RCPA - Rehabilitation and Community Providers Association


Medicare Part D Passive Enrollment Lawsuit Planned
December 1, 2005

The Pennsylvania Health Law Project and Community Legal Services are planning to file a lawsuit against the Centers for Medicare and Medicaid Services “for permitting certain Medicare HMOs (health maintenance organizations) to disenroll some people without their consent from their regular Medicare coverage and put them in a Medicare HMO.” The involved parties are adults aged 21 and older who are Medicare beneficiaries and also are enrolled in AmeriHealth Mercy, Gateway, Keystone Mercy, UPMC for You, and MedPlus plans. On January 1, 2006 these individuals will receive services through a Medicare HMO that is owned by the same company that owns the Medical Assistance HMO in which they are currently enrolled. This process is known as passive enrollment.

Many Medicare beneficiaries will no longer be able to use the doctors (including psychiatrists), hospitals, clinics, laboratories, and other providers with which they are familiar and who had accepted Medicare coverage because they are not part of the Medicare HMO provider network. Medical Assistance will not be able to provide coverage as a secondary payer for services that are provided outside of the Medicare HMO network. The lawsuit is intended to stop this practice

The Pennsylvania Health Law Project has asked PCPA for help in identifying persons who may be affected by passive enrollment and may be interested in being a part of the lawsuit. They are interested in identifying persons aged 21 and older who are enrolled in “regular” Medicare and any of the above listed Medical Assistance managed care plans and meet any of the following criteria:

  • Have cognitive limitations, mental illness, visual impairments, or other functional limitations which limit their ability to read or understand the letter informing them that they would be switched from regular Medicare to a Medicare HMO; and
  • See doctors or use other providers that accept regular Medicare, but do not accept the Medicare HMO into which they will be switched; and
  • Have not yet asked to get out of the Medicare HMO or had problems when they tried to get out of that Medicare HMO.

PCPA members are requested to ask individuals that fit the description above or their substitute decision makers to contact David Gates at 717-236-6310 if they are interested in learning more about the lawsuit. There is no fee or obligation for calling and all calls are confidential.

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