Share
Print Friendly, PDF & Email

Mr. G, a retired professional, is a Medicare beneficiary in his 80s with advanced Parkinson’s disease who experienced a bad fall at home. He was hospitalized and then went to a skilled nursing facility for rehabilitation. Mr. G has always had original Medicare along with a stand-alone Part D plan and a Medicare supplemental (“Medigap”) plan. This coverage has worked well for him, allowing him to see any provider he needed for his serious medical conditions.

In December 2019, while he was in the nursing home recovering from his fall, Mr. G saw a TV commercial for a Medicare Advantage plan promising “zero payment.” He called the plan and spoke to a representative who assured him that he would save money by enrolling. Mr. G enrolled with an effective date of January 1, 2020. However, he did not understand that the Medicare Advantage plan was an HMO with a restricted network, and that many of his providers were not in the network. On January 2, the day Mr. G was being discharged from the nursing facility, his family was told that he was “no longer in fee-for-service Medicare” and that the home health agency they had worked so hard to find to help with the transition back to living at home was not in his MA network and could not be paid by Medicare for Mr. G’s care. His family also determined that other important providers, such as his primary-care physician, were not in the network of the Medicare Advantage HMO. They were in a panic about what to do.

The Center for Medicare Advocacy informed Mr. G’s family that because of the Medicare Advantage Open Enrollment Period, which runs every year from January 1 to March 31, Mr. G could disenroll from the Medicare Advantage plan, and go back to original Medicare with a stand-alone Part D plan. There was a potential problem, however, with his Medigap plan: Mr. G lives in a state that restricts enrollment for Medigap plans to certain times of year and allows those plans to consider pre-existing medical conditions (“medical underwriting”) in issuing policies.[1] With advanced Parkinson’s, it was unlikely that any Medigap plan would accept him, and even if a plan did accept him, it would not be until later in the year. Fortunately, Mr. G’s family had already paid several months’ worth of premiums for his Medigap plan. As long as Mr. G remained current with the premiums, he would stay in that supplemental plan, even though he could not use it while he was in a Medicare Advantage plan.[2] When he was out of the Medicare Advantage plan, he would be able to use the Medigap plan again.

Mr. G’s family called 1-800-Medicare and requested that he be disenrolled from the Medicare Advantage plan and placed back into original Medicare with a stand-alone Part D plan.[3] Normally, this type of disenrollment would take effect the first day of the following month (in this case, February 1). However, based on information from the Center, Mr. G’s family also filed a “complaint” with 1-800-Medicare, explaining the circumstances and requesting retroactive disenrollment from the Medicare Advantage plan so that he would have coverage from original Medicare in the month of January. It was important to use the word “complaint” so that the request would be placed in the “complaint tracking module” and sent to the proper decision-maker. Mr. G’s family insisted on filing the “complaint” despite discouragement by two representatives at 1-800-Medicare, who stated that retroactive disenrollment could not occur under these circumstances. The call took close to 90 minutes. (Persistence is important!) The day after making the call to 1-800-Medicare, Mr. G’s son received a call from a CMS Regional Office stating that Mr. G’s request had been granted. He is back in original Medicare and a Part D plan retroactive to January 1. Now his providers can bill original Medicare, and his Medigap plan is still in place.

Conclusion

Mr. G’s story shows how easy it is to be misled by Medicare advantage marketing, and the consequences that can potentially result for Medicare beneficiaries and their families. Check out the Center for Medicare Advocacy’s Fully-Informed Project[4] for more objective information to consider when choosing between original Medicare and Medicare Advantage.

__________________

[1] Only four states allow either continuous or annual enrollment in Medigap plans without medical underwriting: Connecticut, Massachusetts, New York, and Maine. In all other states, people who switch from a Medicare Advantage plan to original Medicare may be denied a Medigap policy due to pre-existing conditions, with few exceptions. https://www.kff.org/medicare/issue-brief/medigap-enrollment-and-consumer-protections-vary-across-states/
[2] See https://cahealthadvocates.org/medigap/guaranteed-issue/
[3] Importantly, they called with Mr. G on the line so that he could authorize Medicare to speak to his family members.
[4] https://www.medicareadvocacy.org/medicare-fully-informed-project/

Comments are closed.