TONI SAYS: Medicare Advantage HMO NOT accepted at nursing home? | Lifestyles

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Hello Toni:

My mother has a Medicare Advantage HMO and on August 1 she moved right into a nursing home. They’ve a physician who visits the patients who doesn’t 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 may must ambulance her when she needs medical care. Is there a way that she will make a move before Medicare open enrollment in October? I would like to do that ASAP and get her on Original Medicare.

I actually have been following your column and have never seen you address this kind of issue. What do I would like to do?

— Stephanie

Stephanie:

There may be help on your mother and it really will not be as hard as you might think.

Typically, I write about Special Enrollment Periods (SEP) for many who are past 65, retiring and leaving their company advantages, but there may be an SEP for many who are moving into institutional care corresponding to nursing homes.

The Medicare and You Handbook talks in regards to the specific SEPs for Medicare Advantage plans: “Normally, in the event you’re enrolled in a Medicare Advantage Plan, you will need to stay enrolled for the calendar 12 months starting the date your coverage begins. Nevertheless, in certain situations … you might give you the option to affix, 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 prescribed drugs

— Moved into an establishment 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 having the ability to answer “yes” to the qualifying query: Have you ever moved right into a long-term care facility inside a 2-month period, or have you ever moved out of a long-term care facility inside a 2-month period?

You will want to contact Medicare at 800-633-4227 to make the SEP change and provides the Medicare customer support all of your mother’s current prescriptions. They’ll enroll her into whichever Medicare Part D prescription drug plan matches her needs. The Medicare representative will ask you for the date she moved into the nursing home facility, and it should be inside that 2-month window.

If you happen to wait past the 2-month window, then you definately can have to attend until Medicare’s annual open enrollment period which is from October 15 to December 7 every 12 months.

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

Keep in mind that with Original Medicare, she is going to have a Medicare Part A (inpatient hospital) deductible for 2022 of $1556 every 60 days or 6 times a 12 months and a Medicare Part B (medical insurance) one-time annual deductible which changes annually. 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 Complement by answering the health underwriting questions.

Stephanie, your mother’s Medicare Advantage HMO plan’s situation is why an individual enrolling in Medicare should consider Medicare’s different options. Nobody ever knows when a serious illness will strike, and so they might have serious medical care.

Toni King is an creator and columnist on Medicare and medical health insurance issues who spent greater than 27 years as a sales leader within the fields. For answers to Medicare questions, email: info@tonisays.com or call 832-519-8664.

Toni King is an creator and columnist on Medicare and medical health insurance issues who spent greater than 27 years as a sales leader within the fields. For answers to Medicare questions, email: info@tonisays.com or call 832-519-8664.

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