Annual Disenrollment SEP

Feb 2, 2016

  1. insuranceconceptscindy
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    insuranceconceptscindy Guru

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    I'm pretty sure I know the answer, but maybe you guys can help me with a loophole.

    Client signed up for MAPD 4/2013 ($0 plan premium). Had LEP, which came out to $5 per month. We elected SSA deduction. In April 2014, she got a letter saying pay back premiums for the year (2014), she did. Turns out SSA stopped her deduction arbitrarily in 2014. She's now on monthly bill for her LEP, all is good.

    Fast forward to 1/2016- she calls me to ask why the pharmacy said she doesn't have coverage. Odd. I call the plan and they tell me she had not made her LEP premium payment since April 2014! They have let it ride the whole time and now cancelled her. :goofy:

    Any way we can do an ADP SEP to at least get her a PDP? I'm sure there is a rule that says it must be a voluntary disenrollment, but I can't find it.
     
  2. WCMason
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    WCMason Guru

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    There is no ADP, only an MADP. And, unfortunately, since she is not currently in an MA plan, there is no MA to disenroll from.

    Her longshot chance is to request a good cause reinstatement back into the plan that terminated her. Here is a publication that talks about plan termination due to nonpayment of premium:

    https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/downloads/11338-P.pdf
     
    WCMason, Feb 2, 2016
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  3. TwoCents
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    From 1/1 to 2/14 a person has the MADP election to disenroll from a Medicare Advantage plan (with or without drug coverage). A person using this particular election has a coordinating election to enroll into a stand-alone PDP. Since your client did not use the MADP election to terminate her MA then she is not qualified to enroll into a PDP.

    Answer derived from the 2016 CMS Medicare Prescription Drug Benefit Manual Chapter 3 "Eligibility, Enrollment, and Disenrollment" 30.3.8 Item 8D pg 33.
     
  4. insuranceconceptscindy
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    Thank you guys for the links! I got more information- she was actually termed 12/1/15. So there is no loophole. I am having her call Medicare to beg for an SEP, but I can't imagine they would do it for her, since she hasn't paid a dime in almost 2 years.
     
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