Continuity in healthcare remains one of the most important factors in the success of preventive medicine and effective treatment for chronic or acute medical conditions. All Medicare insurance programs renew automatically if relevant premiums are paid and there are no changes to the contract or coverage area associated with your provider. However, certain circumstances can leave you without Medicare coverage or change your choices in providers.
Contract Between Medicare and Providers or Insurers Ends
Original Medicare insurance, Part A and Part B, provides fee-for-service coverage through contracts with hospitals, healthcare facilities and professionals. These contracts can change throughout the year or the location or healthcare professional may not renew their certification with Medicare for the coming coverage year. If this happens, your Medicare membership does not change, but you may need to find a different location or healthcare professional to manage your care.
Benefits can be provided by Part D Prescription Drug, Medigap or Medicare Advantage plans. These private insurers also offer coverage to Medicare recipients through a contract, but it’s possible for them to terminate these contracts midway through a coverage year or fail to renew their contract for the next coverage year.
If your Medicare provider terminates or does not renew their contract with Medicare, you will have a limited opportunity to choose a new provider. In cases where the provider will not renew for the next coverage year, your Special Enrollment Period begins in December and ends on the last day of the following February.
Your Special Enrollment Period lasts for three months when your provider terminates their contract with Medicare mid-year. However, the start of this three-month window is two months before the contract ends, meaning there’s only one month to sign up with a new provider after it ends. If you do not sign up with a new provider during this Special Enrollment Period, your coverage will default back to Original Medicare.
Medicare can also make changes to which healthcare professionals and facilities are certified to provide services, as well as terminate contracts with private insurers. The Special Enrollment Period for this begins one month before the effective termination date and ends two months after it. Additionally, you may wish to review your Medicare benefits each year to check for changes other than contract terminations. Provider networks, prescription medication formularies and cost-sharing details can change from year to year.
Changes to a Insurer’s Medicare Coverage Area
Private insurers who offer benefits through the Part D, Medigap and Medicare Advantage plans can vary from state to state. Coverage areas may also differ from one area to another within a state. These private insurers may change their coverage area without terminating their contract with Medicare, but this may mean you’re left without benefits if this area does not include where you live.
Medicare treats this much like it does when a provider terminates a contract, which means you will have a Special Enrollment Period that begins two months before the coverage area reduction and lasts one month after it occurs.
If you move out of your Medicare provider’s coverage area, a Special Enrollment Period is available to you, but this will depend on how soon before or after the move you report the change in address.
When you inform your provider before you move, you may be given the month before the move takes place and two months afterwards to change providers. After you move, your Special Enrollment Period begins the month in which you provided notification and lasts for two more months after that.