When your doctors leave your Medicare HMO, will the government protect you?

If you opt for an insurer-run Medicare Advantage HMO over government-run traditional Medicare, be prepared for your treating physicians and hospital to leave the HMO’s network. As Susan Jaffe reports for Kaiser Health News, people in Medicare HMOs often face the prospect of either changing their physicians or leaving their HMOs in order to remain with their physicians. But, if they want to disenroll from their HMOs to stay with their physicians, only sometimes will the government grant them a Special Enrollment Period, to switch to traditional Medicare with the guaranteed right to buy supplemental coverage, or another HMO.

Jaffe profiles one older man enrolled in a Humana HMO in Texas, who switched Medicare HMOs to remain with his physicians after they left the Humana HMO. He was luckier than many other Medicare HMO enrollees. Most Medicare HMO enrollees are locked into their Medicare HMOs until the Medicare annual open enrollment period.

More recently, however, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare HMOs, has been giving people, whose physicians or hospitals leave their networks, a three-month Special Enrollment Period. Enrollees can then switch to another Medicare HMO or to traditional Medicare, which has no network and covers care from virtually all doctors and hospitals in the US.

Medicare’s Special Enrollment Period triggers another important right for enrollees. They have a guaranteed right to enroll in a Medicare supplement insurance (Medigap) plan if they switch to traditional Medicare. Insurers cannot turn them away because of their health or charge them more for their coverage. In all but four states–New York, Connecticut, Massachusetts and Maine–Medicare HMO enrollees tend to be locked out of traditional Medicare because they have no right to buy Medicare supplemental insurance and traditional Medicare lacks an out-of-pocket maximum. Insurers can turn people away or charge them high premiums because of preexisting conditions.

Still, CMS allows insurers to enroll people in their Medicare HMOs without alerting people to the fact that key physicians and hospitals are no longer in-network. And, many physicians and hospitals are leaving Medicare HMO networks because the insurers are not paying them appropriately, or denying patients needed care or forcing physicians to spend precious time explaining and justifying their treatment decisions. Indeed in the last two years, triple the number of providers have left Medicare HMO plans as in the past.

In the last 10 months, 41 hospital systems have ended their contracts with 62 Medicare HMOs in 25 states. And, CMS has given some enrollees the ability to disenroll without penalty. But, for reasons that are unclear, Jaffe reports that CMS would neither disclose the Medicare HMOs whose enrollees they gave a Special Enrollment Period nor whether these Medicare HMOs had adequate networks–a sufficient number of physicians and hospitals within a particular travel distance.

Why the secrecy at CMS? As Senator Wyden says, Medicare HMO enrollees should be told that they have a right to switch to traditional Medicare or another HMO when their physicians or hospitals leave the HMO network. The National Association of Insurance Commissioners (NAIC) is seriously concerned about financial and physical harm to Medicare HMO enrollees: “State regulators in several states are seeing hospitals and crucial provider groups making decisions to no longer contract with any MA plans, which can leave enrollees without ready access to care. Lack of CMS guidance could result in unnecessary financial or medical injury to America’s seniors.” Why aren’t Medicare HMO enrollees receiving notice of their rights and free help?

The NAIC wants CMS to give everyone in a Medicare HMO who loses their doctors or hospital the ability to leave during a Special Enrollment Period. Enrollees should not have to figure out their options for themselves.

Last year, 15,000 Humana Medicare HMO enrollees lost coverage from Sanford Health, a very large rural health system in seven states. Sanford’s chief financial officer said it left Humana’s network primarily because Humana was inappropriately delaying and denying care their patients needed. Sadly, concerns about insurers ignoring patient safety and well-being is the typical reason providers leave Medicare HMO networks.

Similarly, around 1,200 Nebraskans enrolled in Great Plains Health HMO, lost their key network providers. They had no choice but to enroll in traditional Medicare. Yet, it took their insurance commissioner six months to persuade CMS to give them a Special Enrollment Period so that they had a guaranteed right to buy a Medigap policy without paying extra because of pre-existing conditions.

And, Delaware’s insurance commissioner had to advocate to CMS to give Cigna Medicare HMO enrollees, who lost coverage from the Bayhealth medical system, the right to a Special Enrollment Period.