Help MAPD Experts!!!!!!!

[BuckNasty]

Hi guys... have a client that has been enrolled in a Medigap plan for a few years. Well, this December UHC suckered her into a MAPD because she called looking for Silver Sneakers.

They never advised her that she doesn't need both MAPD and a Medigap plan so she never cancelled her Medigap. Well, she goes for a mammogram or something, presents her UHC MAPD card and gets hit with a big bill. So here we are, with her wanting to get out of the MAPD that she has had since January 1st.

Let me reiterate that she still has her Medigap plan.

So she calls Medicare and asks about her one year trial right to go back to original Medicare A&B and the rep tells her she can go back but can't enroll in a drug plan until Oct 15.

I decided to call Medicare myself as it is my understanding that she can go back to A&B and should get an SEP to enroll in a Part D Plan.

The rep I spoke with (a disgustingly rude, steaming pile of ghetto trash with the horrendous attitude of someone having zero accountability & the inability to get fired) proceeded to look it up and read outloud that the SEP would only apply if she had DROPPED the Medigap policy, but since she never did, she wouldn't get the SEP.

This seems absurd. Can someone please weigh in here? Much obliged.

 

[goillini52]

Hi guys... have a client that has been enrolled in a Medigap plan for a few years. Well, this December UHC suckered her into a MAPD because she called looking for Silver Sneakers.

They never advised her that she doesn't need both MAPD and a Medigap plan so she never cancelled her Medigap. Well, she goes for a mammogram or something, presents her UHC MAPD card and gets hit with a big bill. So here we are, with her wanting to get out of the MAPD that she has had since January 1st.

Let me reiterate that she still has her Medigap plan.

So she calls Medicare and asks about her one year trial right to go back to original Medicare A&B and the rep tells her she can go back but can't enroll in a drug plan until Oct 15.

I decided to call Medicare myself as it is my understanding that she can go back to A&B and should get an SEP to enroll in a Part D Plan.

The rep I spoke with (a disgustingly rude, steaming pile of ghetto trash with the horrendous attitude of someone having zero accountability & the inability to get fired) proceeded to look it up and read outloud that the SEP would only apply if she had DROPPED the Medigap policy, but since she never did, she wouldn't get the SEP.

This seems absurd. Can someone please weigh in here? Much obliged.

Just sell her a PDP with the SEP, "In the last 12 months I left a Medigap policy to join a Medicare Advantage plan with prescription drug coverage for the first time." The PDP will automatically cancel the MAPD. Sounds like she's still got the Med Supp? Problem solved. I'd have her try refiling the claim after her MAPD has been cancelled.

Cigna Health's Med Supp has Silver Fit, which is similar to Silver Sneakers.

 

[TwoCents]

Let's get some technicalities out of the way. In Medicare Advantage lingo a cancellation is a transaction that removes coverage completely -- as if never enrolled. That's what you want here since she has services that she'd want Orig Medicare and her supp to pay.

A disenrollment has a start date of coverage and an end date. So even if you used goillini52's method and was able to get the PDP started for like 4/1 that would do nothing for the claims/services that have already taken place.

I wouldn't call Medicare back. I would use their online complaint form https://www.medicare.gov/MedicareComplaintForm/home.aspx to explain the situation and ask for a cancellation of the MA plan and a reinstatement effective 1/1/17 for her previous PDP.

 

[goillini52]

Let's get some technicalities out of the way. In Medicare Advantage lingo a cancellation is a transaction that removes coverage completely -- as if never enrolled. That's what you want here since she has services that she'd want Orig Medicare and her supp to pay.

A disenrollment has a start date of coverage and an end date. So even if you used goillini52's method and was able to get the PDP started for like 4/1 that would do nothing for the claims/services that have already taken place.

I wouldn't call Medicare back. I would use their online complaint form https://www.medicare.gov/MedicareComplaintForm/home.aspx to explain the situation and ask for a cancellation of the MA plan and a reinstatement effective 1/1/17 for her previous PDP.

The reason I suggested doing it the way I did, is because the way I understand it, she still has her Med Supp and having the PDP cancel the MAPD seemed like the easiest way. I've never personally ran into this situation, but if she's been paying on her Med Supp and it's still in force, shouldn't it cover that claim. Not sure about how Medicare would handle it.

 

[Cenla Agent]

Unless there is some kind of loophole that I don't know about, (which might include what Two Cents posted above) having the Medigap doesn't matter when it comes to the bill. She doesn't have Original Medicare anymore and the Medigap will only pay after Original Medicare pays. She's got an MA instead of Original Medicare, so the claims are submitted to the MA plan, not Original Medicare. And a Medigap isn't going to pay the "gaps" in an MAPD.

It is illegal to sell a MA plan to someone with a Medigap without the understanding that they will be dropping the supp, as a supp is of no benefit anymore. Of course, who is to say there wasn't that understanding unless it was a recorded call, etc.

Are you sure the provider billed the MA plan instead of Original Medicare? Unless it is a Medicare covered preventive service, she can expect a bill, but a "big" bill is in the eye of the beholder. Is it $200 or $2000? Usually it won't be more than 20% coinsurance.

If she can go back to Original Medicare, she should also be able to go back to a PDP.

