Reform - Medicare Act Enrollment and Lock-In Provisions (Copyright, Center for Medicare Advocacy)

MEDICARE PART D PRESCRIPTION DRUG
ENROLLMENT AND LOCK-IN PROVISIONS

The Medicare Part D Prescription Drug Benefit begins in 2006. This program will limit an individual’s ability to change plans within the course of a year. The information below outlines the "lock-in" provisions of the new Medicare Part D.

Provision of Qualified Prescription Drug Coverage Through Enrollment in Plans:

Beneficiaries will have access to at least two qualifying prescription drug plans, at least one of which will be a stand alone prescription drug plan (PDP). Other plans may be provided by Medicare Advantage (formerly Medicare+Choice) Plans that offer qualified prescription drug coverage (MA-PDs). If two such plans are not available, beneficiaries will be given the opportunity to enroll in a "fall back prescription drug plan."
Beneficiaries enrolled in traditional Medicare will be permitted to obtain qualified prescription drug coverage through enrollment in a PDP. Prescription drug coverage will not be available within the traditional Medicare program itself.
Beneficiaries who join a MA-PD will receive their prescription drug coverage through the MA-PD. They will not be permitted to enroll in a PDP.
Beneficiaries who join Medicare Advantage Plans (MA) that do not offer qualified prescription drug coverage will be barred from enrollment in a PDP, unless the MA is a Medicare Advantage Private Fee-for-Service Plan (MA FFS) or a Medicare Savings Account Plan (MSA) that does not offer qualified prescription drug coverage. Beneficiaries who join such plans will be permitted to obtain qualified prescription drug coverage through enrollment in a PDP.
Dually eligible beneficiaries (those eligible for both Medicare and Medicaid) who fail to enroll in a PDP or an MA-PD, will be automatically enrolled in a qualified prescription drug plan. Enrollment will be done by the Secretary into a plan randomly selected by the Secretary. The beneficiary will have the right to decline or change the enrollment.

Initial Enrollment Into Qualified Prescription Drug Coverage Plans:

The Secretary shall establish a process for the enrollment, disenrollment, termination, and change of enrollment of Part D eligible individuals.
In the case of an individual who is a Part D eligible individual as of November 15, 2005, there shall be an initial enrollment period that shall be the same as the annual, coordinated open election period. In other words, it will run from November 15, 2005 through December 31, 2005.
For individuals who become Part D eligible after November 15, 2005, there shall be an initial enrollment period. The initial enrollment period shall be a period specified by the Secretary during which the individual may elect a qualified prescription drug plan. The period will be designed such that coverage under the elected plan will become effective as of the first date on which the individual may receive coverage. In no case shall such period end before the annual, coordinated open election period ends. Additionally, if any portion of an individual’s initial enrollment period under Part B occurs after the end of the annual, coordinated election period, the initial enrollment period under this part shall further extend through the end of the individual’s initial enrollment period under Part B.

Limited Continuous Open Enrollment and Disenrollment:

At any time during the first six months of 2006, beneficiaries may change their qualified prescription drug coverage. This right may only be exercised once during the six months in question.
After the year 2006, beneficiaries will be able to change their qualified prescription drug coverage only during the first three months of the year. Again, this right may only be exercised once during each open enrollment and disenrollment period.

Limitations on Open Enrollment and Disenrollment:

If an individual was enrolled in an MA that did not provide qualified prescription drug coverage, that individual will not be permitted to change to an MA-PD or a PDP during the open enrollment and disenrollment period. During this period, such a beneficiary will only be permitted to elect coverage under traditional Medicare or coverage under another MA that does not provide qualified prescription drug coverage. This lock-in is especially significant as individuals who later choose to join a qualified prescription drug plan during the next annual, coordinated open election period will face financial penalty for each month not enrolled in such a plan.

If the individual was enrolled in an MA-PD, the individual will be permitted to join another MA-PD or to elect traditional Medicare and enroll in a PDP. The beneficiary will not be permitted to join an MA that does not provide qualified prescription drug coverage. This provision is significant, as it renders the plan involuntary. Once a beneficiary has elected an MA-PD, that individual is locked into Part D Medicare for an entire year.

Annual, Coordinated Open Election Period

The annual, coordinated open election period will run from November 15^th through December 31^st of the year prior to the year in question. For instance, for the year 2007, the annual, coordinated open election period will run from November 15, 2006 through December 31, 2006.

Additional Special Enrollment Periods:

The Secretary shall establish special enrollment periods for the following circumstances:

Involuntary loss of creditable prescription drug coverage. Enrollment in a PDP and prescription drug insurance obtained through an MA-PD are examples of creditable prescription drug coverage. Alternative creditable prescription drug coverage listed in the statute include: Medicaid (Title XIX or 1115 waiver); Group Health Plans; State Pharmaceutical Assistance Programs; Veteran and Military insurance; and Medigap policies. Involuntary loss of creditable prescription drug coverage will include a reduction in coverage that renders a plan no longer creditable. It will not include a failure to pay premiums. A failure to pay premiums will be deemed to be a voluntary loss of creditable prescription drug coverage.
Errors in enrollment
Exceptional circumstance
Medicaid Coverage
Discontinuation of MA-PD election due to change of residence or other change in circumstances as specified by the Secretary. It does not appear that a part-time residence in another state will be deemed by the Secretary to be a change of residence for purposes of qualifying for a special enrollment period.