Hello and welcome!
First I want to introduce myself, I’m Gabriel Liranzo a Medicare Broker Manager for one of the largest health insurance companies in the U.S. I oversee over 700 independent sales agents that sell Medicare Advantage (MAPD) and Prescription Drug Plans (PDP) in the Atlanta, GA area. My role requires (between other things) that I train, motivate and educate independent agents in the world of MAPD and PDP products.
I’ve been in the insurance business for 11 years now and I started in one of the most important roles health insurance companies have, a customer service representative (CSR). I believe that is one of the most important roles because that is the first point of contact for most members with an insurance company. I’ve moved through several positions in my career and they include, CSR senior lead (oversaw a team of 20 CSR’s), broker support for individual under 65 products, account manager for small group commercial products to my current role as a Medicare broker manager. So you could say I’ve been around the block when it comes to health insurance.
I’m also a full time father of three and husband of one beautiful lady. If you want to know a little bit more about me you can click on my profile picture. Check back later if you want to check out our family blog.
Now that you know a little bit about me let’s get started.
Ask Gabe: Take one.
My first topic comes directly from the field, one of my agents reached out to me because one of her clients has lost part B coverage! She wants to know what she could do to help him. So join me as we address her question.
1. Can a Medicare Advantage member who’s lost part B coverage for non payment of their part B premium reinstate their MAPD plan on July 1st?
The short answer is no but there are some exceptions (e.g. LIS). But don’t stop reading just yet as there is more to it. Let’s discuss this particular scenario so you can understand the reason for my response.
This agents client became eligible for part A and B of Medicare last year in 2016 when he turned 65, at which time he enrolled into part B (part A was automatically added as it is in most cases). He didn’t qualify for Extra Help or Low Income Subsidy (LIS) because of his income. When he became Medicare eligible he also enrolled into an MAPD plan or part C, he was so happy with his decision that he went on a long trip. Unfortunately he didn’t elect to have his part B premium deducted out of his social security check and as you can imagine while traveling he forgot to pay his Medicare part B premium. Yikes!
What were the consequences? His insurer had to terminate his MAPD coverage. Why? Well in order to enroll and stay an MAPD plan one must have Medicare part A & B and since he lost the latter he got the ax.
When the client learned that he lost his coverage he called Medicare frantically trying to reactivate his part B coverage. In the end he was able to successfully do it during the Medicare General Election Period (January 1st – March 31st). The problem is that he now has to wait until July 1st for his part B coverage to begin. Which now leaves us with the question at hand.
Where to find the answer.
The best resource besides askgabe.blog is the Enrollment and Disenrollment Guidelines MAPD that the Center for Medicare and Medicaid Services (CMS) issues out every year. It’s a pretty big document but it contains very valuable information, it’s basically the rules that MA and or PDP insurers must follow regarding enrollment and terminations. If you are having trouble sleeping, give those guidelines a read and you’ll find yourself drifting away quickly.
To navigate the 280 plus page PDF document there are three options, first there is the clickable index, second is pressing [Control+F] to open a search box where you can type key words you want to find and lastly, the non-recommend third option, scrolling forever till you find what your looking for.
The first area in the index I would click on is 50.2 – Required Involuntary Disenrollment because here you’ll have the proof that an MA company must terminate a member when they lose entitlement to part A or B of Medicare. From there you can navigate to section 50.2.2 where it gives additional details. See screenshot below.
The guidance is clear but for added reference you can click on Exhibit 14 and see a model template of the letter our client received. It basically contains almost the same language as above except that it includes when their MAPD plan is to terminate, a contact option if they believe the information is wrong and a heads up on enrolling into a Prescription drug plan (part D) so as not to incur a permanent penalty for not having creditable prescription coverage.
It’s important to highlight that in this model letter it doesn’t say that one is able to enroll back into an MAPD plan once they can reinstate their part B coverage, if that was an option it would clearly state it. It’s true one can enroll back into an MAPD during a qualifying SEP or the Annual Enrollment Period (AEP). The problem is that reinstating part B effective July 1st after losing coverage for non premium payment isn’t a qualifying SEP. There is an SEP for those that are enrolling into part B for the first time during the General Election Period but that’s not the scenario we are working with.
This bring us to the next question.
Is there anything we could do to help this beneficiary?
The short answer is yes. Since he lost creditable prescription coverage he is eligible to enroll into a PDP plan but he must do it within two months after his MAPD plans termination. How do I know that? For that I had to reference another SEP listed on a separate Enrollment and Disenrollment Guidelines specifically for PDP plans. It’s found in the same area you would find the one for MAPD plans, here is a link to make your life easier: Enrollment and Disenrollment Guidelines for PDP. Page 34 of this guidelines we will find the following SEP:
So while it may not be the solution we were hoping for, this does help the beneficiary get back his prescription coverage and avoid any permanent part D late enrollment penalties. So where does that leave us in regards to this client? Unfortunately he will have to wait until the AEP to enroll back into an MAPD plan effective 1/1/18. In the meantime he will have Part A and a prescription drug plan (if he used the SEP above) through June. Then come July he’ll have part B and will continue to have it until the end of the year.
Alternative SEPs worth looking into.
As I previously stated the Medicare beneficiary in our scenario didn’t quality for any SEP that would give him a break. But one should always check if one applies. On the E & D Guidelines there are several SEPs that could have granted enrollment into an MAPD plan effective July 1st, some include:
- Low Income Subsidy – as long as one has Extra Help to pay for prescriptions they can enroll into an MAPD/PDP plan every month
- Dual Eligibility, if one is eligible for Medicaid they also have a continual SEP
SEP for Enrollment Into a Chronic Care SNP plan – if beneficiary is eligible for a chronic plan they’ll have a one time SEP to enroll
Less likely SEPs could include:
- Change in residency, a beneficiary moves to a new county where they are now eligible for new plans or where their current plan is not available
SEP to Enroll in an MA Plan, PDP or Cost Plan With a Plan Performance Rating of Five (5) Stars
The Medigap or Supplement route
If Medicare beneficiary doesn’t qualify for any SEP to enroll him during July 1st, he does have the option to enroll into a supplement plan. Note that they’ll be subject to the underwriting requirements but for many it’s a very viable option and definitely better than just Original Medicare.
So the moral of the story is, don’t forget to pay your part B premium otherwise you may have to contend with less than favorable health plan choices.