Please Help Us With the Medicare Plan Mess, State Regulators Ask CMS

State insurance regulators say they have no idea what to tell patients panicked by the big Medicare Advantage plan provider network changes coming in 2025.

Plans are supposed to send notices to enrollees about how their provider networks, benefits and other coverage terms will change in 2025 by Sept. 30. State regulators are asking Chiquita Brooks-LaSure, the administrator of the Centers for Medicare and Medicaid Services, for advice about how CMS will handle Medicare Advantage plan upheaval.

Because of the major network changes looming, “beneficiaries are faced with either paying the increased out-of-network costs or rescheduling their necessary medical services with another provider who may not have prompt availability,” officers at the National Association of Insurance Commissioners write in a letter sent Wednesday to Brooks-LaSure.

That means a failure by CMS to answer questions and come up with solutions could hurt some patients’ health, by causing those patients to put off getting medically necessary care, the NAIC officers warn.

The Senior Issues Task Force, an arm of the NAIC, has posted a copy of the letter under the documents tab in its section of the NAIC’s website.

What it means: For financial professionals who have clients enrolled in Medicare Advantage plans, the impact of the 2025 plan changes could be comparable to the effects of the 2007-2009 Great Recession and the COVID-19 pandemic.

If CMS officials, insurers and health care providers do not find a way to reduce the impact of the plan changes, even financial professionals who have nothing to do with selling Medicare Advantage plans or related products and services themselves may finding themselves trying to advise clients who have no idea where else to turn for help.

The NAIC officials point out that state insurance department employees are already getting many difficult questions from consumers affected by the plan changes.

“State departments of insurance across the country are fielding consumer inquiries about the withdrawal of their providers from MA plans,” officials write. “Since states do not regulate these plans, [Department of Insurance] staff are unable to offer recommendations to consumers beyond referring them to CMS or the administrator of their MA plan.”

The changes could also have a bearing on the November general elections, because the plan changes and resulting confusion are hitting as enrollees and their relatives are about to vote.

The background: Medicare is a federal program that uses revenue from federal payroll taxes to pay for care for people ages 65 and older, some people with disabilities and some people with severe kidney disease.

The original Medicare program was designed in the 1960s and exposes enrollees to many deductibles, coinsurance bills and copayment costs.

About 34 million of the 67 million enrollees use Medicare Advantage plans, which are regulated at the federal level, to fill coverage gaps in in original Medicare.

Another 15 million use an older type of coverage, Medicare supplement insurance, which is often called “Medigap” insurance. Medigap insurance is based on federal laws passed in 1992 but regulated at the state level.

Consumers over 65 can enroll in Medicare Advantage plan coverage without facing medical underwriting both around the time they turn 65 and during an annual enrollment period that runs from Oct. 15 through Dec. 7 every year. They may also be eligible for some other special enrollment periods after they age out of their original signup period.

Medigap underwriting rules differ from state to state. Consumers have a guaranteed ability to sign up without facing medical underwriting only during a signup period around the time they turn 65.

Some states provide more chances for consumers to get Medigap coverage on a guaranteed-issue basis. But, in many states, consumers who age out of the original Medical signup period and suffer from heart disease or cancer have little or no ability to buy Medigap coverage.

Sick consumers can get some ability to buy Medigap after the initial signup period if they qualify for special election period exceptions built into the federal rules. Reasons for Medigap special election periods include moving to a new community and determinations by federal Medicare Advantage plan program managers that a plan has made a “significant provider network change.”

The letter: NAIC President Andrew Mais, Connecticut’s insurance regulator, and three other top NAIC officers signed the letter.

They are asking Brooks-LaSure to tell them how CMS will determine whether a plan has made a “significant provider network change” that could lead to an enrollee getting automatic access to a special election period.

The NAIC officials believe the CMS Medicare Drug and Health Plan Contract and Administration Group is in charge of the options.

A representative from that group was going to speak at a recent NAIC national meeting session, but the representative canceled the appearance right before the meeting, officials write.

The officials are asking Brooks-LaSure to have CMS give a Medicare Advantage plan enrollee an automatic right to sign up for a Medigap policy on a guaranteed-issue basis, without medical underwriting, if a hospital or provider group leaves a Medicare Advantage plan network.

Regulators are also asking Brooks-LaSure:

• Whether Medicare program managers will decide that a plan’s enrollees qualify for a special election period based on significant provider network change enrollee-by-enrollee, for all enrollees or for specified groups of enrollees.
• Whether program managers will consider how far patients are from other in-network providers or how long it would take patients to get to the providers who are still in network when deciding whether patients qualify for special election periods.
• How program managers will communicate decisions about special election period eligibility to the affected patients and to state insurance regulators.
• Whether state insurance regulators can help program managers with special election period determinations.
• What individual patients have to do after program managers make special election period determinations.
• Whether Medicare Advantage plans will have to offer “continuity of care” protections, and cover care from some out-of-network providers as if they were still in-network, for patients who lose a key provider due to network changes.

The NAIC officials said requiring individual patients to try to contact CMS would cause an undue burden for those patients.

“We do not believe a burden should be placed upon beneficiary policyholders,” the NAIC officials write.

Credit: CMS