Tag: Wellcare

When Medicare Advantage Drops Doctors, Some Members Can Switch Plans

By Susan Jaffe  | Kaiser Health News | March 29, 2016 | This KHN story also ran on  nprlogo_112x37

Eliza Catchings has been seeing doctors at the Christie Clinic in central Illinois since 1957. But just after receiving this year’s WellCare Medicare Advantage member card, the insurer told her the clinic was leaving WellCare’s provider network and she would have to choose new doctors.

“I was terrified,” said Catchings, 79, who gets care for diabetes and heart problems. But she was helped by a little-noticed change in federal policy.

Medicare Advantage plans sold by private insurers are an alternative to traditional Medicare, but they cover services only from doctors, hospitals and other providers that are in the insurer’s network. Although providers are allowed to drop out of the plans any time, members can usually change only during the annual sign-up period in the fall. There are exceptions, but until recently losing a provider was not among them.

After insurers dropped hundreds of providers in 2013, the Centers for Medicare and Medicaid Services issued rules giving people a “special enrollment period” to change plans or join regular Medicare if there was a “significant” change in their provider network. The policy took effect in 2015 and applies only to Medicare Advantage members, not to the plans CMS oversees in the health law’s marketplaces. …Yet officials didn’t explain what they considered significant or what would trigger the option.

In the past eight months, Medicare officials have quietly granted the special enrollment periods to more than 15,000 Medicare Advantage members in seven states, the District of Columbia and Puerto Rico based on provider cuts. These decisions offer important details about how members can get permission to follow their doctors who leave their plans. … Medicare doesn’t publicize the option, and few beneficiaries may know about it. Representatives who answered calls earlier in March to Medicare’s toll-free number said nothing could be done.  [Continued on Kaiser Health News or NPR] 

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Dialysis crisis followed shift by Medicaid

By Susan Jaffe | Plain Dealer Reporter | February 12, 2007

 For the past year, a dialysis machine has been keeping Karletta Edwards’ mother alive, substituting for her kidneys to cleanse her blood three times a week.

But in January, shortly after Ohio’s Medicaid program transferred her, along with more than 25,000 other low-income people in Northeast Ohio, into an HMO, something went wrong.

The state’s contracts with insurance companies are expected to save Medicaid $24 million this year, by the time some 125,000 blind, disabled or older people are placed in privately run managed care plans.

Even though the companies are paid 6.6 percent less, Medicaid’s average cost to care for the same population, state officials say the health coverage will remain the same…. Four weeks ago, Edwards received a desperate call from her mother. The transportation service that picked up Emma Hansen from her East Cleveland  home and brought her to the dialysis center didn’t show up. [Continued here]