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. ย CMS’ย Request for Informationย 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 onย additionalย harmful effects.
People who areย steered from Medicare and Medicaid toย the individual market may alsoย experience a disruption in theย continuity and coordination of theirย care as a result of changes in access toย their network of providers, changes inย prescription drug benefits, and loss ofย dental care for certain Medicaidย beneficiaries. If an individual receivesย the benefit of advanced payments thereof (APTC) for a month he orย she is eligible for minimum essentialย coverage, the individual (or the personย who claims the individual as a taxย dependent) may be required to repayย some or all of the APTC at the time suchย person files his or her federal incomeย tax return. Moreover, it is unlawful toย enroll an individual in individualย market coverage if they are known to beย entitled to benefits under Medicare Partย A, enrolled in Medicare Part B, orย receiving Medicaid benefits.
Importantly, those eligible for Medicareย may be subject to late enrollmentย penalties if they do not enroll inย Medicare when first eligible to do soโa monthly premium for Part B may goย up 10 percent for each full 12-monthย period an individual could have hadย Part B, but did not sign up for it.ย Individuals who become eligible forย Medicare based on receipt of Socialย Security benefits based on age or Socialย Security Disability Insurance (SSDI)ย must forgo and if received repay theirย Social Security cash benefits if theyย wish to decline Medicare Part Aย benefits. Additionally, individuals whoย are steered into an individual marketย plan for renal dialysis services and thenย have a kidney transplant while enrolledย in the individual market plan will notย be eligible for Medicare Part B coverageย of their immunosuppressant drugs ifย they enroll in Medicare at a later date.
Action Steps
- Read CMS’ full request for more information.
- Submit your comments by September 22, 2016.
- Please share this info and request with others.
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?
