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!
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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!