Toni Says: Medicare Advantage HMO NOT Accepted with Nursing Home?


Hello Toni:

My mother has a Medicare Advantage HMO and August 1st she moved into a nursing home in the Sugar Land area. They have a doctor who visits the patients and does not accept the HMO which 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 or else they will have to ambulance her when she needs medical care.

 Is there a way that she can make a move because Medicare Open enrollment is not until 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?

Stephanie, a weekly reader

Stephanie: 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 a SEP for those who are moving into institutional care such as nursing homes.

In the Medicare and You Handbook, it talks about the specific Special Enrollment Periods (SEP) for Medicare Advantage plans. The Medicare and You Handbook states, “You generally must stay enrolled in the Medicare Advantage plan for the calendar year. However, you may be able to join, switch, or drop a Medicare Advantage Plan during a Special Enrollment Period (SEP).

Examples of Medicare Advantage Plans SEP are:

Moving Out of Area Enrolled in Medicaid

 Qualify for “Extra Help” for prescription drugs

 Moving into an institution like a nursing home which your mother qualifies for or a long-term care hospital

 Loss of creditable prescription drug coverage. (Insurance through your employer).

The trick to disenrolling from a Medicare Advantage Plan when a SEP is granted is to enroll in a Stand-alone Part D plan and being able to answer the qualifying question which is that you have moved into that facility within a 2-month period or have moved out of the facility within a 2-month period.

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 15th to December 7th every year.

You will need to contact Medicare at 1/800-633-4227 to make the SEP (Special Enrollment Period) change and give the Medicare customer service all your mother’s current prescriptions and 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.

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 1st 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 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.

For assistance with enrolling and personalizing your Medicare contact the Toni Says® office at 832/519-8664 or email your Medicare question to