Options available for loss of Medicare Advantage plan coverage

Published Apr 30, 2017 at 9:00am

It has recently been reported in local media that at least one major group of physicians in Oneida County will not be accepting two major Medicare Advantage plans.

Nationally, the popularity of Medicare Advantage plans has increased dramatically.

According to the Kaiser Family Foundation, since 2004 the number of beneficiaries enrolled in private plans has more than tripled from 5.3 million to 17.6 million in 2016. And, with this increased popularity has come increased problems for patients, providers and insurance companies.

Many patients now face the dual problem of physicians dropping out of insurance plan networks and insurance companies dropping physicians.

This loss of network coverage is a problem that first began to receive wide public attention in 2013.

This article will address three questions:

• First, why are physicians leaving plans?

• Second, why are plans dropping physicians? And

• Finally, what can or should we, as consumers, do when we find our physician is no longer part of our Medicare Advantage plan network of providers?

Why are physiciansleaving plans?

As US News has reported, it is not uncommon for doctors to leave and enter insurance networks. As professionals, with families, children in college and older parents to support, they make work decisions just like the rest of us. They decide to retire (my internist took early retirement last year), they join another practice, relocate to another city or decide that, for a variety of reasons, they can no longer work with your insurance company.  

A few physicians do not participate in Medicare for political reasons. With approximately 5,000 members, the American Association of Physicians and Surgeons (AAPS) recommends that their members not participate in Medicare.The AAPS was founded in 1943 to “fight socialized medicine and to fight the government takeover of medicine.” On the other hand, the American Medical Association was founded in 1847 and has approximately 225,000 members. The AMA has generally been very supportive of Medicare and lobbied Congress for the passage of both Medicare Part D and Affordable Care Act.

Why do insurancecompanies drop physicians?

It is difficult to determine why insurance companies drop particular physician practices from their networks. They are generally only required to give notice, usually 90 days, that they are making the change. There are clauses written into all the contracts between Medicare Advantage plans and the providers in their network that stipulate under what conditions they can make these types of changes. Keep in mind that Medicare Advantage plans are very large. Making a decision to drop 1000 physicians or 10,000 consumers represents a very small fractional change to their total service network.

As a consumer, what options are available?

Medicare Advantage plan beneficiaries who find that their physician is no longer accepting their plan can:

Switch plans during the Annual Open Enrolment Period: If your doctor is no longer part of your Medicare Advantage plan’s network, you can switch Advantage plans during the next annual Open Enrollment Period (generally Oct. 15 through Dec. 7). If your doctor is no longer in any Medicare Advantage plan, or only participates in one that does not fit your needs, you have the option of returning to Original Medicare. If you make this change, you will also need to enroll in a stand-along Medicare Part D drug plan.

• Disenroll from your Medicare Advantage plan and return to Original Medicare during a special enrollment period.

If your doctor is no longer in the provider network for any Medicare Advantage plan (but is still accepting Medicare), you may decide to go back to Original Medicare in order to continue seeing him or her. If you decide to do this after Dec. 7 you can disenroll from your plan during the Medicare Advantage Disenrollment Period (Jan. 1 through Feb. 14). You can also use this disenrollment period to enroll in a stand-alone Medicare Prescription Drug plan.

• Switch plans during a Special Enrolment Period: In some situations, you may qualify to change plans during what is known as a Special Enrollment Period (SEP). These periods have been created to accommodate enrollees who find their plan no longer works for them for a number of reasons, include the following: (1) your Medicare Advantage plan does not renew its plan contract or reduces its service area during the year, (2) violates its contract with Center for Medicare and Medicaid Services (CMS) or (3) CMS terminates your Medicare Advantage plan’s contract as a result of misconduct or other problems.

In the cases listed above, or in others not noted, CMS may decide that the change in your provider network was significant enough to warrant a Special Election Period (SEP). I asked June Hanrahan, senior administrative assistant with the Oneida County Office for the Aging/Continuing Care (OFA) for some clarification.

One of her main tasks is to manage the HIICAP program. According to Hanrahan, “The state Office for the Aging is saying that an SEP is not available because your doctor or medical group that is dropping the insurance plan and it is not the company that is dropping the patients. We have assisted in the referral of several consumes in applying for a special circumstance to Medicare to change plans due to a health issue or life threatening condition. One request was approved and we are for a waiting for a decision on another case.”

• Who do I contact in Oneida County for help with my Medicare Advantage plan? The Oneida County Office for the Aging/Continuing Care/NY Connects Health Insurance Information, Counseling and Assistance program (HIICAP) offices provide their services at no cost to Medicare beneficiaries. HIICAP offices are found at the following locations:

• Ava Dorfman Senior Citizens Civic Center, 305 E. Locust St., with hours of operation on Tuesday and Thursday from 10 a.m. to 2 p.m. Again, while consumers are seen on a “first come, first served” basis you may call the Dorfman Center at 315-337-1648 to see if there are long wait times.

• North Utica Senior Citizens Community Center, 50 Riverside Drive, Utica with hours of operation on Monday, Wednesday and Friday from 10 a.m. to 2 p.m. Consumers are counseled on a “first come, first served” basis. However, if you want to call ahead to see how busy the office is you may call the Center’s HIICAP program at 315-724-8680.

• HIICAP services are provided by Oneida County Office for Aging and Continuing Care/NY Connects. Anyone with questions about HIICAP, including issues with your Medicare Advantage Plan, should call the program directly at 315-798-5456 and press 4 in the choice list. It will direct you to someone who can assist you.

Dr. William Lane is the owner of William Lane Associates, a gerontological firm which located in Homer, NY. He writes a monthly column on HIICAP related issues for the OFA. Dr. Lane does not sell insurance, work for any insurance company or recommend any insurance products.