MA Disenrollment:
What Can a SHIP Counselor Do?

Recently many SHIPs have reported that Medicare beneficiaries are enrolling in Medicare Advantage (MA) plans without adequate knowledge of what they are signing up for and, in some cases, are being enrolled without their consent. Beneficiaries and SHIP counselors are finding out about these practices when issues in accessing health care and coverage arise.

This tip sheet is geared towards helping counselors help beneficiaries who are unable to utilize the MA plan in which they are enrolled. Many of these beneficiaries would prefer to be disenrolled from such MA plans, if possible.

Sometimes a beneficiary may prefer, or be required, to stay in the MA plan. These individuals may need counseling to understand a variety of factors including: what happens to their Medicare benefits when they enroll in MA plans enrollment and disenrollment timeframes and rules provider networks preauthorization and referrals to specialists emergency and urgent out-of-plan use appealing claim denials appealing service request denials how MA plans coordinate with other benefit packages out-of-pocket limits and benefits that are carved out of these limits

Some important questions to ask the beneficiary to determine next steps:

• Are you still in the MA plan?
• Are you having a hard time seeing your doctors and getting the health care you need?
• Do you have outstanding bills?
• Are there any recent changes in your coverage, do you qualify for any special enrollment periods?
• Do you have an enrollment election left?

*The ability to change plans within a specific enrollment period usually is limited to one change per period. This is the reason an individual is encouraged to enroll in a new plan as a means to disenroll them from their previous plan. The action of enrolling takes up an election, as does the action of disenrolling.

Common Questions from Medicare Beneficiaries

In addition to asking the beneficiary questions to help you "troubleshoot", s/he may have some questions for you about his/her enrollment options.

If I am in an enrollment period and have an election left, how do I disenroll from the MA plan?

As mentioned above, the act of enrolling in a new plan effectively disenrolls a Medicare beneficiary from the old plan. It is important to screen all Medicare beneficiaries for appropriate drug coverage by checking drug plan formularies and utilization management techniques (i.e. prior authorization, step therapy, quantity limits) if they have access to joining a Medicare Part D plan (PDP).

• To join a PDP or a different MA or MA-PD, you need to enroll in the new plan.
• To return to Original Medicare without drug coverage, you need to disenroll from the existing MA plan.

To disenroll or enroll in a new plan call 1-800-Medicare, call the plan itself, or enroll online through www.medicare.gov. The disenrollment should be effective on the first day of the following month.

What if I just enrolled in the plan earlier this month and have changed my mind?

Beneficiaries may "cancel" an enrollment if the request for disenrollment is made before the effective date of enrollment. If the cancellation is within an enrollment period, an unused election is retained.

What if I have already used my election?

If a Medicare beneficiary no longer has an election to make a change during an enrollment period, determine if there are any applicable SEPs or if a retroactive disenrollment is possible.

I really want to document my request, how do I do this?

Write down information from each request, including the names of customer service representatives you speak with, as well as the time and date of calls. If issues arise with your disenrollment, Medicare will use these facts to confirm that you took action to disenroll on a particular date. In addition, save copies of faxes with delivery confirmation and (if possible) send letters by certified mail or return receipt. After enrolling in a new plan or disenrolling from a plan, draft and submit a written request for disenrollment with an effective date directly to the plan. Typically, the effective date of any disenrollment will be the first of the month following any action to enroll in a new plan or disenroll from the existing plan.

If I am retroactively disenrolled from a plan, what happens to my coverage?

Retroactive disenrollment can result in reinstatement into a previously held plan with no gap in coverage. During an enrollment period, an individual should enroll in the plan of choice rather than depend on a reinstatement action from CMS. A specific request for reinstatement should be included in any formal retroactive disenrollment request submitted on behalf of a Medicare beneficiary. A request can also be made for retroactive enrollment into a new plan, but there must be evidence that the beneficiary was led to believe they could utilize that plan's services during the time in question.

Counselor follow up: Help the beneficiary disenroll from the MA plan. Confirm that the client is disenrolled from the MA plan through 1-800-Medicare and the plan itself. Determine if the client is having any urgent access to care issues. Help the beneficiary understand current coverage and appeal rights. Verify whether the client has used any in plan services. Submit a request for retroactive disenrollment if appropriate. *When a Medicare beneficiary has out-of-plan claims (that are not for emergency or urgent care services), the client may be an appropriate candidate for retroactive disenrollment. Often, but not always, this request requires that the client has not used any in-plan services (including pharmacy claims).