Medicare Advantage plans have long since been a viable alternative to traditional Medicare. However, a key point to remember is that you only have coverage for services offered by the hospitals, doctors, and other providers within your insurer’s network.
While you may understand this rule, you might not be aware that your provider can drop out of the plan at any time. In contrast, you have to wait for the annual sign-up period each fall. There are exceptions, but for a long time, losing your provider wasn’t one. As a result, if your doctor left Medicare Advantage, you would need to find a new provider until the sign-up period.
A Little Known Change
If you had the same doctor for decades and he suddenly left your Medicare Advantage program, the natural reaction would be to panic. Fortunately, the Centers for Medicare and Medicaid Services (CMS) created new rules to help Medicare Advantage members. These rules came into effect in 2015.
If there is a significant change in your provider network, you can avail of a “special enrollment period” where you may switch plans or go back to regular Medicare. This new window lasts for three months after your provider network changes. Incidentally, this change only relates to Medicare Advantage members.
The rule change occurred because of a cull of providers by Medicare Advantage insurers in 2013. As a result, thousands of seniors across at least 10 different states were without their favored doctor.
You would expect such a major new rule to be widely known across the healthcare landscape, but there seems to be almost an element of secrecy attached. According to a Medicare spokesperson, decisions regarding the special enrollment period are on a case-by-case basis. It appears as if the main criteria include the amount of people affected, the size of the service plan area, the date of the provider terminations, and whether affected beneficiaries receive adequate notice.
Unfortunately, the spokesperson was less forthcoming when it came to specifics, such as the actual number of beneficiaries that would need to suffer effects in order for the new rules to come into play. As a result, we can only look at instances where the special enrollment period was granted to gain clues. Tens of thousands of Medicare Advantage beneficiaries have received the special enrollment period to date. Here are a few examples:
- 3 percent of members in a New West Health Services plan in Montana lost their provider and received the special enrollment period.
- 5 percent of members of a PMC Medicare Choice plan in Puerto Rico also benefited after losing their provider.
We hope that Medicare comes to its senses and stops being vague about the criteria for the special enrollment period. Suddenly losing a doctor you’ve trusted for a very long time is worrying. This new rule can alleviate a lot of stress for Medicare Advantage beneficiaries in this situation. Publicizing it can ensure seniors don’t have to suffer unnecessary burden.