Medicare Open Enrollment runs from October 15 to December 7, granting patients the opportunity to switch from traditional Medicare to a Medicare Advantage plan or move from one Medicare Advantage plan to another. This time of year can be challenging, not only for your agency, which may be impacted by patients’ decisions, but also for patients and their families as they navigate the process and determine the best choices for themselves or their loved ones.
It’s essential to be mindful that open enrollment is underway and to prepare your field staff to answer any questions patients may have. As an agency, you’re allowed to discuss with patients how their care may be impacted by their specific insurance plan. For example, if a patient requires 10 therapy visits but their Medicare Advantage plan only approves six, you can – and are likely required by regulation – to explain why they’re receiving fewer visits and clarify what’s happening with their coverage.
Many patients will decide to switch to a Medicare Advantage plan, or change their current one during this enrollment period, with their new coverage starting on January 1, 2025. However, the updates may not always appear in the system right away. It’s important to talk with your field staff, particularly those handling admission visits, to ensure they’re discussing any new insurance cards or payer-related letters with patients. This way, patients can share this information promptly, helping your team verify coverage and prevent any disruption in payment for services come January 1.
For both home health and hospice, having these conversations is essential. The VBID demonstration for Hospice concludes on December 31, meaning patients will return to traditional Medicare in January, regardless of their current payer. However, as a Medicare-certified Hospice, it’s still important to stay informed about these transitions.
As 2025 begins, agencies should be thorough in checking each patient’s Medicare eligibility file. This isn’t just for new admissions; all patients should be reviewed during the first week of January and then at least weekly through the first quarter. Additionally, throughout the year, patients enrolled in Medicare Advantage plans have the option to switch to a five-star Medicare Advantage plan—or even change to another five-star plan if already enrolled in one. Therefore, it’s crucial to keep checking eligibility regularly in your system.
If your EMR system doesn’t perform these automatic checks, someone on your team should manually verify each patient’s Medicare eligibility—weekly during the first quarter of the year and at least monthly after that. When transitioning to monthly eligibility checks, make sure to verify a patient’s Medicare eligibility during any recertification, even if it’s not their scheduled monthly check. This step is essential regardless of the timing. It’s crucial to understand that without the correct payer information and required authorizations, payments from those payers will not be processed.
Additionally, it must be emphasized that it is possible to receive authorization for a patient who may not be actively enrolled in that plan. Therefore, beyond checking the eligibility file, you must confirm the patient’s current coverage directly with the Medicare Advantage plan. This step ensures they are still enrolled before you proceed with authorization, provide care, and submit billing for the patient.
Healthcare Provider Solutions stands ready to support you with billing for your patients in traditional Medicare or Medicare Advantage, or assisting with your managed care plans, including negotiating and renegotiating rates and establishing contracts. For assistance with this, or any other areas you that you may require help with, please feel free to reach out to us.
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