Hey Medicare Nation!
How many of you have just found out your Doctor is leaving the Medicare Advantage Network you're in?
I'm certain there are "Thousands of you."
That is the #1 complaint I receive from clients, is that their "Doctor" is leaving or has left their Medicare Advantage Plan (MAPD) Network.
Medicare has regulations about how a Medicare Advantage Organization (MAO) can "terminate" a Doctor contracted in their network and in reverse, there are regulations on how a Doctor can leave a MAO.
There are also regulations on how a MAO publishes it's "Provider Directory" for their network.
Chapter 4, Section 110.1.1 of the Medicare Managed Care Manual, titled, Provider Network Standards, lists in part....
"MAO's are required to establish and maintain provider networks that:
...... Are accurately reflected in up-to-date directories. Plans are responsible for verifying and regularly updating their network directories to ensure that providers included in the directories are available to their enrollees (ie, listed providers accept new patients who are enrolled in the plan).
In section 110.2.2 labeled Provider Directory Updates, it states in part:
....MAO's must include information regarding all contracted network providers in directories at the time of enrollment. Directories must include information about the number, mix, and distribution of all network providers. MAO's may have separate directories for each geographic area they serve (e.g. metropolitan areas, surrounding county areas), provided that all directories together cover the entire service area.
Provider Directories must be updated anytime the MAO becomes aware of changes. They have 30 days to update the changes or be non-compliant.
When there is a change to the provider network (a provider is terminated or the provider is leaving the network), The MAO "must make a good faith effort to provide a written notice of a termination of a contracted provider at least 30 calendar days before the termination effective date to all enrollees who are patients seen on a regular basis by the provider whose contract is terminating."
In regards to termination of "Primary Care Physicians," all enrollees who are patients of that primary care professional must be notified."
So.....what's being done about all the inaccuracies to provider directories?
CMS conducted it's first review of 54 Medicare Advantage Organizations (MAO's) online provider directories, between February and August of 2016.
The finding......45% of provider directory locations listed in these online directories were inaccurate!
About one-third of all MAO's with 5,832 providers were reviewed in total.
Twenty-One MAO's received warning letters from CMS around January 6th, and they have 30 days to fix the errors or face possible fines or sanctions, which could include suspending marketing and enrollment of medicare beneficiaries.
Here are the Medicare Advantage Plans that received warning letters from CMS to immediately fix the errors in their provider directories.
Blue Cross & Blue Shield of Rhode Island - RI
Rhode IslandBlue Cross Blue Shield of Michigan - FL MI, MO WI
Catholic Health Partners - IA,KY, MI, OH
CIGNA - IL, IA
Community Health Plan of Washington - WA
Emblem Health Inc. - CT, NY, RI
Fallon Community Health - MA
Gateway Health Plan, LP - OH, PA, WV
Health Partners Plans, Inc. - PA
Highmark Health - PA
Humana Inc. - WI
Indiana University Health - IA
Magellan Health Inc. - NY
Moda, Inc. AK, ID, MT, NM, OR, WA
Molina Healthcare, Inc. - UT
Piedmont Community Health Plan - VA
Premera - WA
Samaritan Health Services - OR
SCAN Health Plan - CA
UnitedHealth Group, Inc. - CO
Wellcare Health Plans - IL
Now.... if you are a member of one of these MAO plans that received a "warning letter," you may qualify for a "Special Enrollment Period," from Medicare.
What should you do?........
1. Call Medicare - 800-633-4227
2. Tell the Medicare employee that you are a member of the ________ Medicare Advantage Plan, that received a "Warning Letter" from CMS for non-compliance of their provider directory.
3. State (if it's true!) that you were not notified by your physician or the MAO of the termination of your doctor, and your directory wasn't updated.
4. VERY IMPORTANT TO STATE.....
Tell the Medicare employee you RELY on the directory to locate an in-network provider, and by the Medicare Advantage Plan & the Doctor NOT informing you that he/she was LEAVING the network, it caused a SIGNIFICANT access to care barrier for you!
Because now...... You can't see your doctor who has taken such good care of you..... due to the error.
5. Ask for a Special Election Period, so that you can choose a Medicare Advantage Plan where your Doctor is in-network.
6. If they grant you the Special Election Period, tell the Medicare employee which Medicare Advantage Plan you want to be on.
7. If they say "NO," Thank the Medicare Representative for their help and say goodbye.
What do you do now????
See if you qualify for a different Special Election Period. Listen to my earlier episode on SEP's.
