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Why Do People Leave Medicare Advantage

Why Do Some People Leave Medicare Advantage?

Although most people still choose Original Medicare to receive their benefits, Medicare Advantage (MA) plan enrollment keeps climbing. According to the Kaiser Family Foundation, around 20.4 million people chose an MA plan in 2018. That’s a little more than one-third of all Medicare beneficiaries. Of course, some enrollees leave Medicare Advantage. This article looks at which enrollees are more likely to leave their MA plan and what happens next.

Who Is Most Likely to Leave a Medicare Advantage Plan?

Early in 2019, the Journal of the American Medical Association (JAMA) published its findings regarding what drives some people to disenroll from their Medicare Advantage plan. Their study included over 13.9 million people enrolled in an MA plan.

What JAMA discovered is that high-need enrollees and those who qualify for both Medicare and Medicaid (dual-eligible) were far more likely to leave Medicare Advantage for Original Medicare.

  • Of Medicare-only beneficiaries, 4.6 percent of high-need enrollees left compared to 3.3 percent of non-high-need
  • Of dual-eligible beneficiaries, 14.8 percent of high-need enrollees left compared to 4.6 percent of non-high-need

Those are overall numbers, but the discrepancies exist whether the members enrolled in a high-quality, 5-star plan or one with lower ratings. Although fewer members with multiple or complex health issues left their 5-star plan, they were still more likely to leave.

Next, JAMA looked at why.

Why Do High-Need Enrollees Leave Medicare Advantage?

Analysis of JAMA’s findings suggests that provider networks and plan restrictions are the main reason high-need enrollees leave their MA plan. This is particularly true for plans with limited provider networks. In addition, plan restrictions like prior authorization or referrals to see a specialist often present difficulties for high-need enrollees’ complex healthcare needs.

Restrictions make it difficult to receive the care you need

Under Original Medicare, beneficiaries may choose any provider who accepts Medicare. This makes managing chronic conditions simpler.

Why Do Dual-Eligible Enrollees Leave Medicare Advantage?

According to the experts, lower income beneficiaries are more likely to have significant healthcare costs. This is due in part to a greater tendency to neglect preventive care. For example, annual wellness exams and screenings help detect issues early. Treatment is easier and more likely to be successful – and cheaper.

In addition, these enrollees are more likely to choose the plan with the cheapest monthly premium. And, unfortunately, these plans often have higher out-of-pocket costs in addition to greater restrictions.

When Can You Leave a Medicare Advantage Plan?

As you probably know, Medicare has specific enrollment periods. Annual Enrollment occurs every year from October 15 through December 7. During this period, anyone can make changes to their Medicare coverage. Medicare Advantage Open Enrollment runs from January 1 through March 31 and allows anyone enrolled in an MA plan to return to Original Medicare or choose a different plan.

In addition to these yearly enrollment periods, Medicare offers Special Enrollment Periods (SEP) for beneficiaries who meet certain requirements. There are literally dozens of special situations. For the full list, please refer to the SEP link above. We offer the following examples for beneficiaries who are simply unhappy with their MA plan.

Dual Eligibility

Beneficiaries who are eligible for both Medicare and Medicaid may leave their MA plan once during the following periods:

  • January – March
  • April – June
  • July – September

During this time, you may join, switch, or leave your MA or prescription drug plan. Changes take effect the following month. You may make a change once during each of the above windows.

Since Annual Enrollment begins October 15 and continues through December 7, giving all enrollees the opportunity to change their plans, this time period is not included for SEPs.

You Are No Longer Eligible for Medicaid

If you lose your Medicaid eligibility, you have 3 months to make one of the following changes:

  • Return to Original Medicare
  • Join an MA or Part D plan
  • Switch from your current MA or Part D plan to another
  • Drop your Part D plan

Your 3-month window opens on whichever date is later: when you became ineligible or received notification. So, if you became ineligible on April 2 but did not receive notification until April 10, your 3-month window begins on April 10 and ends July 10.

You Left a Medigap Policy

If you had a Medigap policy that you left in order to enroll in an MA plan, you may leave that plan if you meet the following conditions:

  • This is the first time you joined a Medicare Advantage plan
  • You leave the MA plan within 12 months of enrolling

If you meet both conditions, you may leave your MA plan for Original Medicare under the trial rights provision. In addition, you have the right to buy the same Medigap policy you had before you switched to MA (assuming the insurance company still offers it). This guaranteed issue right is only available for 123 days. This period begins 60 days before your MA coverage ends. It extends an additional 63 days after you leave the plan.

How to Avoid Choosing the Wrong Medicare Advantage Plan

We’ve talked before about the importance the Medicare Annual Enrollment Period and how to use it to make sure you get the best coverage for your needs. And the researchers at JAMA back us up. They say that one of the main reasons people end up leaving Medicare Advantage is that they failed to research their choice.

With so many factors to consider, it’s no wonder many people feel frustrated. That’s where the licensed agents at Medicare Solutions can help. We explain all of your options and help you choose the best coverage for your unique healthcare needs and budget. The best part? It won’t cost you a penny. Just call 855-350-8101 (TTY 711) to get started.

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