Help me solve this problem!

[shonceman]

My wife and I are on Traditional A&B with a plan G supp. My wife has a pretty severe case of fibromyalgia, and is under care of a pain management practice. Because her pain meds are controlled, she’s required to see them for an office visit once a month. This evening, we received the following letter in the mail (dated 11/20 but envelope not postmarked until 12/6!):

We are writing you to let you know our NEW Office Policy for 2024 that will be going into effect as of January 1st, 2024. To all our patients who are currently Traditional Medicare Members (Red, White & Blue Card) as of December 31 2023 we will NOT be renewing our contract in 2024 with Traditional Medicare. That means that you will either have to get a Medicare Replacement Card or become a Self Pay/Cash payer to remain with us.

If you decide to be a self pay patient you will be responsible for $150.00 per visit that is due at time of service. For those of you who decide to switch to a Medicare Replacement Card for 2024 we are in contract with most Medicare Replacement Plans. Should you have questions….yada yada….

As ticked off as we both are about this, my wife would rather not have to find another clinic. So we’re in a bit of a dilemma. I’m assuming “Medicare Replacement plans” means Med Advantage, correct? AEP just ended on 12/7, correct? SO… we might have considered switching to MA if AEP had not just ended THE DAY BEFORE WE GOT THE LETTER!
If they had mailed it out within a day or two of the date on the letter itself, we wouldn’t be having this problem!!!

I never wrote much MA, and it’s been long enough ago that there was no AEP at that time. So I don’t know if there’s a way around the deadline. Would there be an exception in a case like this or are we just stuck until next AEP?

 

[LostDollar]

@kgmom219 is a forum member, a medicare pro, and local to you.

 

[somarco]

Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so.

Medicare will not pay for care you receive from an opt-out provider (except in emergencies).

You are responsible for the entire cost of your care.

The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.

Opt-out providers do not bill Medicare for services you receive.

[EXTERNAL LINK] - Participating, non-participating, and opt-out Medicare providers


I also found this which needs more exploration . . .

Prior to the 2019 plan year, physicians who are providing services to Medicare Advantage (MA) enrollees are required to enroll as Medicare providers. Currently, healthcare providers are not required to be enrolled in Medicare in order to bill for services provided to MA enrollees, whether those services are covered under the standard or a supplemental MA benefit. However, CMS issued a Final Rule on Nov. 15, 2016, that will require network or contracted providers to be enrolled as Medicare providers starting in 2019, even if the services delivered are covered only under an MA supplemental benefit. 81 Fed. Reg. 80170, 80445. There are other circumstances in which providers must be enrolled in Medicare as of 2019, for example, if providers or suppliers are considered first-tier, downstream and related entities of the MA organization, or participating in a demonstration or pilot program.

[EXTERNAL LINK] - Are Medicare Advantage Physicians Required to Enroll In Medicare? | Insights | Holland & Knight

 

[LostDollar]

is this relevant?
[EXTERNAL LINK] - Medicare Enrollment for Providers No Longer Required Under Medicare Parts C and D | Foley & Lardner LLP

 

[somarco]

is this relevant?
[EXTERNAL LINK] - Medicare Enrollment for Providers No Longer Required Under Medicare Parts C and D | Foley & Lardner LLP

Possibly . . . your link is 2018, mine was 2017.

The opt-out database might be a starting point for @shonceman
[EXTERNAL LINK] - Centers for Medicare & Medicaid Services Data

If they have in fact opted out, there is still this requirement.

The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you.

I still find it odd that a provider would opt out of OM and only participate in MA plans.

And . . . opting out has its' own issues. If I read this chart correctly, it appears a provider cannot opt out of Medicare but participate in MA plans.

https://www.cms.gov/Medicare/Provid...ds/opt-out-decision-matrix-[October-2015].pdf

More on providers withdrawing from OM
https://www.cms.gov/medicare/enroll...p-system-pecos/manage-your-enrollment#opt-out

https://www.ama-assn.org/system/files/2019-05/medicare-options-faq.pdf

 

[sshafran]

My wife and I are on Traditional A&B with a plan G supp. My wife has a pretty severe case of fibromyalgia, and is under care of a pain management practice. Because her pain meds are controlled, she’s required to see them for an office visit once a month. This evening, we received the following letter in the mail (dated 11/20 but envelope not postmarked until 12/6!):

We are writing you to let you know our NEW Office Policy for 2024 that will be going into effect as of January 1st, 2024. To all our patients who are currently Traditional Medicare Members (Red, White & Blue Card) as of December 31 2023 we will NOT be renewing our contract in 2024 with Traditional Medicare. That means that you will either have to get a Medicare Replacement Card or become a Self Pay/Cash payer to remain with us.

If you decide to be a self pay patient you will be responsible for $150.00 per visit that is due at time of service. For those of you who decide to switch to a Medicare Replacement Card for 2024 we are in contract with most Medicare Replacement Plans. Should you have questions….yada yada….

As ticked off as we both are about this, my wife would rather not have to find another clinic. So we’re in a bit of a dilemma. I’m assuming “Medicare Replacement plans” means Med Advantage, correct? AEP just ended on 12/7, correct? SO… we might have considered switching to MA if AEP had not just ended THE DAY BEFORE WE GOT THE LETTER!
If they had mailed it out within a day or two of the date on the letter itself, we wouldn’t be having this problem!!!

I never wrote much MA, and it’s been long enough ago that there was no AEP at that time. So I don’t know if there’s a way around the deadline. Would there be an exception in a case like this or are we just stuck until next AEP?

What state/county are you in? There may be an SEP.

 

[shonceman]

What state/county are you in? There may be an SEP.

Texas - Collin County

 

[LostDollar]

@somarco

I'm sorry, my attention span, reading speed, and reading comprehension is now so poor I cannot begin to read the documents you've linked and relate them to each other.

That's why on the one document I linked, I just asked if it was relevant.

4 brief comments in case they are useful, if not, please just disregard them.

1-the date of the opt out doct is 2015, compared to 2016,2017,2018 and 2019 in other information.

2- I think it was back in 2016,2017,2018, somewhere in those timeframes, there was a lot of discussion about The Villages in FL and their restrictive medical provider situation. I can't remember if that was OM or MA related.

3-Somewhere in a recent thread there was mention of a doc dropping out of Original Medicare. I don't think there were any other details of the situation provided in the post. I don't know if this might be a precursor example of things to come.

4-I think I have the poster right, In a recent thread @Bryan Smith posted about receiving kudos from 1 or more providers for helping them get going with MA and the additional income MA gave the providers. There was no mention of whether or not the providers dropped OM and did only MA or whether the providers dispensed both OM/Medigap/PDP and MA services.

 

[sshafran]

It's not common to see this but it may become more common in the future. Not every provider hates MA.

 

[ValeRosso]

This wouldn't qualify for a SEP. Unless someone knows of any tricks, you're stuck for now.