Listen to Last Friday's episode on 5 STAR Plans.
Listen to the episode on the Medicare Advantage Disenrollment Period. It also includes information on Special Need Plans.
If NONE of these ideas offer you the opportunity to change your Medicare Advantage Plan to a better option, than you will have to remain on the Medicare Advantage Plan you are on until the Annual Enrollment Period to change plans.
Do your Due Dilligence Nation!
Don't enroll in another Medicare Advantage Plan.... just because the doctor who is leaving the network is on that one!
Make sure the plan will fit your Medical, financial and prescription needs for 2017!
Share Medicare Nation with someone!
Teach your parents, your grandparents how to access this podcast! Buy them a smartphone.
The more they know, the less they will ask you for help.
It's not easy being the "Sandwich Generation."
So...... do yourself and your parents a favor and help them listen to Medicare Nation!
Hey Medicare Nation!
Medicare has announced the 2017 "5 Star Plans."
What are 5 Star Plans?
Medicare rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star ratings will help you understand the job a plan is doing.
There are 2 main types of Star Ratings:
1. Overall Star Rating that combines all of the plan's scores.
2. A Summary Star Rating that focuses on a plan's medical or prescription drug services.
A few areas Medicare reviews for these Star Ratings include:
1. How plan members rate their plan's services and care.
2. How well a plan's network of doctors detect illnesses and keep members healthy.
3. How well a plan helps it's members use recommended and safe prescription medications.
A plan can receive a 1 to 5 Star Rating.
5 Stars is Excellent
4 Stars is above average
3 Stars is average
2. Stars is below average
and 1 Star is poor.
You can only switch to a 5 Star Rating Medicare Advantage Plan or a 5 Star Stand-alone Prescription Drug Plan, that is available in your area.
You can only switch to a 5 Star Medicare Advantage Plan, Medicare Cost Plan or Medicare Prescription Drug Plan once from December 8th to November 30th of the next year.
Once you use your election to enroll in a 5 Star Plan, you cannot use it again.
If a Medicare Advantage Plan or a Stand-Alone Prescription Drug Plan has received a 5 Star Rating from Medicare, it doesnot mean you automatically go out and enroll in the 5 Star Plan.
That 5 Star Plan may not fit your unique needs!
The option is available..... if you need it!
Some people enroll in a Medicare Advantage Plan during the Annual Enrollment Period, and only switched plans because they received an incentive from the new plan.
Ex: Your neighbor "Phil" tells you he is on the greatest Medicare Advantage Plan. He receives $30 in "Bandaids" from his plan every month. He tells you to "switch" plans so you can get $30 worth of over-the-counter supplies every month. Phil hands you his "Agent's" card.
You call Phil's "Agent," who gladly comes out and enrolls you into the same exact plan that Phil has. The plan goes into effect January 1st. You call your Primary Doctor on February 6th for an appointment because you think you have the flu.
The secretary advises you that Dr. Jones does not accept the new plan your on. What? You didn't check to see if your Primary Doctor accepts the new plan? Phil's "Agent" didn't check to see if your Primary Doctor was in the new plan's network?
Sorry......you should have done your due diligence. Now you will have to "remain" on this plan until the next Annual Enrollment Period. You are "locked-in," until October 15th.
Maybe you were better off on the plan you originally were on.
In this example, you may have another option!
You find out in January, that XYZ Medicare Advantage Plan has a 5 Star Rating in your area. You can look up the XYZ Plans and determine if one of their plans accepts your Primary Doctor in their network. Check the co-pays, co-insurance and deductibles on the new plan. Check that all your prescription drugs are in the new 5 Star Plan's formulary.
If you like what you found out about the 5 Star Rating Plan that is available in your area, you are allowed to "switch" one time from the Medicare Advantage Plan you are stuck on, to the 5 Star Rating Plan available in your area.
Once you make the election to switch to the 5 Star Plan, you cannot enroll into another plan - whether it has 5 Stars or not.
Only a criteria that fits a Special Election Period will be allowed.
Look on the www.Medicare.gov website for the list of Special Election Period examples.
