Washington, DC (PRWEB) September 10, 2015
Last month, the Centers for Medicare & Medicaid Services (CMS) issued a memo indicating that it will ramp up its use of Special Enrollment Periods (SEPs) for Medicare Advantage (MA) plan members, which allows enrollees to switch to another plan if they didn’t have complete information, for example, if a huge provider system leaves the program or the description of plan benefits is deemed misleading. The Sept. 3, 2015, issue of Atlantic Information Services, Inc.’s (AIS) Medicare Advantage News offers analysis of the new memo, which one prominent industry observer says shows that CMS is going to become much more activist on the network-adequacy issue.
Basic standards require MA organizations (MAOs) to give CMS 90-days’ notice of a significant “no-cause mid-year network change,” according to the memo. CMS then will review the information to determine whether the changes will be substantial enough to trigger an SEP. “CMS views the SEP as an important beneficiary protection and not as a punitive measure triggered by the MAO’s decision to effectuate a significant no-cause mid-year network change,” the memo asserts. “In all instances, the SEP will be effective immediately upon notification to the enrollees of his or her eligibility for the SEP and will continue for an additional two full calendar months.”
Michael Adelberg, senior director at FaegreBD Consulting and a former top CMS official, tells MAN that the memo, along with other previously announced changes to network-advocacy audits and provider directory oversight “strongly suggest that CMS is lowering the bar for the circumstances that might trigger a mid-year provider network change SEP.” Advocates have been urging CMS to take such action, he notes, but the agency didn’t issue any documentation on it until now. “CMS has long had the right to do this, but to date, they’ve been very cautious on acting on it,” Adelberg continues.
“I take the memo as a clear signal that CMS will, at some point soon, start letting beneficiaries switch plans midyear when a health plan network loses a flagship provider group or hospital system during the plan year,” Adelberg adds. “Maybe it will be just one or two sentinel prosecutions, or maybe it will be program-wide when this sort of thing happens.”
Visit https://aishealth.com/archive/nman090315-01 to read the article in its entirety, which also includes comments from a CMS spokesperson. The memo can be read by visiting http://aishealth.com/sites/all/files/cms_ma_provider_network_sep_memo.pdf.
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Medicare Advantage News is the health care industry’s #1 source of timely news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in this hotly contested area of health insurance. Published biweekly since 1994 (when it was Medicare+Choice), the newsletter exists to help plans boost revenues, increase enrollees, cut costs and improve outcomes in Medicare Advantage and Medicaid managed care. Visit http://aishealth.com/marketplace/medicare-advantage-news for more information.
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