New Rules Coming for MAPD Members Losing PCP's?

[kennethbroyles]

USA Today reports online today...

"New Medicare Advantage rules benefit seniors
Starting next year, the government will offer some seniors enrolled in private Medicare Advantage insurance an opportunity to leave those plans if they lose their doctors or other health care providers."

New Medicare Advantage rules benefit seniors

Does anyone have more info?

 

[WCMason]

USA Today reports online today... "New Medicare Advantage rules benefit seniors Starting next year, the government will offer some seniors enrolled in private Medicare Advantage insurance an opportunity to leave those plans if they lose their doctors or other health care providers." New Medicare Advantage rules benefit seniors Does anyone have more info?

I started a thread about this at the end of August when CMS first announced this new SEP for 2015. What was unclear then was regarding whether "significant change in doctor network" meant significant to the individual beneficiary (where loss of one doctor would be significant). As we might expect, it looks like there would have to be a large drop of doctors that affected many beneficiaries to be significant. That SEP, however, might cause plans to give second thought to cutting provider networks if the outcome is that all their members get an SEP to leave their plan immediately.

 

[somarco]

As we might expect, it looks like there would have to be a large drop of doctors that affected many beneficiaries to be significant. That SEP, however, might cause plans to give second thought to cutting provider networks if the outcome is that all their members get an SEP to leave their plan immediately.

Or perhaps they will make the notable changes in providers on a calendar year basis vs mid-year.

They can still fire a particular provider mid-year or that provider can choose to opt out of their contract at renewal.

 

[WCMason]

Or perhaps they will make the notable changes in providers on a calendar year basis vs mid-year. They can still fire a particular provider mid-year or that provider can choose to opt out of their contract at renewal.

That's right. The SEP was created to prevent mid-year, large scale network changes, and will likely have that affect, causing carriers to drop docs more selectively mid-year. If so, this will be a seldom used SEP.

 

[somarco]

While not specific to the MA market, our largest trauma and charity hospital recently broke up with Blue over reimbursement. Grady said the new BX contract was unacceptable. BX refused to budge.

Until this is settled Grady is a non-par hospital for BX policyholders.

 

[vic120]

Im sure it will be a through CMS only SEP

 

[axeman462]

Was this SEP ever created?

I came across a lady whos MAPD is dropping her PCP as of September 1. She wants to keep her PCP, and as a result will need a new MAPD

 

[WCMason]

Was this SEP ever created? I came across a lady whos MAPD is dropping her PCP as of September 1. She wants to keep her PCP, and as a result will need a new MAPD

It exists, but not for anyone who loses a PCP.

 

[YouGotMyMoney]

While not specific to the MA market, our largest trauma and charity hospital recently broke up with Blue over reimbursement. Grady said the new BX contract was unacceptable. BX refused to budge.

Until this is settled Grady is a non-par hospital for BX policyholders.

I believe something similar happened in Central FL with the FL Hosp network they beefed with Humana AND FL BLUE.

 

[axeman462]

It exists, but not for anyone who loses a PCP.

Can you explain how the SEP works, and what the qualifications are?