Auto Enrollment in Medicare Advantage Problematic For Some Seniors
Automatic enrollment in Medicare is a right of passage for many Americans when they reach age 65. But if you’ve had commercial or marketplace insurance up to this point, be sure to open all the mail from your old insurer. Some insurance companies are allowed to automatically enroll you in their Medicare Advantage (MA) plan.
While it sounds like an unexpected convenience, it is a situation that could leave you footing the bill for medical care you thought was covered by Original Medicare.
How does this happen? It seems people, thinking they no longer need to pay attention to their old health insurance company, ignore the mail and miss critical correspondence that allows them to reject the MA plan in favor of another insurance option.
Overview of Enrolling in Medicare
- If you have health insurance and become eligible for Medicare, you may be automatically enrolled in your insurance company’s MA plan instead of Original Medicare.
- Your insurance company is required to send you a letter and provide you with at least 60 days to opt out of the Medicare Advantage plan.
- People who think they are enrolled in Original Medicare, may ignore mail from their old insurance company and miss the opt out letter.
- Not all healthcare providers and hospitals that accept Medicare, will be in-network for your MA plan. And if your care comes from an out-of-network provider, you won’t be covered even if that provider accepts Medicare.
What is Medicare Advantage?
Medicare Advantage, also known as Medicare Part C and MA, is an alternative to Original Medicare. Private insurance companies, not the U.S. government, operate MA plans. But, MA plans must still follow certain rules set by the federal Medicare program. MA plans must provide the same coverage as Original Medicare.
Your Network is Different with a Medicare Advantage Plan
The problem is not all the doctors and hospitals that accept Medicare, will be in your MA plan network. If you seek medical care, treatment or have surgery out of network, that could result in substantial bills.
“In Original Medicare, beneficiaries can choose a provider anywhere across the country that accepts Medicare,” said Raymond Thorn, a spokesman for the Centers for Medicare and Medicaid Services (CMS). “Medicare Advantage plans are operated by private insurance companies approved by Medicare. In most Medicare Advantage plans, enrollees can only go to doctors, other health care providers, or hospitals on the plan's list except in an emergency. Enrollees may also need to get a referral from their primary care doctor.”
Just like with traditional health insurance, people with MA plans will pay less if they use doctors, hospitals and other healthcare providers in the plan's network, and, of course, pay more if they go out of network.
Medicare’s “Seamless Conversion” Program
The issue is some seniors are unaware their insurance company has automatically enrolled them in an MA plan. This is called “seamless conversion” and it is legal.
“By statute and with approval by CMS, an organization that offers both Medicare and non-Medicare health plans may seamlessly enroll current members, who become eligible for Medicare, into the Medicare Advantage plan,” Thorn explained. “The Medicare Advantage issuer must offer ‘seamless conversion’ to all Medicare-eligible members and may not exclude any members.”
Thorn added that Medicare requires health insurance companies send advance notification to individuals to inform them they are being enrolled in an MA plan. Insurers are also required to give seniors the ability to opt-out or join another plan before the MA coverage begins.
“CMS is currently refining its standard operating procedure for accepting, reviewing, responding to, and routinely reviewing requests to use seamless conversion,” Thorn said. “We are also revising our mechanism for tracking and maintaining data related to these requests.”
Thorn noted that CMS does not receive many complaints involving MA coverage issues, but he still had advice for seniors to make sure they completely understand their coverage and do not find themselves with unexpected bills.
What Can you Do to Prevent Medicare Auto-Enrollment?
Don’t ignore your mail.
Insurers are required to send a letter at least 60 days prior to enrolling you in their MA plan. This letter must also include information on how to opt-out or decline the plan before the coverage begins. Here is a link to Priority Health Medicare’s letter. Priority Health is a health insurance company serving Michigan.
“Seniors should open and review all mail from their current insurer, even if they may want Original Medicare for their Medicare coverage,” Thorn said. “If they receive a letter from their current insurer about automatic enrollment into a Medicare Advantage plan, they should contact the insurer to make sure that the new plan meets their needs.”
When evaluating an MA plan ask about provider and pharmacy networks, learn about the plan’s formulary and costs. This can be complicated, but there is help.
Seniors can contact their local State Health Insurance Assistance Program, 1-800-MEDICARE or visit www.medicare.gov for assistance comparing their coverage options.
What if You Want to Get Rid of Your Medicare Advantage Plan?
“Beneficiaries can either stay in the plan or they may take one of two actions at any point before their coverage in the MA plan starts: Contact the plan in writing or by phone to “opt-out” of the automatic enrollment, or enroll in a different MA plan or stand-alone Part D plan,” Thorn said. “If the coverage in the MA plan has started, beneficiaries can call 1-800-MEDICARE to see if they are able to choose a new plan or go back to Original Medicare.”
And at anytime, you can call 1-800-MEDICARE to confirm your Medicare coverage.