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Janie Slaven: TONI SAYS: Medicare Advantage HMO NOT accepted at nursing home?

Times-Tribune - 9/15/2022

Sep. 14—Hello Toni:

My mother has a Medicare Advantage HMO and on August 1 she moved into a nursing home. They have a doctor who visits the patients who does not accept the HMO that she has. The nursing home director is advising me to disenroll her from this plan, so my mother can use the nursing home facility doctor. Otherwise, they will have to ambulance her when she needs medical care. Is there a way that she can make a move before Medicare open enrollment in October? I need to do this ASAP and get her on Original Medicare.

I have been following your column and have never seen you address this type of issue. What do I need to do?



There is help for your mother and it really is not as hard as you may think.

Typically, I write about Special Enrollment Periods (SEP) for those who are past 65, retiring and leaving their company benefits, but there is an SEP for those who are moving into institutional care such as nursing homes.

The Medicare and You Handbook talks about the specific SEPs for Medicare Advantage plans: "In most cases, if you're enrolled in a Medicare Advantage Plan, you must stay enrolled for the calendar year starting the date your coverage begins. However, in certain situations ... you may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period."

Examples of Medicare Advantage Plan SEPs are:

—Moved Out of Area

—Enrolled in Medicaid

—Qualified for "Extra Help" for prescription drugs

—Moved into an institution like a nursing home (which your mother qualifies for) or a long-term care hospital

—Lost creditable prescription drug coverage insurance (through your employer)

The trick to disenrolling from a Medicare Advantage Plan when an SEP is granted is to enroll in a stand-alone Part D plan and being able to answer "yes" to the qualifying question: Have you moved into a long-term care facility within a 2-month period, or have you moved out of a long-term care facility within a 2-month period?

You will need to contact Medicare at 800-633-4227 to make the SEP change and give the Medicare customer service all your mother's current prescriptions. They will enroll her into whichever Medicare Part D prescription drug plan fits her needs. The Medicare representative will ask you for the date she moved into the nursing home facility, and it must be within that 2-month window.

If you wait past the 2-month window, then you will have to wait until Medicare's annual open enrollment period which is from October 15 to December 7 every year.

When Medicare enrolls your mother into the new Medicare Part D plan, she will be disenrolled from the Medicare Advantage plan and back to Original/Traditional Medicare. This will be effective on the first day of the next month.

Remember that with Original Medicare, she will have a Medicare Part A (inpatient hospital) deductible for 2022 of $1556 every 60 days or 6 times a year and a Medicare Part B (medical insurance) one-time annual deductible which changes each year. The Medicare Part B deductible for 2022 is $233 and after the deductible is met, 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 the health underwriting questions.

Stephanie, your mother's Medicare Advantage HMO plan's situation is why a person enrolling in Medicare should consider Medicare's different options. No one ever knows when a serious illness will strike, and they may need serious medical care. — — — Toni King is an author and columnist on Medicare and health insurance issues. For answers to Medicare questions, email: or call 832-519-8664.


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