The 14 Medicare advantage Plans that received "5 Star Ratings" for 2017 are:
Company Name Service Area
1. KS Plan Administrators, LLC - 4 Counties TX
2. Kaiser Found. HP, INC 31 Counties CA
3. Kaiser Found. HP of CO 17 Counties CO
4. Kaiser Found. of the Mid- D.C. & Atlantic States 11 Counties MD 9 Counties VA
5. Tufts Assoc. HMO 10 Counties MA
6. BCBS of MA HMO Blue 11 Counties MA
7. Group Health Plan (MN) 87 Counties MN 8 Counties WI
8. Aultcare Health Ins. Corp 12 Counties OH
9. Physicians Health Choice TX 19 Counties TX
10. Gundersen Health Plan 1 County IA, 8 Counties WI
11. Optimum Healthcare Inc. 25 Counties FL
12. Kaiser Found. HP of NW 9 Counties OR 4 Counties WA
13. Sierra Health & Life Ins. 1 County CO, 1 County KS, 2 Counties MA, 3 Counties MD. 1 County MI, 2 Counties NJ, 2 Counties PA, 2 Counties TX, 1 County in VA
If you live in the service area of the above 5 Star Rated Plans, you should go onto the Medicare.gov website and compare the 5 Star Plan to the Plan you are currently on. Make sure your doctors are in the network. Make sure ALL your prescription drugs are covered in the formulary. Look at the co-pays, co-insurance and any deductibles.
Make sure the "5 Star Plan," is worth "switching" too!
Just because it was given a 5 Star Rating from Medicare, doesn't mean the plan will automatically be the best choice for your unique needs.
Do your Due Diligence!
You can check the Medicare.gov site for any 5 Star Prescription Drug Plans in your service area and Medicare Advantage Plans that are health plans only and do not offer prescription drug coverage on that particular plan.
You can also listen to episode MN061. I give you information on the Medicare Advantage Disenrollment period and information on Special Need Plans.
You don't have to be "stuck" on a Medicare Advantage Plan that doesnot suit your needs.
This is the time of year to make changes. Make sure you switch to a better plan this time!
Send them to Support@TheMedicareNation.com
Thanks for listening to Medicare Nation.
If you like the information that is provided, give us a 5 Star Review on iTunes!
The more reviews we get, the more exposure iTunes will give Medicare Nation, and that means more people will be able to find the show.
Have a happy, peaceful & prosperous week!
Hello Medicare Nation! Happy New Year to everyone.
I hope everyone had a wonderful holiday season.
The Annual Enrollment Period is over. I hope each of you did your due diligence in deciding which plan will fit you best for 2017.
I have many episodes available for you to learn all about Medicare Advantage Plans, Original Medicare and Part D of Medicare.
If you determine the Medicare Advantage Plan you are on is not suitable for you or a loved one in 2017, you may have other options available to you.
Right now, you are in the Medicare Advantage Disenrollment Period. It started on December 8th and will end on February 14th of 2017.
Here is how you "dis-enroll" from a Medicare Advantage Plan during this time period.
1. Call Medicare 800-633-4227
2. Advise the Medicare Representative that you would like to "dis-enroll" from your current Medicare Advantage Plan and go back onto Original Medicare.
3. You can enroll in a stand-alone Part D prescription drug plan.
4. You can also enroll in a Supplement to Original Medicare plan, that will assist you in paying your out of pocket costs for Part A & Part B.
Each Supplement to Original Medicare Plan (Plan A, Plan B, Plan C, Plan D, Plan F, Plan G, Plan J, Plan K, Plan L and Plan N.) cover different out of pocket Medicare costs. Research each one prior to enrolling in the Supplement plan to determine the plan that will fit your health & financial needs for 2017.
If you find it difficult to figure out if Original Medicare and enrolling in a Part D and/or a Supplement to Original Medicare Plan is right for you, contact me at either -
Go to my website..... www.CallSamm.com and tell me in the "Contact Me" how I can assist you.
SPECIAL NEED PLANS
Are you a Diabetic? Do you have COPD? Do you have Cardiovascular Disease?
If you answered "yes" to any of these questions, you may be eligible to enroll in a special needs plan.
A special needs plan is a Medicare Advantage Plan. If you are diagnosed with any of the conditions I listed above, you may use a special election to change to a special needs plan one time during the year.
How do you determine if you have Special Need Plans in your area?
Go to www.medicare.gov and click on the "find health and drug plans." The database will take you through several screens and you should select "special needs plan," when you advise Medicare what type of plan you are on.
The database will provide you with the special need plans in your area.
You can also look under special election periods, to determine if you have a qualified reason to change.
If you like Medicare Nation, please give us a 5 Star Review on iTunes!
When you leave us a great review, iTunes gives Medicare Nation more exposure. More exposure means individuals who need advise about Medicare will find the show!
I appreciate you listening to Medicare Nation!
Have a happy, healthy & prosperous week!