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Medicare Advantage HMO NOT Accepted at Nursing Home? | Life


Hello Tony:

My mom has a Medicare Advantage HMO and on August 1 she moved into a nursing home. They have a doctor who visits patients who don’t accept the HMO she has. The director of the retirement home advises me to unregister her from this plan, so that my mother can call on the doctor of the retirement home. Otherwise, they will have to ambulance her when she needs medical attention. Is there a way for her to get moving before Medicare open enrollment in October? I need to do this ASAP and put her on Original Medicare.

I have followed your column and I have never seen you address this type of problem. What do I have to do?



There is help for your mother and it really isn’t as hard as you think.

Typically, I write about Special Enrollment Periods (SEPs) for those over 65, retiring and leaving company benefits, but there is a SEP for those moving to care facilities such as nursing homes.

The Medicare and You Handbook talks about specific SEPs for Medicare Advantage plans: “In most cases, if you are enrolled in a Medicare Advantage plan, you must remain enrolled for the calendar year from the start date of your cover. However, in some situations…you may be able to join, switch, or drop out of a Medicare Advantage plan during a special enrollment period.

The following are examples of MS from the Medicare Advantage plan:

–Moved out of area

–Enrolled in Medicaid

–Qualified for “Additional Help” for prescription drugs

–Moved to an institution such as a nursing home (for which your mother qualifies) or a long-term care hospital

–Loss of creditable prescription drug coverage insurance (through your employer)

The trick to opting out of a Medicare Advantage plan when an SEP is granted is to enroll in a standalone Part D plan and be able to answer “yes” to the qualifying question: did you move into a long term care facility within 2 months, or did you leave a long term care facility within 2 months?

You will need to contact Medicare at 800-633-4227 to change the SEP and give Medicare Customer Service all of your mother’s current prescriptions. They will enroll him in the Medicare Part D prescription drug plan that will meet his needs. The Medicare representative will ask you for the date she moved into the nursing facility, and it must be within that 2 month window.

If you wait beyond the 2-month window, you will have to wait for Medicare’s annual open enrollment period, which runs from October 15 to December 7 each year.

When Medicare enrolls your mother in the new Medicare Part D plan, she will be de-enrolled from the Medicare Advantage plan and revert to original/traditional health insurance. This will take effect on the first day of the following month.

Remember that with Original Medicare, she will have a Medicare Part A (inpatient inpatient) deductible for 2022 of $1556 every 60 days or 6 times a year and a single annual Medicare Part B (medical insurance) deductible that changes every year. The Medicare Part B deductible for 2022 is $233 and once the deductible is reached, Medicare pays 80% and the Medicare beneficiary (your mother) pays 20% of the Medicare-approved amount. She may qualify for a Medicare supplement by answering health underwriting questions.

Stephanie, your mother’s Medicare Advantage HMO plan situation is why someone enrolling in Medicare should consider the various Medicare options. No one ever knows when serious illness will strike, and they may need serious medical attention.

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Toni King is an author and columnist on Medicare and Medicare issues. She has spent over 27 years as a sales leader in the fields. For answers to Medicare questions, email: info@tonisays.com or call 832-519-8664.