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Flexibility with Mid-Year Plan Changes Coming to Medicare Advantage

There are a number of special exceptions that allow Medicare Advantage beneficiaries to make changes during periods outside of Open Enrollment. However, up until now, beneficiaries were not allowed to switch plans outside of Open Enrollment to follow their doctor to a different plan. This rule is set to change this year, as Medicare will allow for certain beneficiaries to follow doctors to new plans at any time of year. Learn more about the details below.

Following Doctors to New Plans on Medicare Advantage

Medicare Advantage beneficiaries can see any doctor in the network that their plan covers. However, plans sometimes make changes to their networks and coverage, which can result in certain doctors no longer being covered under the plan.

This can create a problem for beneficiaries whose doctors are no longer covered. Beneficiaries have the option of seeing a new doctor that is covered by the plan, but understandably, many wish to continue seeing their old doctor, with whom they already have an established relationship.

Until now, this was not possible under current rules. Beneficiaries had to wait until Open Enrollment to find a new plan under which their old doctor was covered. But in 2015, beneficiaries may not have to wait to make the switch.

The Centers for Medicare and Medicaid Services will examine all network changes made during the year by Advantage plans. If certain conditions “considered significant based on the [effect] or potential to affect, current plan enrollees,” are met, than officials will set up a three-month special enrollment period during which enrollees of the plan under consideration will be allowed to switch plans and follow their doctor to a new plan. From USA Today:

Medicare spokesman Raymond Thorn said the agency will make that “case-by-case” determination based on the number of beneficiaries affected and whether they received adequate and timely advance notice, the size of the plan’s service area, when during the year the provider terminations occur and other factors. He declined to provide details on the minimum number of beneficiaries, providers or service area size that would be necessary. Once Medicare decides that plan members should be allowed to leave their plan, the agency will require the plan to notify its members about their new options.

It’s up to CMS’ discretion as to whether plan members will be granted a special enrollment period. This means that members of a plan cannot just request a special enrollment period and the opportunity to change plans. Still, this new flexibility in plan selection is good news for Medicare Advantage plan members.

Medicare Advantage

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