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Life Health > Health Insurance > Medicare Planning

Feds Toughen Private Medicare Plan Suspension Rules

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The federal government may give Medicare managed care plans more authority to eject disruptive patients.[@@]

The Centers for Medicare and Medicaid Services included that relief for private insurers in one section of a mammoth package of proposed regulations that was released Monday. CMS, the arm of the U.S. Department of Health and Human Services, is proposing the regulations in an effort to implement the Medicare drug benefit and Medicare managed care plan provisions of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

In the past, officials encouraged private health maintenance organizations to participate in the Medicare program, but disputes over reimbursement rates and program rules eventually caused many private HMOs to abandon Medicare. The percentage of Medicare beneficiaries enrolled in Medicare HMOs dropped to 11% this year, from a high of 16% in 1999.

MPDIMA calls for the government to encourage participation by preferred provider organization plans and tempt private insurers back to Medicare with new reimbursement arrangements and changes in program rules.

In the past, private Medicare HMOs had a hard time knowing what to do about disruptive patients and patients who consistently failed to pay co-payments.

The rules would give private HMOs and PPOs more freedom to kick out disruptive patients and deadbeats.

Private Medicare plans would have to keep patients whose disruptive behavior stems from “diminished mental capacity,” but plans could kick out patients “whose violent and threatening behavior put the health and safety of enrollees, staff and the public at risk,” according to a discussion that accompanies the drafts of the proposed regulations.

The proposed rules also provide for an expedited disenrollment process “where there is an immediate threat of health and safety to others” and a higher barrier for reinstatement for individuals kicked out under those circumstances.

Officials are asking for suggestions from the public about the language they should use when referring to the handling of people who chronically fail to come up with their co-pays. Under the proposal, language about chronic failure to make co-payments would be included under the disruptive behavior provision “because it limits the health plan’s ability to provide services both to the individual and potentially to other enrollees.”

Drafts of the new proposed regulations are on the Web at


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