Medicare Advantage ʺseamless conversionʺ

What is Medicare Advantage ʺseamless conversionʺ and why is it important to UR practices?

“Seamless conversion” refers to a carrier’s ability to automatically enroll patients, who are currently covered by that same carrier (e.g., an Exchange product or other commercial plan), into its Medicare Advantage (MA) Plan when those patients become eligible for Medicare (typically when turning 65). Plans must be approved to offer seamless conversion by CMS, and must provide 60 days’ notice to patients who may then choose to opt out of being automatically enrolled in the Plan. While seamless conversion is not new, and was authorized as part of the Balanced Budget Act in 1997 with guidance issued in 2005, the policy has recently undergone scrutiny for potentially inadequately protecting patients who may be surprised to learn of the provider network or cost-sharing features of their plan. The criticism for the process likely comes as a result of increasing controversy over the narrowing of provider networks as highlighted by July reports by Kaiser Health News and the Washington Post, which focused on cases of patients who were not aware of having been converted to MA Plans, and were no longer able to see their same providers, since the process does not require patients to actively “opt in”.

While Medicare Advantage plan design varies significantly from plan to plan, a patient’s network and cost-sharing requirements could change substantially once enrolled. UR practices should be aware of what Plans in their market, if any, currently participate in “seamless conversion” and educate patients on how the new coverage could impact their ability to continue to see their current providers.

CMS issued an October 21st statement that it is “temporarily” suspending acceptance of any new seamless enrollment proposals while it reviews its policies related to seamless conversion. Those MA plans already approved, however, are allowed to continue seamless conversion of members. For a list of plans currently approved for seamless conversion, please see the chart below.

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