megalomaniac (steve_friction) wrote in medicare,
megalomaniac
steve_friction
medicare

Limited Open Enrollment Period

From a release from CMS to all Medicare Advantage Organizations dated February 7, 2007:

“On December 20, 2006 the Tax Relief and Health Care Act of 2006 was enacted. Section 206 of this law amends section 1851 (e)(2) of the Social Security Act to allow beneficiaries enrolled in Original Medicare (only) to have a limited opportunity in 2007-08 to enroll in a Medicare Advantage (MA) plan that does not include Medicare prescription drug coverage (MA-only/stand-alone plan.) CMS will refer to this MA enrollment election period as the Limited Open Enrollment Period (L-OEP).

…. Beneficiaries may remain enrolled in the PDP only if they enroll in a PFFS MA-only plan that does not offer Part D. Thus, if an individual in Original Medicare and a stand-alone PDP elects to enroll in an MA-only coordinated care plan, such as an HMO, PPO or Regional PPO, his or her enrollment in the PDP will be automatically cancelled as of the effective date of enrollment in the MA-only plan.”

This period begins April 1, 2007. I knew that the L-OEP gave people options to join MA plans, but I was quite surprised to find out that it was for Private Fee-For-Service (PFFS) plans only.
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The L-OEP is for people in Original Medicare to join a Medicare Advantage Plan that does not have drug coverage. If the person has Original Medicare and a Medicare drug plan, they will lose the drug plan when they join the Medicare Advantage Plan (based on existing guidance). The paragraph that you pasted about PFFS plans is applicable because you can join a PFFS plan that doesn't offer drug coverage and keep your existing Medicare drug plan. The L-OEP is not only for PFFS plans though.
Yes. Right. That's what it says. Only PFFS plans allow you to keep your PDP.
I didn't mean my last sentence there to sound like it sounds. I meant that I was surprised only PFFS plans allowed you to keep your PDP, when all along I assumed ANY MA plan would let you during this period.
The reason is because you can't have a Medicare Advantage Plan with a stand-alone PDP, regardless of the enrollment period. The L-OEP doesn't have anything to do with drug coverage, which is why CMS didn't include going from Original Medicare to a Medicare Advantage Prescription Drug Plan.
Wait I'm confused with what you're saying.

You CAN have MA plans with stand-alone PDPs.
No you can't. If you want a Medicare Advantage Plan and a prescription drug plan, it has to be a packaged deal (unless it's a PFFS or Cost plan). Many plans offer Medicare Advantage Prescription Drug Plans. However, if the company doesn't offer that, you cannot join their MA Plan and then pick a stand-alone plan.

If someone is in a Medicare Advantage Plan and they join a stand-alone PDP, they will be disenrolled from the MA Plan and return to Original Medicare.
Let's be clear that PFFS plans ARE considered MA plans. So, let's pretend it's December and we're in the OEP. Someone CAN sign up for any MA plan, be it a PFFS, HMO, PPO, whatever, and they can add on a stand-alone PDP. Or, they could take a MA-PD plan, which includes both. You can have a MA plan with one company and take another company's stand-alone PDP. Everything I just said is not related to the present LOEP.


Within the LOEP, they cannot join a PDP for the first time or leave one (nevermind the special circumstances for right now) but if they are on Original Medicare (or also a Medigap plan) they can join a MA plan. However, if they choose to take a HMO or a PPO, they will be disenrolled from their PDP. If they choose a PFFS, they may keep it.

Now, I bet my job and my insurance license that everything I said above is true because if not, Medicare sure hasn't been following their own rules, plus I've been doing this since the drug plans started.

I work for an insurance company and I've got countless clients who have taken our PDPs while keeping another company's MA plan or vice versa, and I have not once heard of someone not being allowed to do so.
I work for Medicare, so I will bet my job that I am correct also. I understand that PFFS Plans are MA Plans. When I say "MA Plans", I'm actually referring to all of the Medicare Health Plans.

You will be disenrolled from your Medicare Advantage Plan (MA or MA-PDP) if you decide to join a Medicare drug plan (PDP). You will return to Original Medicare for your health coverage. 1-800-Medicare gets call every day where this has happened to people.

If you are in a Medicare Private Fee-For-Service plan that does not offer drug coverage, you can add drug coverage during a valid enrollment period without affecting your plan enrollment. If your plan offers drug coverage, you have to take the coverage from your plan. You cannot join a different drug plan.

If you are in a Medicare Cost Plan that does not offer drug coverage, you can add drug coverage during a valid enrollment period without affecting your plan enrollment. If your plan does offer drug coverage, you can get it through your cost plan OR you can buy a separate Medicare drug plan during a valid enrollment period.

CMS FAQ 6462 proves my point very simply.
Question:
I have a Medicare Advantage Plan. The plan offers two options in 2006, one with drug coverage and one without. If I choose the option without drug coverage, can I also join a Medicare Prescription Drug Plan?

Answer:
No. If you choose to stay enrolled in a Medicare Advantage Plan that offers prescription drug coverage through its other plans, you must get your prescription drug coverage from your Medicare Advantage Plan or have no Medicare prescription drug coverage.
I'm surprised to see this as, like I said, I have several clients who have been able to mix their plans with no consequence.
It is a common misconception and we see many cases where the beneficiary gets in trouble by this wrong information. If you have clients that are in an MA Plan and a stand-alone drug plan, it is probably because the system isn’t accurate with their information or they are in a PFFS Plan that doesn’t offer drug coverage or a Cost Plan.
It doesn't help that the M&You book uses hedge words like "usually" and "most" (ref. p35, bullet 4)

Also, what good does this do people whose Rx are not on that company's formulary? They have to change their health plan just to get a Rx covered? Totally weird.

I have not heard of a single problem with this, seriously, which is so surprising, considering what you're saying. And if you work there, of course I believe you, but again, I've not seen it enforced, so I'm just going off of experience here. I mean it adds a whole other level to the eligibility screening that I personally am not doing, as well as my coworkers.

Oy!
Also, let me clarify, I know that it does say what you're saying on p. 43 of the '07 Medicare & You book, and I have heard of a few select plans, like I think there's some Group Health HMO here in WA that doesn't allow you to take another PDP, but those are less common, from my experience.