Question: Hospitals vs Carriers available SEP to move client with MAPD

[Duaine]

A hospital group here in K.C. is in contract dispute with a carrier and will leave the carriers plan on 08/01/24. Letters went out from the carrier to the members so they are notified that they won't be in network as of that date if they don't settle.

I don't see any SEP's to use for this situation. Some agents are saying to use the "Disaster SEP" like the calling centers use all the time but I know that doesn't really fit the circumstance.

When I enroll clients in MAPD's I warn them of this but the $0 offer is irresistible to some of them and the others will never get sick or are too poor.

Any secret SEP's out there?

 

[yorkriver1]

If it's 100% sure, but some reconcile at the last minute.

 

[LostDollar]

If you are on the KS side, maybe there would be a storm disaster sep. I see something about Governor Kelly requesting an extension of some disaster declaration. Don't know about the MO side

 

[straightnochaser]

Just use DST if you need to.

 

[Crisfig]

There is a SEP for when the carrier drops a substantial amount of providers, and they will get a notice about it. If that is not the case, depending on the area and carriers available you might be able to find 5-star plans. I'd be careful with using the disaster SEP if the client has used the last enrollment periods since they will get denied.

 

[somarco]

@yorkriver1 is correct. MOST of these disputes are resolved at the 11th hour.

In late 2022 Northside Hospital in ATL was in a dispute with Anthem/BX. Negotiations were extended several times for 60 days or so. Finally a local court intervened.

As I recall the "no contract" situation went on for 6 - 8 months before finally being resolved. During that time the providers (Northside owns several clinics and provider groups) continued to accept patients.

This has happened in the past involving other carriers such as UHC but those negotiations were not as protracted.

Smaller, rural hospitals have more of a problem with carrier contracts. There are at least two hospitals in rural GA that have a "permanent" divorce with Anthem/BX that will probably never be resolved.

 

[Duaine]

No Five Star Plan in Missouri-Kansas City area.

 

[TwoCents]

There is an SEP for significant change in provider network, but it's not available to agents to write. The client has to call 800-Medicare.

 

[Duaine]

So client calls Medicare. Medicare moves client and agent is Sh*t Out of Luck?