The Medicare Advantage program covers 16 million seniors and provides alternatives to government-based Medicare programs. Under Medicare Advantage, patients can only receive medical care from provider networks
that are contracted to participate in the plan, and must stay with the plan for the remainder of the calendar year, even if they can no longer see their physician because they are no longer under contract with their Medicare Advantage insurance company.
In 2013, Connecticut’s Medicare Advantage plans took a huge hit when UnitedHealthcare, the insurance company, cut Connecticut 2,200 physicians from its health care provider list. As a result, Connecticut patients were forced to leave the doctors who had provided them with services for years, and were also simultaneously unable to switch to another plan, and thus could not return to more traditional Medicare plan options. In response to the turmoil that has been caused by forcing Medicare Advantage seniors to stay in the plan, the government has announced that it will offer some senior patients the option to leave their existing plans if their insurance no longer covers their physician or health care providers.
The Medicare Advantage Special Enrollment Period Option
In 2013, thousands of seniors in Connecticut and nine other states were either assigned new doctors or left without a medical care professional after insurers such as UnitedHealthcare discontinued contracts with certain physicians. In response, Connecticut seniors spoke out at local community gatherings, including one held by the Fairfield County, Connecticut Medical Association, where it was revealed that: “they were being forced to leave their doctors, and there wasn’t anything they could do about it…they couldn’t go to another plan, and they couldn’t go back to traditional Medicare.”
In response, the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health and Human Services, will allow for a special enrollment period in order to change the situations facing senior Medicare Advantage plan members. Medicare officials will be able to allow a specialized three-month enrollment period following network changes. However such a period is allowed only when the network change is “considered significant based on the effect on or potential to affect current plan enrollees.” If such a three-month enrollment period is allowed, patients could exit their existing Medicare Advantage plan and either join another similar plan or a traditional Medicare plan that includes the physician with whom they would like to stay.
The concern is that it is unclear what would be considered “significant” enough to warrant a special three-month enrollment period. A Medicare spokesperson stated that the CMS will make case-by-case determinations when deciding whether to allow special enrollment periods. Such determinations should be based on factors such as the amount of beneficiaries that are being affected, the service area size of the Medicare Advantage plan, and whether timely and adequate advance notice was received, in addition to other factors. However, it remains unclear if there is a minimum amount of beneficiaries, services areas or providers that must be affected in order to warrant a special enrollment period.
Many Medicare members from Connecticut and beyond would like the CMS to allow for special enrollment provisions in situations such as the one facing UnitedHealthcare insurance members. However, the granting of such periods is completely within the discretion of the CMS, and individual beneficiaries who are dealing with a physician no longer being covered by their Medicare Advantage cannot request that a special enrollment period be granted on their behalf. If you need advice on any Medicare or Medicaid-related legal issues, contact the experienced Fairfield County elder law attorneys here at our law firm today.