The Pennsylvania Health Law Project (PHLP), Community Legal Services of Philadelphia, and the Center for Medicare Advocacy reached a verbal settlement agreement with the Centers for Medicare and Medicaid Services (CMS) in Erb v. McClellan on behalf of the over 110,000 individuals with Medicare and Medicaid who were passively enrolled into a Medicare managed care organization (MCO). PHLP shared the terms of the verbal agreement with PCPA. The verbal settlement agreement will be reduced to writing and shared in the future.
- The transition period will be extended through June 30. During this period those who were passively enrolled in a Medicare MCO can continue to see out-of-network providers, will not be subject to prior authorization requirements, and can continue to receive non-formulary medications that they were taking prior to January 1.
- All passively enrolled individuals must make a decision by June 30 whether to remain in the MCO or disenroll. If an individual is uncertain whether the MCO will cover the medications and providers that the individual needs, then legal advocacy groups recommend that the individual disenroll from the MCO.
- Individuals can disenroll by selecting another plan to be effective the first of the next month, calling 800-MEDICARE and requesting disenrollment effective either the first day of the following month or the first day of the current month, or faxing a written disenrollment request to the CMS regional office at 215-861-4140. Those who disenroll are to receive confirmation within seven days and are held harmless for any charges incurred as a result of delays in processing disenrollments.
- Dual eligible individuals who were passively enrolled in a Medicare MCO will receive written notice from CMS with the next week informing them of the changes to the transition period and of options for disenrollment.
- Providers that bill Medicare will also receive notice from CMS.
- The Medicare MCOs must contact enrollees who have used out-of-network providers to inform them that the provider is not in the network and that they must select another provider or another form of coverage.
- PHLP and Community Legal Services request that problems be reported to them for tracking and referral to CMS. Problems can be addressed to PHLP (800-274-3258 or ahalperin@phlp.org) or to Community Legal Services at (215-227-2400, x2418 or kcostello@clsphila.org).
- The Pennsylvania APPRISE Program (800-783-7067) is available to assist individuals in selecting the right plan to meet their needs.
Contact Betty Simmonds with questions.
