% 68%
EmblemHealth Medicare 10,202 13% 5 100% 71% 79%
Fidelis Care 1925 2% 3 0% 73% 66%
Healthfirst Medicare Plan 11,271 14% 3 67% 70% 74%
Humana 220
<1%
1 100% 18% 26%
Liberty Health Advantage 1,051 1% 1 100% 27% 32%
MetroPlus Health Plan 256
<1%
1 0% 36% 42%
Quality Health Plans <50
<1%
2 100% 18% 26%
Touchstone Health 1,977 2% 4 0% 36% 34%
UnitedHealth Group 29,417 36% 4 50% 77% 77%
Anthem 1,259 2% 1 100% 64% 68%
Aetna 3,550 8% 1 100% 38% 51%
BCBS 7,548 17% 4 100% 61% 77%
Humana 3,949 9% 3 67% 27% 38%
Molina Healthcare 242 1% 1 100% 38% 51%
SelectHealth 8,130 18% 1 0% 31% 36%
UnitedHealth Group 20,835 47% 3 100% 69% 86%
SOURCE: Kaiser Family Foundation analysis of Medicare Advantage plans' hospital netw orks in 20 counties, 2016.
NOTES: AMCs are Academic Medical Centers. BCBS are BlueCross BlueShield affiliates.
Denominator of Medicare Advantage enrollees only includes plans that were analyzed as part of this analysis.
Medicare Advantage Hospital Networks: How Much Do They Vary? 37
1
Jacobson G, Casillas G, Damico A, Neuman T, and Gold M. “Medicare Advantage 2016 Spotlight: Enrollment Market Update,” Kaiser
Family Foundation, May 2016. Available at: http://kff.org/medicare/issue-brief/medicare-advantage-2016-spotlight-enrollment-
market-update/
2
See Centers for Medicare and Medicaid Services, Memo to Medicare Advantage Organizations “Enrollment Opportunities for
Individuals Affected by a Significant Provider Network Change,” August 27, 2015.
3
Jacobson G, Swoope C, Perry M, and Slosar MC. “How are Seniors Choosing and Changing Health Insurance Plans?” Kaiser Family
Foundation, May 2014. Available at: http://kff.org/medicare/report/how-are-seniors-choosing-and-changing-health-insurance-plans/
4
For example, see Centers for Medicare and Medicaid Services, “CY2016 MA HSD Provider and Facility Specialties and Network
Adequacy Criteria Guidance.” Available at: https://www.cms.gov/Medicare/Medicare-
Advantage/MedicareAdvantageApps/Downloads/CY2016_MA_HSD_Network_Criteria_Guidance.pdf For more information about
requirements for Medicare Advantage plans and how they compare to Qualified Health Plans and Medicare Managed Care
Organizations, see Lipschutz D, Callow A, Pollitz K, et al., “Comparison of Consumer Protections in Three Health Insurance Markets:
Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations,” March 2015. Available at:
http://kff.org/medicare/report/comparison-of-consumer-protections-in-three-health-insurance-markets/
5
Centers for Medicare and Medicaid Services, “Announcment of Calendar Year 2017 Medicare Advantage Capitation Rates and
Medicare Advantage and Part D Payment Policies and Final Call Letter,” April 4, 2016, page 157. Available at:
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf For more
information about how Medicare Advantage requirements compare to requirements for Qualified Health Plans and Medicaid Managed
Care Organizations, see Lipschutz D, Callow A, Pollitz K, et al., “Comparison of Consumer Protections in Three Health Insurance
Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations,” March 2015. Available at:
http://kff.org/medicare/report/comparison-of-consumer-protections-in-three-health-insurance-markets/
6
US Government Accountability Office, “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network
Adequacy,” August 2015. Available at: http://www.gao.gov/products/GAO-15-710
7
Gold M, Hurley R, Lake T, Ensor TW, and Berenson RA. “Arrangements Between Managed Care Plans and Physicians: Results from
1994 Survey of Managed Care Plans.” Selected External Research Series no. 3. Washington, DC: Physician Payment Review
Commission, February 1995. Lake T, Gold M, and Hurley R. “HMO Provider Networks in Medicare+Choice: Comparing Medicare and
Commercial Lines of Business.” Managed Care Quarterly, vol. 9, no. 4, autumn 2001, pp. 16-22. And Gold M, Mittler J, Draper D, and
Rousseau D. “Participation of Plans and Providers in Medicaid and SCHIP Managed Care.” Health Affairs, vol. 22, no. 1,
January/February 2003, pp. 230-240.
