Changing Medicare Part D Plans after AEP

Every year, there is a time to enroll into a Medicare part D prescription drug plan. This happens during the annual enrollment period, AEP. Once that time ends, most people are not able to enroll into a different prescription drug plan for any reason. The choice they made during that time of the year is usually the choice they have to say with for the rest of that calendar year. Those that didn’t make any changes will remain with their previous carrier for the next calendar year. Every year, thousands of enrollees are surprised when they request a change to a different provider and are told they are not able to enroll into a different prescription drug plan until the next AEP or unless they have a special election period, SEP.

Those that want to change after an enrollment period has changed normally have these thoughts when they run into an unexpected problem. They may have assumed a medication was covered by their prescription drug plan and it’s not. They may have assumed their expenses wouldn’t be as much as they are. There are a number of reasons a Medicare beneficiary may want to change prescription drug plans. While those problems and concerns are valid, those reasons won’t allow them to change their prescription drug plan.

Why Can’t It Be Changed?

When the Medicare part D prescription drug plan program was created, it was created so that approved insurance providers could offer the plans to the public. Although the insurance providers are independent, they have to follow the rules that were set by the Centers for Medicaid and Medicare Services, CMS. CMS is the governing board for all Medicare part D providers and if those rules are not followed, the insurance providers face penalties and the risk of having their approval taken.

The Centers for Medicaid and Medicare Services created the rules of enrollment and the length of time for coverage. CMS says that unless there is a ruling from CMS, an IEP (initial enrollment period) or SEP (special election period), the beneficiary cannot change their prescription drug plan provider until the next annual enrollment period. Those that have grave concerns with their Medicare prescription drug plan provider can always appeal to CMS to have their provider changed but it can’t be done by the insurance provider.

Enrollment Period Options

Although people have valid concerns and want to change their prescription drug plans when they are dissatisfied, there are specific times that can be done without CMS interference. Those that want to change their Medicare prescription drug options find it’s easy to do if they fall into one of the other enrollment options.

IEP-Initial Enrollment Period- The Initial Enrollment Period for Medicare part D prescription drug plans happens routinely for those that are Medicare eligible.

Those that meet these requirements are able to enroll into a different prescription drug plan than the one they currently have:

·         Newly eligible for Medicare because of disability

·         Just turned 65 years old

·         Just enrolled in Medicare Part A

·         Just enrolled in Medicare Part B

Those are the most common qualifiers for those that want to enroll in a prescription drug plan that is different from their current provider.

SEP-Special Enrollment/Election Period- A special election period is a period of time that makes a person eligible to change from one prescription drug plan provider to another for a very specific reason. There are times that things happen through no fault of the Medicare beneficiary. CMS realizes that and has made a set standard of reasons available for those that need to change their plans. These situations include:

·         Moved from the service area

·         Just moved back into the country

·         Just moved into/out of an institution

·         Just released from jail/prison

·         Currently living in a long term care facility

·         Receiving LIS (low income subsidy)

·         Receiving SPAP assistance (receiving state pharmaceutical assistance program help)

·         Loss of employer coverage

·         Involuntary loss of credible coverage (the plan is no longer available)

There are several other reasons that would allow a person to change from one prescription drug plan to another in the middle of the benefit year. Those that qualify for a special election period will be able to change their Medicare prescription drug plan by calling the company they want to carry their prescription drug plan or they can call CMS to make the change.

For those that are having problems with their prescription drug plans but don’t fall under those categories, CMS is available to help. There are many other circumstances that aren’t listed or discussed. When there is a problem with a prescription drug plan provider, it’s best to try to work things out with that provider. If no compromise can be made, CMS will make the final determination.

Dec. 23 13'
My wife has Humana Gold Plus (HMO): Her Dr has suggested she get a Bone Density [Bone Mass Measurement]check. She had this done a year ago. In your 2012 Member Benefit Package book under Preventive Services , Item 23, under Original Medicare it sattes -Bone Mass Measurement. Covered once every 24 months . While under adjoining column Humana Gold Plus H1406-022 (HMO) Bone Mass Measurement it makes no mention of the once every 24 months restriction.My question: Is she covered under this insurance if she opts to have this test, or does she have to wait until the 24 months since her last test to be covered?Also, her primary Dr has also requested she undergo a Colonoscopy.My question: Does she require a referral to be covered.?
May. 26 14'

Get in on the discussion!