Little Known Rule Allows Some Seniors to Change Medicare Advantage Plans When Plans Drop Their Doctors

May 4, 2016

Medicare Advantage plans are an attractive alternative to original Medicare or original Medicare plus private supplemental Medicare plans for some seniors. However, Medicare Advantage plans have some limitations. While the plans can drop care providers and providers can drop out of plans anytime they want, in the past seniors were allowed to change plans just once a year, with some exceptions. This meant some seniors had to change doctors to continue receiving care.

However, in 2013, the Centers for Medicare and Medicaid Services (CMS) issued rules giving Medicare Advantage plan members a “special enrollment period” based on what the CMS called a “significant” change in their provider networks. The rules went into effect last year and so far, CMS has allowed more than 15,000 people to change plans based on changes in their providers.

But two obstacles stand in the way of more seniors taking advantage of the option. First, CMS is not publicizing the benefit, so many members don’t know about it. Second, CMS has not clarified what it means by a “significant” change.

In a recent article in Kaiser Health News, Medicare Deputy Administrator Sean Cavanaugh offered an explanation for what CMS looks for in granting special enrollment periods: “What we’re looking for is whether their selection of a plan was based on a network and the presence of certain physicians and that their [the plan member’s] selection would’ve been different.”

Cavanaugh further advised members to call CMS’ help line, 800-Medicare, to request permission to leave their plans because they lost their doctors. But he cautioned that members are being allowed to switch plans only “in rare situations.”

Still, for employers with retirees who currently have Medicare Advantage plans or are considering one, the new rule is important to know about: it could provide a pathway for retirees to maintain their long-standing relationships with their care providers.

To read the complete article in Kaiser Health News, click here.

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