CHA Calls for Medigap Guaranteed Issue Rights when Providers Withdraw from Medicare Advantage Plans

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Bonnie Burns, Training and Policy Specialist with California Health Advocates, spearheaded a letter calling for a Medigap guaranteed issue right for beneficiaries when providers withdraw from Medicare Advantage (MA) plans. As a long-time consumer representative with National Association of Insurance Commissioners (NAIC), Burns and other consumer representatives sent this letter to NAIC’s Senior Issues Task Force Chair and Vice Chair asking them to request that the Secretary of Health and Human Services activate a “sleeping” Medigap guaranteed issue protection in the existing NAIC Model Medigap Regulation which is also the federal minimum standard.

That provision establishes a Medigap guaranteed issue when an individual “meets exceptional conditions as the Secretary may provide.” In light of the rapid departure of providers from Medicare Advantage (MA) networks recently, we believe the “exceptional conditions” standard has been met, and the Secretary and NAIC have a duty to provide consumers with Medigap guaranteed issue.

During the 2023 Annual Enrollment Period (AEP), the Health Insurance Counseling and Advocacy Program (HICAP) in California and the State Health Insurance Assistance Programs (SHIP) around the country counseled many MA members whose health care providers had terminated their relationship with MA plans.

In one Southern California County alone the termination of MA contracts by a large health care provider affected more than 32,000 Medicare beneficiaries. MA plan members who wanted to return to Original Medicare did not have a Special Enrollment Period (SEP) to return to Original Medicare and therefore were not guaranteed the right to a Medigap under federal law, or under most state laws. They are now trapped in the MA system and struggling to find new providers who will accept their MA plan. While federal law explicitly provides a SEP in certain specific circumstances, it’s unclear if current policy provides that protection to consumers when health care providers choose to end their contract with an MA plan.

The Centers for Medicare and Medicaid Services (CMS) has the legal authority to establish SEPs when an individual or group of individuals meets exceptional conditions specified by CMS. Such “exceptional conditions” could apply to situations in which health care providers or large medical systems choose to leave a MA plan at any time during a plan year.

Read the full letter for details.

Karen Joy Fletcher

Our blogger Karen Joy Fletcher is CHA’s Communications Director. With a Masters in Public Health from UC Berkeley, she is the online “public face” of the organization, provides technical expertise, writing and research on Medicare and other health care issues. She is responsible for digital content creation, management of CHA’s editorial calendar, and managing all aspects of CHA’s social media presence. She loves being a “communicator” and enjoys networking and collaborating with the passionate people and agencies in the health advocacy field. See her current articles.