8
Coe E, Leprai C, Oatman J, and Ogden J. “Hospital networks: Configurations on the exchanges and their impact on premiums,”
McKinsey & Company, December 2013. Available at: http://healthcare.mckinsey.com/hospital-networks-configurations-exchanges-
and-their-impact-premiums; Bello J, Coe E, Kari K, Oatman J, and Rivera S. “Exchanges year 2: New findings and ongoing trends,”
McKinsey & Company, December 2014. Available at: http://healthcare.mckinsey.com/exchanges-year-2-new-findings-and-ongoing-
trends; Dorner SC, Jacobs DB, and Sommers BD. “Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the
Affordable Care Act.” JAMA. 2015; 314(16): 1749-1750. Sloan C and Carpenter E. “Exchange Plans Include 34 Percent Fewer Providers
than the Average for Commercial Plans.” Avalere, July 2015. Available at: http://avalere.com/expertise/managed-
care/insights/exchange-plans-include-34-percent-fewer-providers-than-the-average-for-comm/print; also reference the skinny on
narrow networks; Polsky D and Weiner J. “State Variation in Narrow Networks on the ACA Marketplaces,” Robert Wood Johnson
Foundation, August 2015. Available at: http://ldi.upenn.edu/sites/default/files/rte/state-narrow-networks.pdf
9
Bauman N, Coe E, Ogden J, and Parikh A. “Hospital networks: Updated national view of configurations on the exchanges,” McKinsey
& Company, June 2014. Available at: http://healthcare.mckinsey.com/hospital-networks-updated-national-view-configurations-
exchanges
10
Haeder SF, Weimer DL, and Mukamel DB. “California Hospital Networks Are Narrower In Marketplace Than In Commercial Plans,
But Access and Quality Are Similar,” Health Affairs, May 2015; 34(12): 741-748.
11
Bauman N, Bello J, Coe E, and Lamb J. “Hospital networks: Evolution of the configurations on the 2015 exchanges,” McKinsey &
Company, April 2015. Available at: http://healthcare.mckinsey.com/sites/default/files/2015HospitalNetworks.pdf
12
Manatt Health, “Directory Assistance: Maintaining Reliable Provider Directories for Health Plan Shoppers,” California HealthCare
Foundation, September 2015. Available at:
http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20D/PDF%20DirectoryAssistanceProvider.pdf; Resneck JS,
Quiggle A, Liu M, and Brewster DW. “The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage
Health Plans in an Era of Narrow Networks.” JAMA Dermatol. 2014; 150(12):1290-1297.
13
Bauman N, Bello J, Coe E, and Lamb J. “Hospital networks: Evolution of the configurations on the 2015 exchanges,” McKinsey &
Company, April 2015. Available at: http://healthcare.mckinsey.com/sites/default/files/2015HospitalNetworks.pdf
14
The only other study that has examined the breadth of plans’ provider networks based on the share of hospitals included in each plan
is McKinsey & Company’s study that examined plans available on the 2015 ACA exchanges. That study found that 55% of these plans
had broad networks, 22% had narrow networks, 17% had ultra-narrow networks, and 6% had tiered networks. McKinsey’s “narrow
network” size category corresponds to our study’s “medium” size category (30-69% of hospitals), and the “ultra-narrow” category is the
Medicare Advantage Hospital Networks: How Much Do They Vary? 38
same as our study’s “narrow” size (less than 30% of hospitals). (See Table 1 for the differences in definitions.) A comparison of
McKinsey’s results with ours indicates that broad networks were more common among ACA exchange plans than Medicare Advantage
plans available in 2015. The share of plans with networks that include less than 30% of hospitals is similar among ACA exchange plans
and Medicare Advantage plans. Our study did not separate tiered networks into a separate category because they accounted for less
than 1% of the plans examined.
15
This would generally be true unless the HMO enrollee received authorization from the plan to receive care from an out-of-network
provider.
16
Kaiser Family Foundation, “A Primer on Medicare,” March 2015. Available at: http://kff.org/medicare/report/a-primer-on-
medicare-key-facts-about-the-medicare-program-and-the-people-it-covers/
17
Potetz L and DeWilde LF. “Cancer and Medicare: A Chartbook,” American Cancer Society Cancer Action Nework, February 2009.
