Have You Seen Providers Guiding Beneficiaries to Enroll in Marketplace Plans?

Have you seen any healthcare providers encouraging beneficiaries to enroll in Marketplace plans? If so, the Centers for Medicare and Medicaid Services (CMS) wants to know. CMS has received reports of providers and provider affiliated organizations steering Medicare and/or Medicaid beneficiaries into Marketplace Qualified Health Plans for their own financial benefit. In some cases, providers are even covering beneficiaries’ premiums and cost-sharing, as they still end up making more of a profit from Marketplace plans’ higher reimbursement rates.  CMS’ Request for Information is particularly interested in the various circumstances and extent to which these practices are happening. They are collecting public comments through 5 p.m. on September 22, 2016. You can submit them here.

These practices can have several harmful effects on beneficiaries, including disruption to provider networks, lifetime financial penalties for late enrollment into Medicare Parts B and D, and potential loss of dental care and loss of balance billing protections for those on Medicaid. Below is an excerpt from CMS’ Request for Information on additional harmful effects.

People who are steered from Medicare and Medicaid to the individual market may also experience a disruption in the continuity and coordination of their care as a result of changes in access to their network of providers, changes in prescription drug benefits, and loss of dental care for certain Medicaid beneficiaries. If an individual receives the benefit of advanced payments thereof (APTC) for a month he or she is eligible for minimum essential coverage, the individual (or the person who claims the individual as a tax dependent) may be required to repay some or all of the APTC at the time such person files his or her federal income tax return. Moreover, it is unlawful to enroll an individual in individual market coverage if they are known to be entitled to benefits under Medicare Part A, enrolled in Medicare Part B, or receiving Medicaid benefits.

Importantly, those eligible for Medicare may be subject to late enrollment penalties if they do not enroll in Medicare when first eligible to do so—a monthly premium for Part B may go up 10 percent for each full 12-month period an individual could have had Part B, but did not sign up for it. Individuals who become eligible for Medicare based on receipt of Social Security benefits based on age or Social Security Disability Insurance (SSDI) must forgo and if received repay their Social Security cash benefits if they wish to decline Medicare Part A benefits. Additionally, individuals who are steered into an individual market plan for renal dialysis services and then have a kidney transplant while enrolled in the individual market plan will not be eligible for Medicare Part B coverage of their immunosuppressant drugs if they enroll in Medicare at a later date.

Action Steps

For more information on navigating Medicare and the Marketplace, read our article series:

What to Do If You Have a Covered California Plan & Become Eligible for Medicare?

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.