When Medicare Advantage Plans Terminate Coverage

At the beginning of each calendar year, Medicare Advantage (MA) plans can make changes to their benefits, premiums, copayments and geographic service areas. They must notify their members every fall of the changes they intend to make the following year. They can add or drop benefits, change premiums and copayments, and begin or discontinue serving a certain county or region. MA plans must get permission from the Centers for Medicare and Medicaid Services (CMS) before making any changes, and notify their members by early October of changes effective January 1 of the following year.

MA plans are required to provide all Medicare-covered services. They are not required to offer additional benefits, remain in business in certain areas, or continue their contracts with certain doctors or hospitals.

If Your MA Plan Stops Providing Benefits in Your Area

If your MA plan stops providing benefits in your area at the end of the year, you have the right — regardless of age or health condition — to join another MA plan if one is available where you live, or to return to Original Medicare and join a Part D plan. Your Special Election Period (SEP) is from December 8 of the current year through the end of February of the next year.

Note that this SEP gives you another chance to enroll in an MA or Part D plan in addition to the Annual Election Period, also known as Open Enrollment, from October 15 through December 7, when you can switch, enroll in or disenroll from MA and Part D plans. Any plan changes made before December 31 are effective January 1. Plan changes made after December 31 are effective the first day of the following month. If you switch to a new MA plan, make sure your doctor, the medical group that provides your care and your local hospital are all in the new MA plan network and plan to stay in it. If you find you need to switch doctors, make sure the doctor you choose is taking new patients.

If you return to Original Medicare, you also have the guaranteed-issue right to buy a standardized Medicare supplement policy, also known as Medigap. You have the right to apply for Medigap plans A, B, C, F (including the high deductible option), K, L, M or N, and you can apply anytime after the Medicare Advantage plan first notifies you that they are leaving. You have up to 123 days after your Medicare Advantage plan benefits actually end to apply for a guaranteed issue Medigap policy.

Insurance companies must let you buy 1 of these 8 standardized Medigap plans — A, B, C, F (with or without the high deductible option), K, L, M or N — regardless of your health condition, unless you are younger than 65 and have end-stage renal disease (ESRD).

Because you have a guaranteed-issue right to buy 1 of these 8 Medigap policies, companies selling the policies cannot impose a waiting period before covering your pre-existing health conditions or charge you a higher premium than what is paid by other people your age. Some companies that sell both MA plans and Medigap policies may offer you the right to enroll in their Medigap policy, but if your MA plan stops providing benefits in your area, you may choose any Medigap policy. Learn more about guaranteed-issue periods.

Note: Since the Medicare Part D drug benefit became available in 2006, no Medigap policies sold after January 2006 are permitted to include drug coverage. However, you may purchase drug coverage through a Prescription Drug Plan (PDP). Learn more about prescription drugs.

If Your MA Plan Increases Costs, Drops Benefits or Ends Its Relationship with Your Doctor

You have the right to switch to a Medigap policy if your MA plan increases the costs you pay by raising or adding copayments. You can also switch to Medigap if your MA plan drops benefits or terminates its relationship with a medical professional who is treating you. Note: the right to switch to a Medigap policy due to increased costs or adding copayments is only available if you buy a policy offered by your MA plan, or any company that is a part of the same corporation as your MA plan.

If the MA plan you belong to doesn’t sell a Medigap policy, you still have the right to buy a Medigap from any other company IF your MA plan increased your premium or your copayments by 15% or more, reduced your benefits, or terminated its relationship with your medical provider who was treating you.

You can purchase one of the guaranteed issue Medigap policies, beginning on the date you are notified of any reduction of benefits or increase in premium or cost-sharing or termination of a relationship with your provider and no later than 63 days after those benefits end.

The guaranteed issue right to buy a Medigap does not always coincide with a period when you can disenroll from your MA plan. MA plans can’t reduce their benefits or increase premium or cost-sharing during the plan year. Any reduction in benefits or increase in premium or cost-sharing applies for the new plan year only. In these situations, you may disenroll during the Annual Election Period (AEP) – October 15 to December 7 – and use the guaranteed issue period to buy a Medigap. An MA plan may, however, discontinue its contract with a provider anytime during the year. This means, even though you may have a guaranteed right to buy a Medigap when a provider no longer has a contract with your MA plan, you may not also have a federal right to disenroll from that MA plan when your provider’s contract is terminated.

Note: Although provider contracts can potentially change at any time, an MA plan must make a “good faith effort” to notify all affected beneficiaries at least 30 calendar days before a provider contract terminates.

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