Available at: http://www.allhealth.org/briefingmaterials/CancerandMedicareChartbookFinalfulldocumentMarch11-1412.pdf
18
McClellan MB and Staiger DO. “Comparing Hospital Quality at For-Profit and Not-for-Profit Hospitals,” National Bureau of
Economic Research, January 2000. Pages 93-112. Foster D and Zrull L. “Hospital Performance Differences by Size and Teaching
Status,” Truven Health Analytics, June 2013. Available at:
http://100tophospitals.com/portals/2/assets/HOSP_12677_0513_100TopHospPerformanceClass_RB_WEB.pdf
19
McFarland DC, Ornstein KA, and Holcombe RF. “Demographic Factors and Hospital Size Predict Patient Satisfaction Variance –
Implications for Hospital Value-Based Purchasing.” Journal of Hospital Medicine. 2015; 10:503-509. Blizzard R. “Does Hospital Size
Matter for Inpatient Satisfaction?” Gallup, July 2004. Available at: http://www.gallup.com/poll/12499/does-hospital-size-matter-
inpatient-satisfaction.aspx
20
Bauman N, Bello J, Coe E, and Lamb J. “Hospital networks: Evolution of the configurations on the 2015 exchanges,” McKinsey &
Company, April 2015. Available at: http://healthcare.mckinsey.com/sites/default/files/2015HospitalNetworks.pdf
21
For an example of the difficulties that may be encountered when switching from Medicare Advantage to traditional Medicare, see
Neuman T, “Traditional Medicare … Disadvantaged?” March 31, 2016. Available at: http://kff.org/medicare/perspective/traditional-
medicare-disadvantaged/
22
Jacobson GA, Neuman P, and Damico A. “At Least Half of New Medicare Advantage Enrollees Had Switched From Traditional
Medicare During 2006-11” Health Affairs. January 2015; 34(1):48-55.
23
US Government Accountability Office, “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network
Adequacy,” August 2015. Available at: http://www.gao.gov/products/GAO-15-710
24
Lipschutz D, Callow A, Pollitz K, et al., “Comparison of Consumer Protections in Three Health Insurance Markets: Medicare
Advantage, Qualified Health Plans and Medicaid Managed Care Organizations,” March 2015. Available at:
http://kff.org/medicare/report/comparison-of-consumer-protections-in-three-health-insurance-markets/
25
Centers for Medicare and Medicaid Services, “Announcment of Calendar Year 2017 Medicare Advantage Capitation Rates and
Medicare Advantage and Part D Payment Policies and Final Call Letter,” April 4, 2016, page 157. Available at:
https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf For more
information about how Medicare Advantage requirements compare to requirements for Qualified Health Plans and Medicaid Managed
Care Organizations, see Lipschutz D, Callow A, Pollitz K, et al., “Comparison of Consumer Protections in Three Health Insurance
Markets: Medicare Advantage, Qualified Health Plans and Medicaid Managed Care Organizations,” March 2015. Available at:
http://kff.org/medicare/report/comparison-of-consumer-protections-in-three-health-insurance-markets/
26
Kaiser Family Foundation, “A Primer on Medicare,” March 2015. Available at: http://kff.org/medicare/report/a-primer-on-
medicare-key-facts-about-the-medicare-program-and-the-people-it-covers/
27
US Government Accountability Office, “Medicare Advantage: Actions Needed to Enhance CMS Oversight of Provider Network
Adequacy,” August 2015. Available at: http://www.gao.gov/products/GAO-15-710
28
See The Dartmouth Atlas of Health Care. Available at: http://www.dartmouthatlas.org/data/region/
29
See US Census Bureau definitions of Metropolitan and Micropolitan Statistical Areas. Available at:
http://www.census.gov/population/metro/
the henry j. kaiser family foundation
Headquarters
2400 Sand Hill Road
Menlo Park, CA 94025
Phone 650-854-9400 Fax 650-854-4800
Washington Oces and
Barbara Jordan Conference Center
1330 G Street, NW
Washington, DC 20005
Phone 202-347-5270 Fax 202-347-5274
www.k.org
This publication (#8882) is available on the Kaiser Family Foundation’s website at www.k.org.
Filling the need for trusted information on national health issues, the Kaiser Family Foundation is
a nonprot organization based in Menlo Park, California.
