Medicaid Medicare Your Coverage Options

People with Medicare and Medicaid in Special Needs Plans at extra risk

Written by Diane Archer

A paper in Health Affairs by Marc A. Cohen et al. explains that people with Medicare and Medicaid, “dual-eligibles,” enrolled in commercial Medicare Special Needs Plans, a type of Medicare Advantage plan, are now at extra risk. A new guideline by the Center for Medicare and Medicaid Services (CMS) severely restricts their right to disenroll from these plans. Yet, the data show that dual-eligibles with complex conditions may need to leave Special Needs Plans in order to get appropriate care.

Dual-eligibles with complex conditions have been disenrolling at high rates from Special Needs Plans. And, it’s likely it’s because they are not getting the care they need. It’s hard to believe that dual-eligibles are jumping at the chance to leave their SNPs if they are getting the care they need. Changing health plans is never fun, always involves time and energy, and usually also stress and frustration.

Keeping enrollees who choose to leave SNPs from disenrolling is not in these enrollees’ best interests. As of January 1, 2019, however, dual-eligibles may not leave their Special Needs Plan any month of the year, a protection they have always had. They must remain in their SNPs for at least three months, except during the Medicare Advantage Open Enrollment Period, between January and March of each year. Many states limit the disenrollment rights of dual-eligibles even further.

The new guideline from the Centers for Medicare and Medicaid Services (CMS) supports the financial interests of Special Needs Plans (SNPs) that fail to provide good care to their enrollees. Cohen et al. explain that there is a high correlation between enrollees with complex conditions disenrolling from SNPs and low-quality SNPs. Another recent study showed high rates of disenrollment from Medicare Advantage plans for dual-eligibles with complex conditions.

The new policy compromises the health of low income older adults and people with disabilities. It gives SNPs the ability to count on additional Medicare and Medicaid income that they previously had not been able to count on, even when they deliver poor care. Supporters of the new policy claim that it gives enrollees more time to adjust to the SNPs. Of course, if the SNPs are not serving their needs, it’s unclear why forcing enrollees to remain in the SNPs is helpful to them.

To determine whether disenrollment from SNPs was associated with poor SNP performance, the paper’s authors looked at SNP quality measures. They found that the SNPs with poor performance were far more likely to see high disenrollment rates. Unfortunately, dissatisfied enrollees will no longer be able to leave as quickly as they had been able to.

Here’s more from Just Care:


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