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A Brief Survey of Recent Reports, and a New Special Enrollment Period for 2015

Medicare's Annual Coordinated Election Period (ACEP) for Medicare Advantage and Part D plans began on October 15th and runs through December 7th.  During the ACEP, often referred to as "open enrollment," Medicare beneficiaries who do not have a Part D plan can enroll in one, and those who already have Part D coverage can change plans.  Beneficiaries can also return to traditional Medicare from a Medicare Advantage (MA) plan, enroll in an MA plan, or change MA plans.  Enrollment requests made during the ACEP will have an effective date of January 1 of the following year – January 1, 2015.[1]

Medicare beneficiaries should review their plan options carefully each year to make sure they are getting the coverage they need.  The following provides brief summaries of recent information regarding the 2015 landscape of Part C and D plans, oversight of such plans, and a new Special Enrollment Period concerning provider network terminations effective 2015.

2015 Landscape of Plans

According to the Kaiser Family Foundation, key changes in 2015 Part C and D plans include a "modest" change in the total number of Medicare Advantage plans available for 2015 (approximately 3% of people are currently in MA plans that won't be offered in 2015).  In addition, while 2015 will see the fewest number of Part D plans offered nationwide since 2006, on average, beneficiaries in each region will still have 30 stand-alone prescription drug plans (PDPs) to choose from.  The Kaiser report is available at:

Private Medicare Plan Quality and Efficacy

On the one hand…

Overall MA Quality Ratings Are Increasing

According to CMS data analyzed by Avalere Health, overall MA quality ratings are improving; see Avalere's analysis at:

On the other hand…

Enforcement Actions Are Increasing

On October 16, 2014, CMS issued "The 2013 Part C and Part D Program Annual Audit and Enforcement Report", which says enforcement actions against Medicare Advantage plans and Medicare Prescription Drug Plans tripled between 2012 and 2013.  The Report is available at:  

The Number of Drugs Covered is Decreasing While Restrictions on Accessing Drugs are Increasing

According to a report by HealthPocket, there has been a decrease in the average number of drugs covered by Part D plans (including Medicare Advantage-Prescription Drug Plans) while restrictions on drugs have increased.  The report is available at:

Ongoing Concern about Overpayments to MA Plans

The Center for Public Integrity recently conducted an investigation of Medicare Advantage payment and "found that billions of tax dollars are wasted every year through manipulation of a Medicare payment tool called a 'risk score.'" See "Medicare Advantage Money Grab" available at:  The Center for Public Integrity has also recently highlighted the Department of Health and Human Services' Agency for Healthcare Research and Quality's call for tightening MA auditing standards, (see: and the launch of a Government Accountability Office (GAO) audit of MA plan payment accuracy (see:  

Medicare Advantage Provider Network Terminations – New SEP for 2015

As discussed in previous Alerts, Medicare Advantage (MA) plans are increasingly dropping doctors and other health care providers from their contracted networks.  This often occurs in the middle of a plan year, when most plan enrollees are not permitted to change plans.[2]  MA enrollees generally get little advance warning, and some lose access to doctors they have seen for a long time, despite joining the plan specifically because their doctor was part of the network.  In an effort to strengthen MA enrollee consumer protections, in June 2014, Congresswoman Rosa DeLauro (D-CT) and Senators Sherrod Brown (D-OH) and Richard Blumenthal (D-CT) introduced the Medicare Advantage Participant Bill of Rights Act of 2014 (H.R. 4998/S. 2552).  Among other things, this bill would prohibit MA plans from dropping providers in the middle of the plan year and would improve notice to plan enrollees about annual changes to provider networks.

Absent passage of this bill, MA plan enrollees whose providers are cut from their plan's network have little recourse.  Starting in 2015, however, CMS has instituted a limited Special Enrollment Period (SEP) possibility for certain MA enrollees following certain provider network terminations.  This SEP will be available on a case-by-case basis when CMS "determines that changes to an MA plan's provider network that occur outside the course of routine contract initiation and renewal cycles are considered significant based on the affect or potential to affect [sic], current plan enrollees."   In other words, if just your doctor is terminated during the year, this SEP right won't likely apply; however, if your doctor and an undefined "significant" number of additional providers are terminated, an SEP might be available to you.

See the Medicare Managed Care Manual, Ch. 2, Section 30.4.6 – reprinted below and available at the following link:

30.4.6 – SEP for Significant Change in Provider Network

An SEP exists for situations in which CMS determines that changes to an MA plan's provider network that occur outside the course of routine contract initiation and renewal cycles are considered significant based on the affect or potential to affect, current plan enrollees.

CMS will establish an SEP, on a case by case basis, if it determines a network change to be significant. The SEP will be in effect once CMS makes its determination and enrollees have been notified. The SEP begins the month the individual is notified of the network change and continues for an additional two months. Enrollment in the new plan is effective the first day of the month after the plan receives the enrollment request.

The scope of the SEP will be determined by CMS, and it may include enrollees who have been affected, or who may be affected, by the network change. Individuals eligible for the SEP may disenroll from the MA plan and elect Original Medicare or another MA plan, including an MA-PD even if they did not have prescription drug coverage previously. CMS will provide specific instructions directly to the affected organization, including instructions on required beneficiary notifications and information to be provided to affected beneficiaries regarding other enrollment options, if applicable.


Beneficiaries should use the Annual Coordinated Election Period (October 15 – December 7) to carefully examine their Medicare coverage options.  Just because an MA or Part D plan worked for someone last year does not mean that plan will meet their needs in the coming year.   Further, protections like those included in the Medicare Advantage Participant Bill of Rights Act are needed to ensure private Medicare Advantage plans provide adequate provider networks and fair access to Medicare coverage.

D. Lipschutz, October, 2014




[1]  See, e.g., the Center's Weekly Alert "Annual Enrollment for Medicare Advantage Part C and D: October 15 – December 7" (September 18, 2014), available at:
[2] See, e.g., the Center's Weekly Alert "United Healthcare Dramatically Reducing CT Medicare Advantage Plans – Check YOUR State" (October 10, 2013), available at:  



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