Hey Medicare Nation!
Over 17.5 Million of you are on a Medicare Advantage plan. And many of you have been, or know of a situation where your doctor has left the “network” and you are told by your Medicare Advantage Plan Carrier that you must find a new doctor. You tell your Medicare Advantage Plan carrier that you would like to change plans to keep your doctor, and they will tell you something that goes like this….”I’m sorry, you are unable to change plans mid-year. You will have to wait until the Annual Enrollment Period occurs to change plans, unless you have a special election. So….you’ll need to change doctors at this time.”
Well…..on today’s show, I’m going to discuss a “special election (SEP),” called – “Significant Network Change,” that many, many Insurance Agents don’t even know about.
Revisions were made to the Medicare Managed Care Manual, which went into effect on April 22, 2016.
The Significant Network Change Special Election Period, as written in the Medicare Managed Care Manual is listed as:
“Pursuant to 42 CFR § 422.62(b)(4), enrollees who meet the exceptional conditions of being substantially affected by a significant no-cause provider network termination may be afforded a special election period (SEP). If CMS determines that an MAO’s network change is significant with substantial enrollee impact, then a “significant network change SEP” may be warranted. CMS will use a variety of criteria for making this determination, such as:
(1) the number of enrollees affected;
(2) the size of the service area affected;
(3) the timing of the termination;
(4) whether adequate and timely notice is provided to enrollees,
(5) and any other information that may be relevant to the particular circumstance(s).
The Medicare Advantage Organization will be required to notify eligible enrollees of the significant network change SEP if the SEP is granted by CMS. SEPs will not be granted when MAOs make changes to their network that are effective on January 1 of the following contract year, as long as affected enrollees are notified of the changes prior to the AEP.
According to the rules, if a Medicare Insurance Carrier makes a “significant change” to one of their Medicare Advantage plan’s networks, that plan’s beneficiaries could possibly be granted a Special Election Period. This provider network change SEP allows beneficiaries “three months” to switch to traditional Medicare, with or without a stand-alone Prescription Drug Plan, or switch to a different Medicare Advantage plan, with or without Part D coverage. Whether or not beneficiaries qualify for this SEP is entirely up to CMS.
CMS states in the Medicare Managed Care Manual that they may grant a provider network change SEP to beneficiaries based on some of the following factors:
So…..if you have lost your primary care doctor, due to a non-cause termination in your Medicare Advantage Network, and it has caused you a “significant change” to your healthcare due to your doctor’s termination from the network, call Medicare and fight for this SEP!
If Medicare denies your request for a SEP and you honestly feel you qualify under one or more of the criteria stated……. Call me and hire me to contact Medicare on your behalf!
I have listed other Special Enrollment instances when you can make changes to your Medicare Advantage Plan outside of the Annual Enrollment Period.
For a complete list, go to www.Medicare.gov
TRADITIONAL MEDICARE SPECIAL ENROLLMENT PERIOD
Here’s quick guide to when you can make changes to your Medicare Advantage Plan:
You can make your initial selection of a Medicare Advantage Plan when you enroll in Medicare at age 65.
The Special Election Period that qualifies you to change your Medicare Advantage Plan, is what we want to focus on today. There are certain circumstances which allow you to qualify for this option.
If You Move
When there are plan changes with Medicare Contracts:
If you have a chronic illness, cancer, cardiovascular disease or other medical conditions, a Medicare Supplement (MediGap) plan does not have to enroll you after your first year of enrollment. You need to be careful and make sure you are going to be able to get coverage when you change plans. The Medicare Supplement carrier may not take you due to pre-existing conditions and once you drop your Medicare Advantage Plan, you may be "locked out" and not able to re-enroll until the next open enrollment period..Medicare Supplement Carriers can discriminate due to pre-existing conditions!
The price of Medicare Supplement plans do change as you age, and where you live. Keep that in mind.
Need more information on "Special Enrollment Periods?"
See the entire list at www.Medicare.gov
Do you have questions or feedback? I’d love to hear it!
I may answer one of your questions on the air!
Thank you for listening! If you enjoyed this podcast, please subscribe and leave a 5 star rating and review in iTunes! (Click here)
Find out more information about Medicare on Diane Daniel’s website!