What are the rules about beneficiaries wishing to change from a Medicare Advantage plan to Original Medicare?

All beneficiaries may make these enrollment changes during the Annual Enrollment Period, which is between November 15 and December 31 each year. Also, limited enrollment changes may also be made during January 1 and March 15 of each year, the MA Open Enrollment Period. During this MA-OEP, beneficiaries may not enroll in or disenroll from Part D coverage, but they may make changes to how they receive their Medicare services.

There are several situations that warrant a Special Enrollment Period (SEP) to disenroll from an MA plan. First, if a beneficiary enrolls in an MA plan (for the first time ever) and drops a Medigap plan to enroll in the MA plan, the beneficiary has 12 months to disenroll from the MA plan. This is called an MA Trial SEP.

Second, if a beneficiary is new to Medicare and immediately joins an MA plan, the beneficiary has 12 months to disenroll from the MA plan. This is called a SEP 65 and the beneficiary has guaranteed issue rights for Medigap in the same way they would upon turning 65. This is not an issue for some states because different states have different rules about Medigap and pricing rules.

Third, CMS has established a SEP that allows anyone who claims to have been confused (or did not understand what s/he was signing up for) and enrolled in an MA plan the right to disenroll at any time. The beneficiary does not need proof of being confused or misled; s/he should only have to say something to that effect to 1-800-Medicare, and Medicare is supposed to allow a disenrollment.

HAP Tool for More Information: http://www.hapnetwork.org/assets/pdfs/2007-MA-OEP-chart.pdf.

Source: http://www.hapnetwork.org/assets/pdfs/2007-MA-OEP-chart.pdf

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