Ghost Networks in Medicare Advantage: Implications for Mental Healthcare Access for Older Adults

• In Event: From Coverage to Care: Networks, Cost-Sharing, and Access

Abstract

Introduction/Background: Approximately 20% of older adults (age 65+) experience symptoms of depressive disorder or anxiety, and many face an outsized risk of suicide. However, less than 40% of older adults with any mental illness used any mental health care in 2021. For older adults enrolled in Medicare Advantage, provider networks are one plan design feature that may affect access. “Ghost networks” occur when providers are listed in network directories but are inactive (not billing) because, for example, they have moved, no longer accept the beneficiary's insurance plan, or have closed their panel to new patients. Exposure to large "ghost networks" may be especially detrimental to access because beneficiaries might select a plan based on the advertised in-network provider directory.

Purpose/Research Question: This study identifies the prevalence and characterizes specialty mental health ghost networks and providers in Medicare Advantage.

Methods: We used 2019 county-level MA Enrollment data from CMS, specialty mental health taxonomy codes, and provider network data from Ideon to identify all “in-network” specialty mental health providers, by plan and county, in individual market HMO and PPO plans as advertised in MA provider directories. We compared the advertised networks of providers to billing providers (at the county-plan level) from the MA Encounter files to identify the “realized network” of specialty mental health providers. The size of the ghost network, by county, for each plan was calculated as the percentage of advertised in-network providers who did not bill at least
11 encounters in the calendar year. This threshold was necessary because cell sizes below 11 are masked in the Encounter file for privacy reasons. We use descriptive statistics to explore differences between ghost and billing providers.

Results/Findings: There were 155,928 unique specialty mental health providers listed in MA directories across 2,008 counties in 2019. Among these providers, 37,833 (24.3%) billed for at least 11 visits. More than 3 in 4 (75.7%) of mental health providers listed in MA provider directories were inactive across all MA plans. The average size of a plan's specialty mental health "ghost network" was 49.0%, meaning nearly half of all in-network providers in a plan-county network billed no or low (<11 encounters) visits to that plan in the calendar year. The average specialty mental health provider was in-network for 5.9 plans, and the average network contained 59.6 specialty mental health providers.

Conclusion/Implications: Mental health care is a critical need in the Medicare population, yet barely half of specialty mental health providers advertised as in-network for MA plans were actively billing. Enhanced oversight and enforcement of network adequacy requirements, including proportions of "ghost networks", are critical for transparency in MA and addressing barriers to mental health care access.

Author

• Rachel Smith, University of Maryland
  Presenting Author