Luke Stara
Department of Insurance
Lincoln, NE - The federal government has recently sent this information to the Department of Insurance with regard to Great Plains Hospital no longer taking Medicare Advantage plans.
The Centers for Medicare and Medicaid Services (CMS) provided the Nebraska Department of Insurance with this letter:
"In response to your inquiry regarding the termination of Great Plains Health as a contracted provider with the following Medicare Advantage (MA) health plans in Nebraska: Aetna, Centene Health, and Blue Cross/Blue Shield of Nebraska, CMS has determined that the provider terminations constitute a significant provider network change. Consequently, the MA plans are required, pursuant to 42 CFR. 422.62(b)(23)(iii), to notify affected beneficiaries of their right to a special enrollment period (SEP), including guaranteed issue rights to a Medigap plan, which would allow disenrollment from their plan and enrollment in another MA plan or Original Medicare. CMS provides model language for the plan to use in the letter to affected beneficiaries regarding the SEP and Medigap guaranteed issue rights.
The SEP is available to enrollees who are assigned to, currently receiving care from, or who have received care within the past three months from a provider or facility being terminated from the MA organization's (or MA-PD) plan’s provider network. The SEP begins the month enrollees are notified of eligibility for the SEP and ends two calendar months after the month in which enrollees are notified of their eligibility.
If an affected beneficiary utilizes the SEP and decides to enroll into Original Medicare, they would have a guaranteed issue right to enroll into Medigap plans A, B, C, D, G, F, K, and L unless they turn 65 after January 1, 2020, and are prohibited from purchasing plans C and F. Please note that beneficiaries who do not meet the MACRA “Newly Eligible Medicare Beneficiary” definition who are exercising guaranteed issue rights under section 1882(s)(3)(B)(ii) are precluded from enrollment in Medigap plans D or G.
Eric Dunning, Director
Department of Insurance
1526 K Street, Suite 200
PO Box 95087
Lincoln, Nebraska 68509-5087
OFFICE 402-471-2201 FAX 402-471-4610 doi.nebraska.gov
With respect to your question about CMS’ authority to grant an SEP and guaranteed issue rights to a Medigap plan, section 1882(s)(3)(B)(ii) of the Social Security Act outlines guaranteed issuance rights provided to MA enrollees under certain circumstances. In turn, Section 1851(e)(4)(D) outlines the authority of the HHS Secretary to establish MA SEPs that coincide with those GI rights. The SEPs are cited at 42 CFR 422.62(b).
Please contact Derrick Claggett at [email protected] if you have any further questions."