Medicare Deadline Approaches: Special Notes

December 7 Approaches Quickly

The Annual Election Period runs between October 15 and December 7. During this period, you can change your Medicare Advantage or your stand-alone prescription plan. Further, you can change your mind, as many times, as you want, through the end of December 7. The last plan selected is the one that will be in effect on January 1, 2017.

Medicare Advantage Plans Evolve

Depending on the Medicare Advantage plan, you may be required to have a Primary Care Physician, whose referral is necessary in advance of seeing a specialist. Generally speaking, this is an HMO. For HMOs, it can be the case that you would be responsible for the entire cost if the healthcare provider is not part of the network. There is also a twist, called HMO-POS, where in some instances, you can receive healthcare services from providers that are outside the network.

There’s more. There has been an increasing number of HMO and HMO-POS plans that will allow you to visit a specialist, who is inside the network, without a referral. This may be called “Open Network” by your Medicare Advantage provider.  

As always the case, PPOs will allow you to receive healthcare services from providers outside the network, but you must keep in mind that your out-of-pocket expenses will very likely to be higher, when compared to using providers inside the network. In addition, it is usually the case that your health deductible will be much higher when you use providers outside the network.

Dental / Vision

Many Medicare Advantage plans have very basic dental and vision benefits embedded within the plan. However, these benefits are usually very light. For example, it is usually the case that major restorative dental services are not included.

Many (if not most) Medicare Advantage plans also include an enhanced dental/vision option. This year, there are additional restrictions, mandated by the CMS (Center for Medicare and Medicaid Services), that disallow the marketing of these enhanced features in advance of a person enrolling in a Medicare Advantage plan. However, if a consumer proactively asks, then the question can be answered.

Medicare Advantage and Observation Status

The newly-enacted “two midnight rule” should make the controversy that surrounds observation status and skilled nursing facility care less difficult to manage. To review, if you are a patient in a hospital for a period that crosses two midnights, then you are presumed to be admitted on an inpatient basis, in which case you are covered by Medicare Part A, and if you stay over 3 midnights, then that will allow you to receive skilled nursing care  (or home health care) for the first 20 days, without charge.

Unfortunately, that does not completely solve the issue. For example, you could be admitted to a Skilled Nursing Facility directly, without hospital admission. While not the most probable outcome, these types of circumstances can occur more than originally believed. The point? Certain Medicare Advantage plans eliminate the requirement for inpatient hospital stay altogether, and beneficiaries in those plans can receive skilled nursing facility care without fulfilling the 3-day inpatient hospital stay altogether.

The General Point

These are just a few simple examples of details embedded in Medicare Advantage plans. It is an admittedly incomplete list. However, the general point is that the details within the Medicare Advantage plans can offer features (or risks) that may mean that using the time, between now and December 7, to review the plans available to you, a worthwhile use of time.

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