5,400 Beneficiaries to be Disenrolled from Kaiser’s Special Needs Plan

5,400 Beneficiaries to be Disenrolled from Kaiser’s Special Needs Plan

Kaiser will be disenrolling more than 5,400 beneficiaries from the Kaiser’s Senior Advantage Medicare Medi-Cal Plan, a Medicare Advantage Special Needs Plan (SNP), by December 31, 2011. This involuntary disenrollment will affect beneficiaries in 30 counties. Counties with more than 200 beneficiaries being disenrolled include: Alameda, Contra Costa, Fresno, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego and Santa Clara. Below are: 1) some background about this involuntary disenrollment; 2) tips on how to help these beneficiaries; and 3) an outline of their options.

Why are these beneficiaries being disenrolled?

A provision in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required that each enrollee in a Special Needs Plan (SNP) meet the “special needs” criteria for joining the plan. For example, as of January 1, 2010, an SNP for dual-eligibles can accept only enrollment requests from beneficiaries with both full Medi-Cal and Medicare; they cannot enroll people with Share of Cost (SOC) Medi-Cal, or other beneficiaries who do not have full Medi-Cal and Medicare. Furthermore, if an SNP has enrollees who no longer meet the “special needs” criteria, the SNP sponsor is required to disenroll them by the end of 2011.

Because Kaiser accepted beneficiaries who did not meet the criteria prior to the effective date of the MIPPA provision, Kaiser now must disenroll these members who have not and who are not likely to meet the “special needs” criteria by December 31, 2011 to comply with this provision. Most of the affected members are Medicare beneficiaries who have Medi-Cal with a SOC and have not met their SOC as of December 31, 2009. Kaiser has sent the notice in English and Spanish to these members letting them know that they will be disenrolled. The notice also included information about beneficiaries’ rights to join other MA plans, including Kaiser’s Senior Advantage MA plan which would ensure continuity of care with their Kaiser doctors.

Beneficiaries have the option to join any Medicare Advantage plan, or go back to Original Medicare. If they decide to join another Medicare Advantage or Part D plan, they have a Special Election Period (SEP) between October 15, 2011 through February 29, 2012 to do so. Regardless of what plan they choose, however, they will probably face higher copayment liability and, in some cases, significant premiums compared to when they were in the Kaiser SNP.

Options for beneficiaries being disenrolled

  1. Join another Medicare Advantage plan. These beneficiaries can enroll in another Medicare Advantage plan that is not an SNP, including Kaiser’s Senior Advantage MA plan or any other MA plan available in their county. Beneficiaries that enroll in a plan on or before December 31, 2011, will have their new coverage effective January 1, 2012. Beneficiaries who do not enroll in another plan by the end of December will be returned to Original Medicare. They will not have Part D coverage unless they also enroll themselves into a Part D plan before December 31, 2011. They will, however, still have a Special Election Period (SEP) to join another MA plan and/or Part D plan that is accepting new members through February 29, 2012.If affected beneficiaries desire to keep their current Kaiser doctors and other medical specialists, they may enroll in Kaiser Senior Advantage to stay in the Kaiser network. These beneficiaries must make sure to enroll in Kaiser Senior Advantage before December 31, 2011 to ensure continuity of care. Otherwise, as mentioned above, they will be returned to Original Medicare as of January 1, 2012. They can still join Kaiser Senior Advantage after January 1, 2012, but their benefits in Kaiser would not start until the following month. For example, if they enroll in January 2012, coverage by Kaiser Senior Advantage would start February 1, 2012. Or if they enroll in February 2012, Kaiser coverage would not start until March 1, 2012. As a result, these beneficiaries would have Original Medicare and would not be able to see their Kaiser doctors until their Kaiser coverage begins.
  1. Return to Original Medicare and join a stand-alone prescription drug plan (PDP). Another option these affected beneficiaries have is to return to Original Medicare. They may do so by enrolling in a stand-alone Medicare Part D plan or by taking no action. If they join a stand-alone Part D plan by December 31, 2011, the Part D plan will be effective January 1, 2012 along with Original Medicare. They may also want to apply for Extra Help to help them pay for the Part D plan. Local Health Insurance Counseling and Advocacy Programs (HICAPs) help people apply for Extra Help.If they take no action by December 31, 2011, they will have Original Medicare effective January 1, 2012. They will not have Part D coverage. They can still join a stand-alone Medicare Part D plan between January 1 and February 29, 2012. If they do, the Part D plan will be effective the first day of the following month.

Please note that being disenrolled from a SNP because a beneficiary does not meet the “special needs” criteria does not give the beneficiary a guaranteed issue right to buy a Medigap. If a beneficiary has another event that triggers a guaranteed issue right, such as losing full Medi-Cal, the beneficiary would then have a guaranteed issue right to buy a Medigap.

See our Medigap section for more info on guaranteed issue rights.

Other money-saving options to consider for beneficiaries being disenrolled

  1. Sign up for the Part D Extra Help, also known as the Low Income Subsidy (LIS). If a beneficiary does not already have the Extra Help to assist in covering one’s Part D drug premiums, deductibles and copayments, s/he should apply for it at their local HICAP. Even if they have not met their SOC, they may be eligible for the Extra Help if they meet the income and resource limits. Depending on their income and resources, they may receive full or partial subsidy to help pay the Part D plan costs. More info: Extra Help.
  2. Apply for a Medicare Savings Program (MSP). Apply for one of these Medicare Savings Programs (MSPs): Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB) or Qualified Individual (QI). All of these MSPs pay the Medicare Part B monthly premium ($99.90 in 2012), and the QMB program pays the Medicare Part A premium and Medicare Parts A and B deductibles and coinsurance. Medi-Cal may have screened these beneficiaries for MSPs before putting them in the Medi-Cal SOC program, but their situation may have changed and they may now qualify for one of the MSPs. More info: MSPs.
  1. Apply for California’s 250% Working Disabled Program (WDP). If beneficiaries qualify for this state program, they receive full Medi-Cal benefits as long as they pay the program’s premium which is based on a sliding scale. They will also qualify for the Part D Extra Help program to help cover their Part D drug costs. More info: California’s 250% WDP.

Affected beneficiaries can contact Kaiser with questions at 1-866-424-8268. They can also contact their local HICAP at 1-800-434-0222.

Karen Fletcher
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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