Medicare Advantage Disenrollment: Don't Get Trapped
by Barbara Parrott McGinity, LMSW
As a result of the Medicare Modernization Act of 2003, there has been a significant increase in Medicare Advantage (MA) plans and a systematic push to market these plans to Medicare beneficiaries. This has led to a great deal of confusion and countless incidents of abuses in the marketing and sales of these plans by their sponsors and by their contracted agents, which in the state of Texas, have to be licensed insurance agents.
Market violations usually include misleading information or questionable sales tactics. In most cases we hear about, the agent has used a telemarketing firm to set up an appointment and too often these people lead the beneficiary to think that someone who actually works for Medicare is coming to see them. Once in the door, the agents give misleading information or fail to fully explain the terms and conditions of the plan. In some cases, the agents have even forged the names on the applications and many do not even realize they have been enrolled in a plan.
Examples of abuses include: 1) telling beneficiaries that there is no premium for a plan, when in fact there is a substantial monthly premium; 2) promising that you can go to any doctor when in fact, their current doctor may not accept that insurance plan; 3) enrolling individuals who have language barriers or cognitive impairments; 4) not explaining in detail that the MA plan replaces their Medicare; and 5) failing to make sure the beneficiary has the time to fully understand the consequences of their enrollment.
As beneficiaries began to realize they were either duped into enrolling or they were not provided adequate information when they did enroll, they and their advocates began to alert Congress about the problems with MA marketing. This resulted in a Senate hearing and new action by the Center for Medicare and Medicaid Services (CMS). During the summer, some plans voluntarily removed themselves from the market until they could get their house in order. CMS also began to look at their rules regarding disenrollment.
Normally, once you are enrolled in a plan, you are locked into that plan until the enrollment period of January 1 to March 31 ends. With the large number of complaints and problems, CMS has allowed those beneficiaries who felt they were mislead to be disenrolled from the plan and moved back to traditional Medicare. But problems still persist.
It can take months for the Medicare computers to identify a beneficiary as disenrolled from a plan. This can result in unpaid medical bills, and the beneficiary may start to receive debt collection notices. Healthcare providers have problems billing Medicare because their claims get denied because CMS reports the beneficiary as being in a plan, but the plan has dropped them and is not paying the provider either.
Even when beneficiaries are successful in obtaining a disenrollment or retroactive disenrollment from an MA plan they can still face a host of other problems. For example, an individual enrolled in an HMO who obtains medical care from non-network providers will have to contact each provider and ask that they bill traditional Medicare for the services they received while enrolled in the MA plan. Also, individuals who dropped their Medigap policies when they enrolled in an MA plan may be able to get their Medigap plan back, but they will be responsible for any coinsurance or deductible that they incurred during the period of MA enrollment.
While CMS has provided beneficiaries who are unfairly trapped in an MA plan through misleading or deceptive sales practices, an avenue to return to traditional Medicare, the burden to navigate these waters is left up to the beneficiary alone. It is important that individuals who work with this population familiarize themselves with these issues so they can provide the assistance and support beneficiaries need to resolve issues around their Medicare coverage.
Barbara Parrott McGinity, LMSW
Program Director
Better Business Bureau Education Foundation
