Medicare Advantage Plan Terminating or Reducing Their Service Area: Understand Your Rights

By Nick Hildenbrand

Medicare Advantage plans can drop you at the end of the plan year if the plan does not renew its contract with Medicare. A plan that does not renew its contract with Medicare may decide to drop select geographic areas of service, or it may decide to nonrenew the entire plan.

A plan may involuntarily disenroll you for failure to pay premiums timely, for causing a disruption in the plans ability to deliver health care services, or if it cannot meet your medical needs. If you are involuntarily disenrolled, you are automatically returned to coverage under original Medicare at the beginning of the month following your involuntary disenrollment.

A Medicare Advantage plan is required to notify members of Medigap guaranteed issue rights when disenrolling to Original Medicare during a Special Enrollment Period (SEP) if they are terminating or reducing their service area. In a majority of cases, the plan must send written notice to all Medicare members at least 60 days before the effective date. Nevertheless, if CMS initiates a termination, members will be notified 30 days before the effective date. In certain situations a Medigap issuer may require the beneficiary to provide further documentation of their guaranteed issue rights as a result of disenrollment.

If you are involuntarily disenrolled because your Medicare Advantage plan nonrenews its plan, you have the right to apply for a Medigap policy, as long as you do so within 63 days of notice of the nonrenewal.

If you voluntarily disenroll because you decide a Medicare Advantage plan is not right for you, you may have a right to Medicare supplement coverage as long as you have not been covered by a Medicare Advantage plan before and you disenroll from the Medicare Advantage plan within 12 months of your enrollment. This right is limited to the same Medicare supplement in which you were most recently previously enrolled, excluding any outpatient prescription drug coverage. If you do not have a right to get your same Medicare supplement coverage back, you will have to complete the medical questions on an application for Medicare supplement and the insurance company can deny your application.

Guaranteed Issuance Rights: Enrollment in an MA plan at age 65 If you enrolled in a MA plan when you turned 65, you have Medigap guaranteed issue rights if you disenrolled from the plan within the first 12 months. Your Medigap Guarantee Issue Period starts 60 days prior to your disenrollment and ends 63 days after your disenrollment. In this situation, you are eligible for all Medigap policies.

Guaranteed Issuance Rights: If you are over age 65, enrolled in a Medicare Advantage plan for the first time and you disenroll from the plan within the first 12 months You must have had a Medigap policy prior to your MA enrollment. Your Medigap Guarantee Issue Period starts 60 days prior to your disenrollment and ends 63 days after your disenrollment. If the Medigap plan you owned prior to enrollment in the MA plan is still being offered, you must return to that plan. Otherwise, you can choose from plans A, B, C, F, K or L.

The Medigap issuer cannot impose conditions on coverage or discriminate in pricing based on your age or health status except as permitted by state rating regulations. They also cannot charge pre-existing condition exclusions, even without creditable coverage. Keep in mind, you must exercise your Guaranteed Issuance rights within 63 days of the disenrollment date from the Medicare Advantage plan.

Our licensed insurance agents are available to help answer any specific or detailed questions you have.

About the Author:

You may also like...