Enrollment and Disenrollment in Medicare Plans: LTC Facility Responsibilities
Jeannine LeCompte, Compliance Research Specialist
Although any change in a resident’s healthcare coverage must be initiated by the beneficiary or their authorized representative, it follows that if they require assistance, a long-term care facility should have a mechanism in place to offer such help or guidance. To this end, it is helpful—especially for staff who might not be fully up to speed with the exact requirements—to have a written guide ready which can be given to the resident upon request.
This guide will be of great assistance to the resident, and will also ensure that the facility complies with the regulations regarding enrollment/disenrollment from Medicare plans—and that no resident rights are infringed upon. These resident rights are enumerated under the freedom of choice provisions of sections §1802 and §1902(a)(23) of the Social Security Act, which state that any individual entitled to insurance benefits under Medicare or Medicaid may obtain health services from any institution, agency, or person qualified to participate under that title, and have an absolute right to choose their Medicare Part D plans.
An important part of a facility’s written guide should be a full explanation of the impact to the beneficiary should they change plans—for example from original Medicare to a stand-alone drug plan. Such information must include an explanation, made in a manner which is understandable to the recipient and/or his or her representative, that should they change plans, they might lose or gain certain benefits and that deductibles and co-pays might increase or decrease.
In addition, specific information with regard to changes in membership of Medicare Advantage prescription drug plans (MAPDs) or Medicare-Medicaid plans (MMP) might lead to changes in prescription drug coverage.
It is also important for recipients to understand that once a change in Medicare options has been made, it may not be possible to change back (for example, a recipient may not be able to re-enroll in an MAPD) and that benefits surrendered in this way can be lost forever.
The written policy guide should also specify under which circumstances the facility can assist a beneficiary with a plan change, and contain the requirement that the recipient or their representative sign a document acknowledging full understanding of the information provided to them. This is particularly important when there is a change in coverage. This signed document should also contain an attestation signed by the facility staff member that assisted with the change in enrollment stating that the recipient requested the change.