I don't think I've ever come across a case where someone exercised their trial right and hadn't dropped the supp or at least intended to. That's the whole idea, at least with regard to those who understood what they were doing. But I have come across a good many people who were taken advantage of by agents and didn't know that they weren't going to have Original Medicare and their supp anymore. Most of the time, they won't report the agent to the DOI, and the DOI isn't interested in hearing one agent say another one is a crook.

The CMS rep may have been reading from page 23 in "Choosing a Medigap."

(Trial right) You dropped a Medigap policy to join a Medicare
Advantage Plan for the first time, you’ve been in the plan less than a year, and you want to switch back.

I don't know whether or not this language is the final word.

There is also the SEP where the member alleges that she was misled into enrolling into MA. But that also involves dropping medigap according to "Choosing a Medigap."

 

[TwoCents]

Unless there is some kind of loophole that I don't know about, (which might include what Two Cents posted above) having the Medigap doesn't matter when it comes to the bill. She doesn't have Original Medicare anymore and the Medigap will only pay after Original Medicare pays. She's got an MA instead of Original Medicare, so the claims are submitted to the MA plan, not Original Medicare. And a Medigap isn't going to pay the "gaps" in an MAPD.

It is illegal to sell a MA plan to someone with a Medigap without the understanding that they will be dropping the supp, as a supp is of no benefit anymore. Of course, who is to say there wasn't that understanding unless it was a recorded call, etc.

Are you sure the provider billed the MA plan instead of Original Medicare? Unless it is a Medicare covered preventive service, she can expect a bill, but a "big" bill is in the eye of the beholder. Is it $200 or $2000? Usually it won't be more than 20% coinsurance.

If she can go back to Original Medicare, she should also be able to go back to a PDP.

I don't think I've ever come across a case where someone exercised their trial right and hadn't dropped the supp or at least intended to. That's the whole idea, at least with regard to those who understood what they were doing. But I have come across a good many people who were taken advantage of by agents and didn't know that they weren't going to have Original Medicare and their supp anymore. Most of the time, they won't report the agent to the DOI, and the DOI isn't interested in hearing one agent say another one is a crook.

The CMS rep may have been reading from page 23 in "Choosing a Medigap."



I don't know whether or not this language is the final word.

There is also the SEP where the member alleges that she was misled into enrolling into MA. But that also involves dropping medigap according to "Choosing a Medigap."

As long as the MA is in force, Orig Medicare will reject any claim submitted to it. To get any kind of coverage claims would have to be filed to the MA and of course we all know it's pointless to have the MA and Medigap overlap as the Medigap won't pay anything since OM won't pay anything. Around and around she goes!

 

[yogooglethis]

Hi guys... have a client that has been enrolled in a Medigap plan for a few years. Well, this December UHC suckered her into a MAPD because she called looking for Silver Sneakers.

They never advised her that she doesn't need both MAPD and a Medigap plan so she never cancelled her Medigap. Well, she goes for a mammogram or something, presents her UHC MAPD card and gets hit with a big bill. So here we are, with her wanting to get out of the MAPD that she has had since January 1st.

Let me reiterate that she still has her Medigap plan.

So she calls Medicare and asks about her one year trial right to go back to original Medicare A&B and the rep tells her she can go back but can't enroll in a drug plan until Oct 15.

I decided to call Medicare myself as it is my understanding that she can go back to A&B and should get an SEP to enroll in a Part D Plan.

The rep I spoke with (a disgustingly rude, steaming pile of ghetto trash with the horrendous attitude of someone having zero accountability & the inability to get fired) proceeded to look it up and read outloud that the SEP would only apply if she had DROPPED the Medigap policy, but since she never did, she wouldn't get the SEP.

This seems absurd. Can someone please weigh in here? Much obliged.

why would an agent conceal the fact that a medigap is pointless if enrolled in MA -if anything it s the biggest selling point of MA vs. medigap. Every year after the AEP I get a phone call from at least 1 client I switched from medigap to ma, and who i specifically told they need to cancel their med supps as of 1/1 , wondering why they are still being billed for a med supp.IMO nothing in this scenario indicates the ma agent was misrepresenting anything.BTW if it was a preventive mammogram the copay is 0 on all ma plans so I would bet dollar to donuts the provider billed original medicare instead of the ma plan.


as far as getting off the the ma plan use a sep trial period part D enrollment- if this was there first enrollment in MA.The fact that she still has the med supp doesn't matter

 

[goillini52]

why would an agent conceal the fact that a medigap is pointless if enrolled in MA -if anything it s the biggest selling point of MA vs. medigap. Every year after the AEP I get a phone call from at least 1 client I switched from medigap to ma, and who i specifically told they need to cancel their med supps as of 1/1 , wondering why they are still being billed for a med supp.IMO nothing in this scenario indicates the ma agent was misrepresenting anything.BTW if it was a preventive mammogram the copay is 0 on all ma plans so I would bet dollar to donuts the provider billed original medicare instead of the ma plan.


as far as getting off the the ma plan use a sep trial period part D enrollment- if this was there first enrollment in MA.The fact that she still has the med supp doesn't matter

Hey, that's what I said.